60. Neo has been\\n weaned off as of 1630\\n Respiratory failure, chronic\\n Assessment:\\n Pt. remains intubated and is presently on P.S. settings of . Resp\\n rate is controlled and pt. voices no complaints of SOB.\\n Action:\\n Pt. is scheduled for rigid bronch, with expected time to O.R. around\\n 1800.\\n Response:\\n O2 sats remain >97%. Pt. denies any SOB.\\n Plan:\\n Extubate pt. post bronch.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2138-09-27 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 340500,\n \"text\": \"Chief Complaint: respiratory failure\\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\\n including tracheobronchiomalacia, trach / decannulation, and recent\\n tracheal fistula repair (on ENT service at on ) c/b MRSA\\n pneumonia presenting with respiratory distress\\n 24 Hour Events:\\n INVASIVE VENTILATION - STOP 11:18 AM\\n PICC LINE - STOP 12:48 AM\\n PICC LINE - START 12:52 AM\\n Extubated yesterday. Was on cpap per her request which she uses at\\n home.\\n BP as low as 80s/40s, resolved without intervention.\\n History obtained from Patient\\n Allergies:\\n Heparin Agents\\n Thrombocytopeni\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\\n Vancomycin - 09:03 AM\\n Infusions:\\n Other ICU medications:\\n Lorazepam (Ativan) - 07:50 PM\\n Morphine Sulfate - 08:08 PM\\n Other medications:\\n zoloft, seroquel, aspirin, simvastatin, lamictal, senna, insulin\\n sliding scale, protonix, colace, lasix 40 mg daily, atrovent,\\n albuterol, ativan 0.5 mg IV q6h, morphine 1 mg IV prn\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:49 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: 36.1\\nC (96.9\\n HR: 93 (75 - 93) bpm\\n BP: 122/48(66) {82/40(51) - 143/70(98)} mmHg\\n RR: 18 (15 - 24) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 60 Inch\\n Total In:\\n 523 mL\\n 160 mL\\n PO:\\n TF:\\n IVF:\\n 223 mL\\n Blood products:\\n Total out:\\n 1,620 mL\\n 235 mL\\n Urine:\\n 1,620 mL\\n 235 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,097 mL\\n -75 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n Ventilator mode: Standby\\n FiO2: 70%\\n SpO2: 96%\\n ABG: ///28/\\n Ve: 8.9 L/min\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Anxious\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 10.5 g/dL\\n 369 K/uL\\n 87 mg/dL\\n 1.0 mg/dL\\n 28 mEq/L\\n 3.7 mEq/L\\n 15 mg/dL\\n 104 mEq/L\\n 142 mEq/L\\n 30.3 %\\n 7.7 K/uL\\n [image002.jpg]\\n 09:05 AM\\n 12:45 AM\\n 03:50 AM\\n 11:40 AM\\n 04:25 AM\\n 03:11 AM\\n 03:35 AM\\n WBC\\n 13.1\\n 10.3\\n 8.0\\n 10.4\\n 8.2\\n 7.7\\n Hct\\n 32.3\\n 30.5\\n 27.7\\n 28.3\\n 26.9\\n 30.3\\n Plt\\n 74\\n 423\\n 369\\n Cr\\n 1.3\\n 1.3\\n 1.2\\n 1.2\\n 1.0\\n 1.0\\n TropT\\n 0.03\\n <0.01\\n 0.03\\n 0.13\\n 0.08\\n Glucose\\n 70\\n 168\\n 120\\n 161\\n 205\\n 87\\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.1 mg/dL,\\n Mg++:1.8 mg/dL, PO4:3.2 mg/dL\\n Imaging: CXR: clear\\n Microbiology: C diff negative.\\n Assessment and Plan\\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\\n including tracheobronchiomalacia, trach / decannulation, and recent\\n tracheal fistula repair (on ENT service at on ) c/b MRSA\\n pneumonia presenting with respiratory distress. Suspect mucus plug as\\n the etiology +/- aspiration. Now much improved, s/p extubation\\n yesterday.\\n 1) Respiratory failure: Acute event the other night appears to be due\\n to a mucus plug with aspiration in RLL. No airway pathology seen on\\n rigid bronch.\\n - aspiration precautions\\n - no evidence of pneumonia, off antibiotics\\n - standing inhalers\\n - CPAP prn per home regimen\\n - appreciate ENT & IP input\\n 2) Elevated troponin/Hx CHF: Likely demand in setting of hypotension,\\n now resolving. No ECG changes.\\n - on home dose of lasix\\n - hold anithypertensives given bp 80s/40s overnight\\n 3) F/E/N: Diet per speech/swallow recommendations.\\n 4) Anxiety: ativan prn (home regimen.)\\n ICU Care\\n Nutrition:\\n Comments: advance diet as above\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n PICC Line - 12:52 AM\\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: 25 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2138-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 340641,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - patient weaned to nasal cannula during day, CPAP at night. No events\\n of respiratory distress overnight.\\n - Patient received one extra dose of PO ativan 0.5mg overnight for\\n anxiety\\n Allergies:\\n Heparin Agents\\n Thrombocytopeni\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Vancomycin - 09:03 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:53 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.1\\nC (97\\n HR: 75 (71 - 94) bpm\\n BP: 98/54(64) {83/38(53) - 138/79(91)} mmHg\\n RR: 16 (8 - 21) insp/min\\n SpO2: 94%\\n Heart rhythm: SA (Sinus Arrhythmia)\\n Height: 60 Inch\\n Total In:\\n 660 mL\\n 112 mL\\n PO:\\n 460 mL\\n TF:\\n IVF:\\n 40 mL\\n 112 mL\\n Blood products:\\n Total out:\\n 1,325 mL\\n 15 mL\\n Urine:\\n 1,325 mL\\n 15 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -665 mL\\n 97 mL\\n Respiratory support\\n O2 Delivery Device: CPAP mask\\n SpO2: 94%\\n ABG: ///29/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 420 K/uL\\n 10.6 g/dL\\n 115 mg/dL\\n 0.9 mg/dL\\n 29 mEq/L\\n 3.7 mEq/L\\n 13 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 30.5 %\\n 6.8 K/uL\\n [image002.jpg]\\n 09:05 AM\\n 12:45 AM\\n 03:50 AM\\n 11:40 AM\\n 04:25 AM\\n 03:11 AM\\n 03:35 AM\\n 04:12 AM\\n WBC\\n 13.1\\n 10.3\\n 8.0\\n 10.4\\n 8.2\\n 7.7\\n 6.8\\n Hct\\n 32.3\\n 30.5\\n 27.7\\n 28.3\\n 26.9\\n 30.3\\n 30.5\\n Plt\\n 74\\n 423\\n 369\\n 420\\n Cr\\n 1.3\\n 1.3\\n 1.2\\n 1.2\\n 1.0\\n 1.0\\n 0.9\\n TropT\\n 0.03\\n <0.01\\n 0.03\\n 0.13\\n 0.08\\n Glucose\\n 70\\n 168\\n 120\\n 161\\n 205\\n 87\\n 115\\n Other labs: PT / PTT / INR:13.8/30.1/1.2, CK / CKMB /\\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.3 mg/dL,\\n Mg++:2.0 mg/dL, PO4:3.4 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 12:52 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2138-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 340644,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - patient weaned to nasal cannula during day, CPAP at night. No events\\n of respiratory distress overnight.\\n - Patient received one extra dose of PO ativan 0.5mg overnight for\\n anxiety\\n Allergies:\\n Heparin Agents\\n Thrombocytopeni\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Vancomycin - 09:03 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:53 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.1\\nC (97\\n HR: 75 (71 - 94) bpm\\n BP: 98/54(64) {83/38(53) - 138/79(91)} mmHg\\n RR: 16 (8 - 21) insp/min\\n SpO2: 94%\\n Heart rhythm: SA (Sinus Arrhythmia)\\n Height: 60 Inch\\n Total In:\\n 660 mL\\n 112 mL\\n PO:\\n 460 mL\\n TF:\\n IVF:\\n 40 mL\\n 112 mL\\n Blood products:\\n Total out:\\n 1,325 mL\\n 15 mL\\n Urine:\\n 1,325 mL\\n 15 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -665 mL\\n 97 mL\\n Respiratory support\\n O2 Delivery Device: CPAP mask\\n SpO2: 94%\\n ABG: ///29/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 420 K/uL\\n 10.6 g/dL\\n 115 mg/dL\\n 0.9 mg/dL\\n 29 mEq/L\\n 3.7 mEq/L\\n 13 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 30.5 %\\n 6.8 K/uL\\n [image002.jpg]\\n 09:05 AM\\n 12:45 AM\\n 03:50 AM\\n 11:40 AM\\n 04:25 AM\\n 03:11 AM\\n 03:35 AM\\n 04:12 AM\\n WBC\\n 13.1\\n 10.3\\n 8.0\\n 10.4\\n 8.2\\n 7.7\\n 6.8\\n Hct\\n 32.3\\n 30.5\\n 27.7\\n 28.3\\n 26.9\\n 30.3\\n 30.5\\n Plt\\n 74\\n 423\\n 369\\n 420\\n Cr\\n 1.3\\n 1.3\\n 1.2\\n 1.2\\n 1.0\\n 1.0\\n 0.9\\n TropT\\n 0.03\\n <0.01\\n 0.03\\n 0.13\\n 0.08\\n Glucose\\n 70\\n 168\\n 120\\n 161\\n 205\\n 87\\n 115\\n Other labs: PT / PTT / INR:13.8/30.1/1.2, CK / CKMB /\\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.3 mg/dL,\\n Mg++:2.0 mg/dL, PO4:3.4 mg/dL\\n Assessment and Plan\\n Ms. is a 67F with CAD s/p CABG, CHF, COPD and complicated\\n pulmonary history with prolonged tracheostomy with recent decannulation\\n and subsequent fistula closure (on ENT service at on ) with\\n complicated MRSA PNA presented with worsened respiratory distress. Now\\n s/p bronchoscopy which did not reveal significant upper airway\\n stenosis.\\n .\\n 1. Respiratory failure. Patient was intubated on after episode of\\n flash pulmonary edema while being bathed and concern for upper airway\\n obstruction due to previous intubations/trach. Patient also has\\n history of trace aspiration. Completed 10 day course for aspiration\\n pneumonia on . Rigid bronchoscopy on showed no significant upper\\n airway stenosis. Extubated successfully on . No episodes of\\n respiratory distress overnight, but given history, will watch closely\\n today as patient is advanced on her diet with aspiration precautions.\\n - IP and ENT following, appreciate recs\\n - watch patient closely overnight as we advance her diet today\\n - strict aspiration precautions with PO intake\\n regular food with thin\\n liquids with aspiration precautions, but pills must be taken with\\n thickened liquids\\n - continue nebs\\n - continue home lasix for interstial edema\\n - ativan prn for anxiety\\n .\\n 2.Hypotension. Patient off pressors, still with some low BP overnight,\\n but asymptomatic\\n - monitor BP and fluid boluses prn\\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\\n edema/HTN. Troponins have trended down.\\n -continue ASA, BB\\n - consider resuming ACEI when BP tolerates and if renal function\\n continues to improve\\n .\\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\\n on . CXR yesterday showed mild interstitial edema. Currently\\n euvolemic, but will continue home lasix dose. TTE recently done\\n () showed preserved EF with some focal wall motion abnormality.\\n Patient euvolemic and net even overnight without any additional\\n diuretics\\n -continue home lasix\\n -monitor I/Os\\n -Continue BB\\n - holding ACEI until blood pressure stable\\n .\\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\\n - consider resuming lisinopril when BP tolerates, Cr improved\\n 6. COPD.\\n -continue nebs\\n .\\n 7. Depression/anxiety. Patient has significant anxiety.\\n -ativan prn anxiety, caution not to oversedate. Can change Ativan from\\n IV to PO\\n -Continue home lamotrigine, quetiapine, sertraline\\n .\\n 8. Hyperlipidemia:\\n -Continue statin\\n ICU Care\\n Nutrition: Advance diet to regular diet with aspiration precautions,\\n pills with thickened liquids\\n Glycemic Control:\\n Lines:\\n RIC - 10:00 AM\\n PICC Line - 09:34 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: pantoprazole\\n VAP: Extubated\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU care for now\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2138-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 340645,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - patient weaned to nasal cannula during day, CPAP at night. No events\\n of respiratory distress overnight.\\n - Patient received one extra dose of PO ativan 0.5mg overnight for\\n anxiety\\n Allergies:\\n Heparin Agents\\n Thrombocytopeni\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Vancomycin - 09:03 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Morphine 1 mg IV prn hip pain\\n Ativan PO/ IV prn anxiety\\n Lasix 40 mg daily\\n Lactulose 30 mg daily\\n Albuterol q4 hr\\n Atrovent\\n Colace 100 \\n Pantoprazole 40 IV daily\\n Chlorhexidine mouthwash\\n Senna\\n Lamotrigine 25 mg \\n Simvastatin 40 mg daily\\n Aspirin 81 daily\\n Seroquel\\n Sertraline 100 daily\\n Albuterol/ipratroprium nebs\\n Insuline sliding scale\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:53 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.1\\nC (97\\n HR: 75 (71 - 94) bpm\\n BP: 98/54(64) {83/38(53) - 138/79(91)} mmHg\\n RR: 16 (8 - 21) insp/min\\n SpO2: 94%\\n Heart rhythm: SA (Sinus Arrhythmia)\\n Height: 60 Inch\\n Total In:\\n 660 mL\\n 112 mL\\n PO:\\n 460 mL\\n TF:\\n IVF:\\n 40 mL\\n 112 mL\\n Blood products:\\n Total out:\\n 1,325 mL\\n 15 mL\\n Urine:\\n 1,325 mL\\n 15 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -665 mL\\n 97 mL\\n Respiratory support\\n O2 Delivery Device: CPAP mask\\n SpO2: 94%\\n ABG: ///29/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 420 K/uL\\n 10.6 g/dL\\n 115 mg/dL\\n 0.9 mg/dL\\n 29 mEq/L\\n 3.7 mEq/L\\n 13 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 30.5 %\\n 6.8 K/uL\\n [image002.jpg]\\n 09:05 AM\\n 12:45 AM\\n 03:50 AM\\n 11:40 AM\\n 04:25 AM\\n 03:11 AM\\n 03:35 AM\\n 04:12 AM\\n WBC\\n 13.1\\n 10.3\\n 8.0\\n 10.4\\n 8.2\\n 7.7\\n 6.8\\n Hct\\n 32.3\\n 30.5\\n 27.7\\n 28.3\\n 26.9\\n 30.3\\n 30.5\\n Plt\\n 74\\n 423\\n 369\\n 420\\n Cr\\n 1.3\\n 1.3\\n 1.2\\n 1.2\\n 1.0\\n 1.0\\n 0.9\\n TropT\\n 0.03\\n <0.01\\n 0.03\\n 0.13\\n 0.08\\n Glucose\\n 70\\n 168\\n 120\\n 161\\n 205\\n 87\\n 115\\n Other labs: PT / PTT / INR:13.8/30.1/1.2, CK / CKMB /\\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.3 mg/dL,\\n Mg++:2.0 mg/dL, PO4:3.4 mg/dL\\n Assessment and Plan\\n Ms. is a 67F with CAD s/p CABG, CHF, COPD and complicated\\n pulmonary history with prolonged tracheostomy with recent decannulation\\n and subsequent fistula closure (on ENT service at on ) with\\n complicated MRSA PNA presented with worsened respiratory distress. Now\\n s/p bronchoscopy which did not reveal significant upper airway\\n stenosis.\\n .\\n 1. Respiratory failure. Patient was intubated on after episode of\\n flash pulmonary edema while being bathed and concern for upper airway\\n obstruction due to previous intubations/trach. Patient also has\\n history of trace aspiration. Completed 10 day course for aspiration\\n pneumonia on . Rigid bronchoscopy on showed no significant upper\\n airway stenosis. Extubated successfully on . No episodes of\\n respiratory distress overnight, but given history, will watch closely\\n today as patient is advanced on her diet with aspiration precautions.\\n - IP and ENT following, appreciate recs\\n - watch patient closely overnight as we advance her diet today\\n - strict aspiration precautions with PO intake\\n regular food with thin\\n liquids with aspiration precautions, but pills must be taken with\\n thickened liquids\\n - continue nebs\\n - continue home lasix for interstial edema\\n - ativan prn for anxiety\\n .\\n 2.Hypotension. Patient off pressors, still with some low BP overnight,\\n but asymptomatic\\n - monitor BP and fluid boluses prn\\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\\n edema/HTN. Troponins have trended down.\\n -continue ASA, BB\\n - consider resuming ACEI when BP tolerates and if renal function\\n continues to improve\\n .\\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\\n on . CXR yesterday showed mild interstitial edema. Currently\\n euvolemic, but will continue home lasix dose. TTE recently done\\n () showed preserved EF with some focal wall motion abnormality.\\n Patient euvolemic and net even overnight without any additional\\n diuretics\\n -continue home lasix\\n -monitor I/Os\\n -Continue BB\\n - holding ACEI until blood pressure stable\\n .\\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\\n - consider resuming lisinopril when BP tolerates, Cr improved\\n 6. COPD.\\n -continue nebs\\n .\\n 7. Depression/anxiety. Patient has significant anxiety.\\n -ativan prn anxiety, caution not to oversedate. Can change Ativan from\\n IV to PO\\n -Continue home lamotrigine, quetiapine, sertraline\\n .\\n 8. Hyperlipidemia:\\n -Continue statin\\n ICU Care\\n Nutrition: Advance diet to regular diet with aspiration precautions,\\n pills with thickened liquids\\n Glycemic Control:\\n Lines:\\n RIC - 10:00 AM\\n PICC Line - 09:34 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: pantoprazole\\n VAP: Extubated\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU care for now\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2138-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 340652,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - patient weaned to nasal cannula during day, CPAP at night. No events\\n of respiratory distress overnight.\\n - diet advanced following speech/swallow guidelines. Patient tolerating\\n regular diet with aspiration precautions. Pills with thickened liquids\\n - Patient received one extra dose of PO ativan 0.5mg overnight for\\n anxiety\\n Allergies:\\n Heparin Agents\\n Thrombocytopeni\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Vancomycin - 09:03 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Morphine 1 mg IV prn hip pain\\n Ativan PO/ IV prn anxiety\\n Lasix 40 mg daily\\n Lactulose 30 mg daily\\n Albuterol q4 hr\\n Atrovent\\n Colace 100 \\n Pantoprazole 40 IV daily\\n Chlorhexidine mouthwash\\n Senna\\n Lamotrigine 25 mg \\n Simvastatin 40 mg daily\\n Aspirin 81 daily\\n Seroquel\\n Sertraline 100 daily\\n Albuterol/ipratroprium nebs\\n Insuline sliding scale\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:53 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.1\\nC (97\\n HR: 75 (71 - 94) bpm\\n BP: 98/54(64) {83/38(53) - 138/79(91)} mmHg\\n RR: 16 (8 - 21) insp/min\\n SpO2: 94%\\n Heart rhythm: SA (Sinus Arrhythmia)\\n Height: 60 Inch\\n Total In:\\n 660 mL\\n 112 mL\\n PO:\\n 460 mL\\n TF:\\n IVF:\\n 40 mL\\n 112 mL\\n Blood products:\\n Total out:\\n 1,325 mL\\n 15 mL\\n Urine:\\n 1,325 mL\\n 15 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -665 mL\\n 97 mL\\n Respiratory support\\n O2 Delivery Device: CPAP mask\\n SpO2: 94%\\n ABG: ///29/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 420 K/uL\\n 10.6 g/dL\\n 115 mg/dL\\n 0.9 mg/dL\\n 29 mEq/L\\n 3.7 mEq/L\\n 13 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 30.5 %\\n 6.8 K/uL\\n [image002.jpg]\\n 09:05 AM\\n 12:45 AM\\n 03:50 AM\\n 11:40 AM\\n 04:25 AM\\n 03:11 AM\\n 03:35 AM\\n 04:12 AM\\n WBC\\n 13.1\\n 10.3\\n 8.0\\n 10.4\\n 8.2\\n 7.7\\n 6.8\\n Hct\\n 32.3\\n 30.5\\n 27.7\\n 28.3\\n 26.9\\n 30.3\\n 30.5\\n Plt\\n 74\\n 423\\n 369\\n 420\\n Cr\\n 1.3\\n 1.3\\n 1.2\\n 1.2\\n 1.0\\n 1.0\\n 0.9\\n TropT\\n 0.03\\n <0.01\\n 0.03\\n 0.13\\n 0.08\\n Glucose\\n 70\\n 168\\n 120\\n 161\\n 205\\n 87\\n 115\\n Other labs: PT / PTT / INR:13.8/30.1/1.2, CK / CKMB /\\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.3 mg/dL,\\n Mg++:2.0 mg/dL, PO4:3.4 mg/dL\\n Assessment and Plan\\n Ms. is a 67F with CAD s/p CABG, CHF, COPD and complicated\\n pulmonary history with prolonged tracheostomy with recent decannulation\\n and subsequent fistula closure (on ENT service at on ) with\\n complicated MRSA PNA presented with worsened respiratory distress. Now\\n s/p bronchoscopy which did not reveal significant upper airway\\n stenosis.\\n .\\n 1. Respiratory failure. Patient was intubated on after episode of\\n flash pulmonary edema while being bathed and concern for upper airway\\n obstruction due to previous intubations/trach. Patient also has\\n history of trace aspiration. Completed 10 day course for aspiration\\n pneumonia on . Rigid bronchoscopy on showed no significant upper\\n airway stenosis. Extubated successfully on . No episodes of\\n respiratory distress overnight, but given history, will watch closely\\n today as patient is advanced on her diet with aspiration precautions.\\n - IP and ENT following, appreciate recs\\n - watch patient closely overnight as we advance her diet today\\n - strict aspiration precautions with PO intake\\n regular food with thin\\n liquids with aspiration precautions, but pills must be taken with\\n thickened liquids\\n - continue nebs\\n - continue home lasix for interstial edema\\n - ativan prn for anxiety\\n .\\n 2.Hypotension. Patient off pressors, still with some low BP overnight,\\n but asymptomatic\\n - monitor BP and fluid boluses prn\\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\\n edema/HTN. Troponins have trended down.\\n -continue ASA, BB\\n - consider resuming ACEI when BP tolerates and if renal function\\n continues to improve\\n .\\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\\n on . CXR yesterday showed mild interstitial edema. Currently\\n euvolemic, but will continue home lasix dose. TTE recently done\\n () showed preserved EF with some focal wall motion abnormality.\\n Patient euvolemic and net even overnight without any additional\\n diuretics\\n -continue home lasix\\n -monitor I/Os\\n -Continue BB\\n - holding ACEI until blood pressure stable\\n .\\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\\n - consider resuming lisinopril when BP tolerates, Cr improved\\n 6. COPD.\\n -continue nebs\\n .\\n 7. Depression/anxiety. Patient has significant anxiety.\\n -ativan prn anxiety, caution not to oversedate. Can change Ativan from\\n IV to PO\\n -Continue home lamotrigine, quetiapine, sertraline\\n .\\n 8. Hyperlipidemia:\\n -Continue statin\\n ICU Care\\n Nutrition: Advance diet to regular diet with aspiration precautions,\\n pills with thickened liquids\\n Glycemic Control:\\n Lines:\\n RIC - 10:00 AM\\n PICC Line - 09:34 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: pantoprazole\\n VAP: Extubated\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU care for now\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2138-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 340653,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - patient weaned to nasal cannula during day, CPAP at night. No events\\n of respiratory distress overnight.\\n - diet advanced following speech/swallow guidelines. Patient tolerating\\n regular diet with aspiration precautions. Pills with thickened liquids\\n - Patient received one extra dose of PO ativan 0.5mg overnight for\\n anxiety\\n Allergies:\\n Heparin Agents\\n Thrombocytopeni\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Vancomycin - 09:03 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Morphine 1 mg IV prn hip pain\\n Ativan PO/ IV prn anxiety\\n Lasix 40 mg daily\\n Lactulose 30 mg daily\\n Albuterol q4 hr\\n Atrovent\\n Colace 100 \\n Pantoprazole 40 IV daily\\n Chlorhexidine mouthwash\\n Senna\\n Lamotrigine 25 mg \\n Simvastatin 40 mg daily\\n Aspirin 81 daily\\n Seroquel\\n Sertraline 100 daily\\n Albuterol/ipratroprium nebs\\n Insuline sliding scale\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:53 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 36.1\\nC (97\\n HR: 75 (71 - 94) bpm\\n BP: 98/54(64) {83/38(53) - 138/79(91)} mmHg\\n RR: 16 (8 - 21) insp/min\\n SpO2: 94%\\n Heart rhythm: SA (Sinus Arrhythmia)\\n Height: 60 Inch\\n Total In:\\n 660 mL\\n 112 mL\\n PO:\\n 460 mL\\n TF:\\n IVF:\\n 40 mL\\n 112 mL\\n Blood products:\\n Total out:\\n 1,325 mL\\n 15 mL\\n Urine:\\n 1,325 mL\\n 15 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -665 mL\\n 97 mL\\n Respiratory support\\n O2 Delivery Device: CPAP mask\\n SpO2: 94%\\n ABG: ///29/\\n Physical Examination\\n GEN: NAD, sleeping, easily aroused\\n HEENT: MMM\\n CV: RRR\\n Pulm: bibasilr rales, occ scattered rhonchi\\n Abd: obese, soft, nt/nd\\n Ext: no c/c.e\\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 420 K/uL\\n 10.6 g/dL\\n 115 mg/dL\\n 0.9 mg/dL\\n 29 mEq/L\\n 3.7 mEq/L\\n 13 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 30.5 %\\n 6.8 K/uL\\n [image002.jpg]\\n 09:05 AM\\n 12:45 AM\\n 03:50 AM\\n 11:40 AM\\n 04:25 AM\\n 03:11 AM\\n 03:35 AM\\n 04:12 AM\\n WBC\\n 13.1\\n 10.3\\n 8.0\\n 10.4\\n 8.2\\n 7.7\\n 6.8\\n Hct\\n 32.3\\n 30.5\\n 27.7\\n 28.3\\n 26.9\\n 30.3\\n 30.5\\n Plt\\n 74\\n 423\\n 369\\n 420\\n Cr\\n 1.3\\n 1.3\\n 1.2\\n 1.2\\n 1.0\\n 1.0\\n 0.9\\n TropT\\n 0.03\\n <0.01\\n 0.03\\n 0.13\\n 0.08\\n Glucose\\n 70\\n 168\\n 120\\n 161\\n 205\\n 87\\n 115\\n Other labs: PT / PTT / INR:13.8/30.1/1.2, CK / CKMB /\\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.3 mg/dL,\\n Mg++:2.0 mg/dL, PO4:3.4 mg/dL\\n Assessment and Plan\\n Ms. is a 67F with CAD s/p CABG, CHF, COPD and complicated\\n pulmonary history with prolonged tracheostomy with recent decannulation\\n and subsequent fistula closure (on ENT service at on ) with\\n complicated MRSA PNA presented with worsened respiratory distress. Now\\n s/p bronchoscopy which did not reveal significant upper airway\\n stenosis.\\n .\\n 1. Respiratory failure. Patient was intubated on after episode of\\n flash pulmonary edema while being bathed and concern for upper airway\\n obstruction due to previous intubations/trach. Patient also has\\n history of trace aspiration. Completed 10 day course for aspiration\\n pneumonia on . Rigid bronchoscopy on showed no significant upper\\n airway stenosis. Extubated successfully on . No episodes of\\n respiratory distress overnight, but given history, will watch closely\\n today as patient is advanced on her diet with aspiration precautions.\\n - IP and ENT following, appreciate recs\\n - watch patient closely overnight as we advance her diet today\\n - strict aspiration precautions with PO intake\\n regular food with thin\\n liquids with aspiration precautions, but pills must be taken with\\n thickened liquids\\n - continue nebs\\n - continue home lasix for interstial edema\\n - ativan prn for anxiety\\n .\\n 2.Hypotension. Patient off pressors, still with some low BP overnight,\\n but asymptomatic\\n - monitor BP and fluid boluses prn\\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\\n edema/HTN. Troponins have trended down.\\n -continue ASA, BB\\n - consider resuming ACEI when BP tolerates and if renal function\\n continues to improve\\n .\\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\\n on . CXR yesterday showed mild interstitial edema. Currently\\n euvolemic, but will continue home lasix dose. TTE recently done\\n () showed preserved EF with some focal wall motion abnormality.\\n Patient euvolemic and net even overnight without any additional\\n diuretics\\n -continue home lasix\\n -monitor I/Os\\n -Continue BB\\n - holding ACEI until blood pressure stable\\n .\\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\\n - consider resuming lisinopril when BP tolerates, Cr improved\\n 6. COPD.\\n -continue nebs\\n .\\n 7. Depression/anxiety. Patient has significant anxiety.\\n -ativan prn anxiety, caution not to oversedate. Can change Ativan from\\n IV to PO\\n -Continue home lamotrigine, quetiapine, sertraline\\n .\\n 8. Hyperlipidemia:\\n -Continue statin\\n ICU Care\\n Nutrition: Advance diet to regular diet with aspiration precautions,\\n pills with thickened liquids\\n Glycemic Control:\\n Lines:\\n RIC - 10:00 AM\\n PICC Line - 09:34 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: pantoprazole\\n VAP: Extubated\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU care for now\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2138-09-28 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 340660,\n \"text\": \"Respiratory failure, chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2138-09-28 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 340661,\n \"text\": \"Respiratory failure, chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2138-09-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 339863,\n \"text\": \"67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\\n prolonged tracheostomy with recent decannulation and subsequent fistula\\n closure (on ENT service at on ) with complicated MRSA PNA\\n presented with worsened respiratory distress. Patient with acute event\\n of respiratory failure overnight requiring intubation.\\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\\n including tracheobronchiomalacia, trach / decannulation, and recent\\n tracheal fistula repair (on ENT service at on ) c/b MRSA\\n pneumonia presenting with respiratory distress. Her recent worsening\\n appears most consistent with a multifactorial etiology: upper airway\\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\\n recent MRSA pneumonia. No problems with the surgical site. Suspect\\n mucus plug as the etiology\\n Pt. has been evaluated and is presently a\\nadd on\\n case for the O.R. to\\n perform a rigid bronchoscopy, by M.D.\\n Pulmonary edema\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2138-09-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 339920,\n \"text\": \"67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\\n prolonged tracheostomy with recent decannulation and subsequent fistula\\n closure (on ENT service at on ) with complicated MRSA PNA\\n presented with worsened respiratory distress. Patient with acute event\\n of respiratory failure overnight requiring intubation.\\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\\n including tracheobronchiomalacia, trach / decannulation, and recent\\n tracheal fistula repair (on ENT service at on ) c/b MRSA\\n pneumonia presenting with respiratory distress. Her recent worsening\\n appears most consistent with a multifactorial etiology: upper airway\\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\\n recent MRSA pneumonia. No problems with the surgical site. Suspect\\n mucus plug as the etiology\\n Pt. has been evaluated and is presently a\\nadd on\\n case for the O.R. to\\n perform a rigid bronchoscopy, by A. M.D.\\n Pulmonary edema\\n Assessment:\\n Pt\\ns am CXR shows slight congestion.\\n Action:\\n Lasix 40mg po via OGT administered.\\n Response:\\n Pt. has diuresed appropriately with this. Lungs are clear mid to upper\\n lobes and remain diminished bibasilar.\\n Plan:\\n Daily CXR along with lasix 40mg po qd order.\\n Hypotension (not Shock)\\n Assessment:\\n Pt\\ns B/P remains labile. Map\\ns occasionally drop below 60.\\n Action:\\n Pt. remains on Neo gtt at 0.75mcq/kg/min.\\n Response:\\n Pt.\\ns map\\ns have been better controlled with Neo support.\\n Plan:\\n To wean Neo gtt when able, while maintaining map\\ns >60. Neo has been\\n weaned off as of 1630\\n Respiratory failure, chronic\\n Assessment:\\n Pt. remains intubated and is presently on P.S. settings of . Resp\\n rate is controlled and pt. voices no complaints of SOB.\\n Action:\\n Pt. is scheduled for rigid bronch, with expected time to O.R. around\\n 1800.\\n Response:\\n O2 sats remain >97%. Pt. denies any SOB.\\n Plan:\\n Extubate pt. post bronch.\\n Pt. has received Vicoden one tab, twice. And, Ativan 1.5 mg throughout\\n this shift. Last dose for both was 1740. Report called to in the\\n O.R. at 1810. Pt. is to be taken down shortly for bronchoscopy. Pt\\n husband is aware.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2138-09-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 340151,\n \"text\": \"Chief Complaint: respiratory failure\\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\\n including tracheobronchiomalacia, trach / decannulation, and recent\\n tracheal fistula repair (on ENT service at on ) c/b MRSA\\n pneumonia presenting with respiratory distress. Her recent worsening\\n appears most consistent with a multifactorial etiology: upper airway\\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\\n recent MRSA pneumonia.\\n 24 Hour Events:\\n BRONCHOSCOPY - At 07:00 PM\\n Rigid bronchoscopy reportedly normal. Extubated in OR but became\\n hypoxic, felt related to sedation so reintubated.\\n Given lasix for pulmonary edema on CXR.\\n Allergies:\\n Heparin Agents\\n Thrombocytopeni\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\\n Vancomycin - 09:03 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n senna, lamictal, simvastatin, aspirin 81 mg daily, seroquel, zoloft,\\n peridex, colace, protonix, insulin SQ, atrovent, albuterol, lasix 40 mg\\n daily, propofol is off\\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 11:07 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.8\\nC (100.1\\n Tcurrent: 37.4\\nC (99.3\\n HR: 86 (54 - 86) bpm\\n BP: 127/73(86) {92/44(55) - 130/73(86)} mmHg\\n RR: 21 (13 - 24) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 60 Inch\\n Total In:\\n 1,242 mL\\n 493 mL\\n PO:\\n TF:\\n IVF:\\n 942 mL\\n 223 mL\\n Blood products:\\n Total out:\\n 1,660 mL\\n 905 mL\\n Urine:\\n 1,660 mL\\n 905 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -418 mL\\n -412 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): 73 (73 - 541) mL\\n PS : 10 cmH2O\\n RR (Set): 8\\n RR (Spontaneous): 24\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n RSBI: 43\\n PIP: 17 cmH2O\\n SpO2: 98%\\n ABG: ///29/\\n Ve: 11.1 L/min\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Head, Ears, Nose, Throat: Normocephalic, trach site healing well\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Absent, Left: Absent\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 9.1 g/dL\\n 423 K/uL\\n 205 mg/dL\\n 1.0 mg/dL\\n 29 mEq/L\\n 3.5 mEq/L\\n 14 mg/dL\\n 100 mEq/L\\n 137 mEq/L\\n 26.9 %\\n 8.2 K/uL\\n [image002.jpg]\\n 09:05 AM\\n 12:45 AM\\n 03:50 AM\\n 11:40 AM\\n 04:25 AM\\n 03:11 AM\\n WBC\\n 13.1\\n 10.3\\n 8.0\\n 10.4\\n 8.2\\n Hct\\n 32.3\\n 30.5\\n 27.7\\n 28.3\\n 26.9\\n Plt\\n 74\\n 423\\n Cr\\n 1.3\\n 1.3\\n 1.2\\n 1.2\\n 1.0\\n TropT\\n 0.03\\n <0.01\\n 0.03\\n 0.13\\n 0.08\\n Glucose\\n 70\\n 168\\n 120\\n 161\\n 205\\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\\n Mg++:1.8 mg/dL, PO4:2.8 mg/dL\\n Imaging: CXR: bilateral LL infiltrates, minimal.\\n Assessment and Plan\\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\\n including tracheobronchiomalacia, trach / decannulation, and recent\\n tracheal fistula repair (on ENT service at on ) c/b MRSA\\n pneumonia presenting with respiratory distress. Her recent worsening\\n appears most consistent with a multifactorial etiology: upper airway\\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\\n recent MRSA pneumonia. No problems with the surgical site. Suspect\\n mucus plug as the etiology +/- aspiration.\\n 1) Respiratory failure: Acute event the other night appears to be due\\n to a mucus plug vs aspiration. No airway pathology seen on rigid\\n bronch which would limit extubation.\\n - good RSBI this AM, comfortable on , so will proceed with\\n extubation.\\n - no evidence of pneumonia, off antibiotics\\n 2) Hypotension: Resolved. off neo. Likely related to propofol.\\n 3) Elevated troponin/Hx CHF: Likely demand in setting of hypotension,\\n now resolving. No ECG changes. Goal euvolemic. Restart\\n antihypertensives in AM if stable today.\\n 4) ARF: Resolved. Creatinine improved.\\n 5) F/E/N: NPO, restart clear liquids tonight if she does well. Follow /\\n replete lytes as needed. Goal euvolemic for now.\\n ICU Care\\n Nutrition:\\n Comments: holding TF for extubation\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n RIC - 10:00 AM\\n PICC Line - 09:34 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Family meeting held Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2138-09-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 340031,\n \"text\": \"67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\\n prolonged tracheostomy with recent decannulation and subsequent fistula\\n closure (on ENT service at on ) with complicated MRSA PNA\\n presented with worsened respiratory distress. Patient with acute event\\n of respiratory failure overnight requiring intubation.\\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\\n including tracheobronchiomalacia, trach / decannulation, and recent\\n tracheal fistula repair (on ENT service at on ) c/b MRSA\\n pneumonia presenting with respiratory distress. Her recent worsening\\n appears most consistent with a multifactorial etiology: upper airway\\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\\n recent MRSA pneumonia. No problems with the surgical site. Suspect\\n mucus plug as the etiology\\n Pt to OR for Rigid bronch; official report not yet available.\\n According to a verbal report, the condition of the airway should not\\n interfere with a successful extubation.\\n The patient was awake and alert on return from OR; Pt became agitation\\n when she learned that the tube would stay in until morning. Propofol\\n was resumed then held for low Blood Pressure; Pt did not tolerate;\\n Propofol resumed at 30mcg; Ativan 0.5mg adm x2 ~midnight. Neo added.\\n Frequent runs PVCs. Sm-mod amt thick ET secr. OG placed for oral med\\n adm. Foley output 30-60/hour.\\n Respiratory failure, chronic\\n Assessment:\\n Rigid Bronch; Pt somnolent after procedure; Re-intubated until a.m.\\n Action:\\n Provided sedation for comfort; Resp support increased to MVV\\n Response:\\n Pt required more Propofol than previously; increased to 30mcg then\\n tapered back to 15mcg). HR low 50s on 30mcg.\\n Plan:\\n Wean Propofol and Neo in preparation for extubation in am.\\n Hypotension (not Shock)\\n Assessment:\\n Hypotensive during Propofol administration\\n Action:\\n Neo re-started for BP support\\n Response:\\n BP 100s-1teens and MAPS >60\\n Plan:\\n Wan Neo off when sedation lightened/DCd.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2138-09-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 340311,\n \"text\": \".\\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\\n including tracheobronchiomalacia, trach / decannulation, and recent\\n tracheal fistula repair (on ENT service at on ) c/b MRSA\\n pneumonia presenting with respiratory distress. Her recent worsening\\n appears most consistent with a multifactorial etiology: upper airway\\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\\n recent MRSA pneumonia. No problems with the surgical site. Suspect\\n mucus plug as the etiology required reintubation on had rigid\\n bronch on resulted as WNL now s/p extubation.\\n Respiratory failure, chronic\\n Assessment:\\n Pt on Face Tent initially; Requested CPAP mask ( unit) ~8pm.\\n Anxiety contributes to SOB\\n Low sats on CPAP\\n Action:\\n Contact Respiratory to assists patient with CPAP mask. O2 increased\\n on BIPAP/Resp treatments ordered and administered for low sats.\\n Ativan 0.5 IV for anxiety and Morphine 1mg IV for pain adm at 8pm.\\n Ativan 0.5mg PO for anxiety adm at 0030\\n Response:\\n Pt slept; BP dropped briefly to MAP50-60; UOP maintained at 30cc+; O2\\n sats improved after resp treatments, 02 flow adjustment and Ativan.\\n Plan:\\n Continue CPAP nocturnally; pt uses during day. , Cool Mist face tent\\n during the day. Encourage deep breathing. Advance diet/Aspiration\\n precautions.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2138-09-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 340309,\n \"text\": \"Respiratory failure, chronic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2138-09-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 340419,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Patient Extubated. Initially on face tent, but patient requested\\n CPAP.\\n Asymptomatic hypotension of 80s/40 that resolved without intervention.\\n Patient is hungry and requring advancement of her diet\\n INVASIVE VENTILATION - STOP 11:18 AM\\n PICC LINE - STOP 12:48 AM\\n PICC LINE - START 12:52 AM\\n Allergies:\\n Heparin Agents\\n Thrombocytopeni\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\\n Vancomycin - 09:03 AM\\n Infusions:\\n Other ICU medications:\\n Lorazepam (Ativan) - 07:50 PM\\n Morphine Sulfate - 08:08 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 06:39 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: 36.3\\nC (97.4\\n HR: 79 (66 - 91) bpm\\n BP: 121/55(72) {82/40(51) - 143/73(98)} mmHg\\n RR: 17 (15 - 24) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 60 Inch\\n Total In:\\n 523 mL\\n 60 mL\\n PO:\\n TF:\\n IVF:\\n 223 mL\\n Blood products:\\n Total out:\\n 1,620 mL\\n 135 mL\\n Urine:\\n 1,620 mL\\n 135 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,097 mL\\n -75 mL\\n Respiratory support\\n O2 Delivery Device: CPAP mask\\n Ventilator mode: Standby\\n Vt (Spontaneous): 73 (73 - 432) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 24\\n PEEP: 5 cmH2O\\n FiO2: 100%\\n PIP: 17 cmH2O\\n SpO2: 93%\\n ABG: ///28/\\n Ve: 8.9 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 369 K/uL\\n 10.5 g/dL\\n 87 mg/dL\\n 1.0 mg/dL\\n 28 mEq/L\\n 3.7 mEq/L\\n 15 mg/dL\\n 104 mEq/L\\n 142 mEq/L\\n 30.3 %\\n 7.7 K/uL\\n [image002.jpg]\\n 09:05 AM\\n 12:45 AM\\n 03:50 AM\\n 11:40 AM\\n 04:25 AM\\n 03:11 AM\\n 03:35 AM\\n WBC\\n 13.1\\n 10.3\\n 8.0\\n 10.4\\n 8.2\\n 7.7\\n Hct\\n 32.3\\n 30.5\\n 27.7\\n 28.3\\n 26.9\\n 30.3\\n Plt\\n 74\\n 423\\n 369\\n Cr\\n 1.3\\n 1.3\\n 1.2\\n 1.2\\n 1.0\\n 1.0\\n TropT\\n 0.03\\n <0.01\\n 0.03\\n 0.13\\n 0.08\\n Glucose\\n 70\\n 168\\n 120\\n 161\\n 205\\n 87\\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.1 mg/dL,\\n Mg++:1.8 mg/dL, PO4:3.2 mg/dL\\n Assessment and Plan\\n In Summary, Ms. is a 67F with CAD s/p CABG, CHF, COPD and\\n complicated pulmonary history with prolonged tracheostomy with recent\\n decannulation and subsequent fistula closure (on ENT service at \\n on ) with complicated MRSA PNA presented with worsened respiratory\\n distress. Now s/p bronchoscopy which did not reveal significant upper\\n airway stenosis.\\n .\\n 1. Respiratory failure. Patient was intubated on after episode of\\n flash pulmonary edema while being bathed and concern for upper airway\\n obstruction due to previous intubations/trach. Patient also has\\n history of trace aspiration. Copmleted 10 day course for aspiration\\n pneumonia on . Anxiety also contributes to patient\\ns respiratory\\n distress. Bronchoscopy on showed no significant upper airway\\n stenosis. Will need permanent trach if extubation is unsuccessful\\n today.\\n - extubate today\\n - continue nebs\\n - continue home lasix for interstial edema\\n - ativan prn\\n - transition to PO meds if successfully extubated\\n .\\n 2. Hypotension. Patient required pressors while on propofol for\\n sedation. Will wean neo and extubate today. Hopeful that patient will\\n not require pressors when not on sedation.\\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\\n edema/HTN. Troponins have trended down.\\n -continue ASA, BB\\n - consider resuming ACEI tomorrow if hemodynamically stable\\n .\\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\\n on . CXR yesterday showed mild interstitial edema. Currently\\n euvolemic, but will continue home lasix dose. TTE recently done\\n () showed preserved EF with some focal wall motion abnormality.\\n Patient euvolemic and net even overnight without any additional\\n diuretics\\n -continue home lasix\\n -monitor I/Os\\n -Continue BB\\n - holding ACEI until blood pressure stable for 24 hours off pressors\\n .\\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\\n - consider resuming lisinopril in AM\\n 6. COPD.\\n -continue nebs\\n .\\n 7. Depression/anxiety. Patient has significant anxiety.\\n -ativan prn anxiety, caution not to oversedate\\n -Continue home lamotrigine, quetiapine, sertraline\\n .\\n 8. Hyperlipidemia:\\n -Continue statin\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n RIC - 10:00 AM\\n PICC Line - 09:34 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: pantoprazole\\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU care for now\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2138-09-27 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 340446,\n \"text\": \"Chief Complaint: respiratory failure\\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\\n including tracheobronchiomalacia, trach / decannulation, and recent\\n tracheal fistula repair (on ENT service at on ) c/b MRSA\\n pneumonia presenting with respiratory distress\\n 24 Hour Events:\\n INVASIVE VENTILATION - STOP 11:18 AM\\n PICC LINE - STOP 12:48 AM\\n PICC LINE - START 12:52 AM\\n Extubated yesterday. Was on cpap per her request which she uses at\\n home.\\n BP as low as 80s/40s, resolved without intervention.\\n History obtained from Patient\\n Allergies:\\n Heparin Agents\\n Thrombocytopeni\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\\n Vancomycin - 09:03 AM\\n Infusions:\\n Other ICU medications:\\n Lorazepam (Ativan) - 07:50 PM\\n Morphine Sulfate - 08:08 PM\\n Other medications:\\n zoloft, seroquel, aspirin, simvastatin, lamictal, senna, insulin\\n sliding scale, protonix, colace, lasix 40 mg daily, atrovent,\\n albuterol, ativan 0.5 mg IV q6h, morphine 1 mg IV prn\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:49 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: 36.1\\nC (96.9\\n HR: 93 (75 - 93) bpm\\n BP: 122/48(66) {82/40(51) - 143/70(98)} mmHg\\n RR: 18 (15 - 24) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 60 Inch\\n Total In:\\n 523 mL\\n 160 mL\\n PO:\\n TF:\\n IVF:\\n 223 mL\\n Blood products:\\n Total out:\\n 1,620 mL\\n 235 mL\\n Urine:\\n 1,620 mL\\n 235 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,097 mL\\n -75 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n Ventilator mode: Standby\\n FiO2: 70%\\n SpO2: 96%\\n ABG: ///28/\\n Ve: 8.9 L/min\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Anxious\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 10.5 g/dL\\n 369 K/uL\\n 87 mg/dL\\n 1.0 mg/dL\\n 28 mEq/L\\n 3.7 mEq/L\\n 15 mg/dL\\n 104 mEq/L\\n 142 mEq/L\\n 30.3 %\\n 7.7 K/uL\\n [image002.jpg]\\n 09:05 AM\\n 12:45 AM\\n 03:50 AM\\n 11:40 AM\\n 04:25 AM\\n 03:11 AM\\n 03:35 AM\\n WBC\\n 13.1\\n 10.3\\n 8.0\\n 10.4\\n 8.2\\n 7.7\\n Hct\\n 32.3\\n 30.5\\n 27.7\\n 28.3\\n 26.9\\n 30.3\\n Plt\\n 74\\n 423\\n 369\\n Cr\\n 1.3\\n 1.3\\n 1.2\\n 1.2\\n 1.0\\n 1.0\\n TropT\\n 0.03\\n <0.01\\n 0.03\\n 0.13\\n 0.08\\n Glucose\\n 70\\n 168\\n 120\\n 161\\n 205\\n 87\\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.1 mg/dL,\\n Mg++:1.8 mg/dL, PO4:3.2 mg/dL\\n Imaging: CXR: clear\\n Microbiology: C diff negative.\\n Assessment and Plan\\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\\n including tracheobronchiomalacia, trach / decannulation, and recent\\n tracheal fistula repair (on ENT service at on ) c/b MRSA\\n pneumonia presenting with respiratory distress. Suspect mucus plug as\\n the etiology +/- aspiration. Now much improved, s/p extubation\\n yesterday.\\n 1) Respiratory failure: Acute event the other night appears to be due\\n to a mucus plug vs aspiration. No airway pathology seen on rigid\\n bronch.\\n - aspiration precautions\\n - no evidence of pneumonia, off antibiotics\\n - standing inhalers\\n - CPAP prn per home regimen\\n - appreciate ENT & IP input\\n 2) Elevated troponin/Hx CHF: Likely demand in setting of hypotension,\\n now resolving. No ECG changes.\\n - on home dose of lasix\\n - hold anithypertensives given bp 80s/40s overnight\\n 3) F/E/N: Diet per speech/swallow recommendations.\\n 4) Anxiety: ativan prn (home regimen.)\\n ICU Care\\n Nutrition:\\n Comments: advance diet as above\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n PICC Line - 12:52 AM\\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:\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1032156,\n \"text\": \", D. MED MICU-7 10:02 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: OGT placement\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman s/p bronch. new OGT placement\\n REASON FOR THIS EXAMINATION:\\n OGT placement\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: NG tube tip is out of view below the diaphragm likely in the stomach.\\n Improved interstitial pulmonary edema and improved right lower lobe aeration.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1031968,\n \"text\": \" 4:12 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o infiltrate\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with respiratory distress possibly in setting of mucous\\n plugging with\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 10:43 AM\\n 1. Interval worsening of moderate-to-severe interstitial edema.\\n 2. Right basal opacity, developing pneumonia or aspiration are not excluded,\\n repeat radiograph after improvement of edema would be helpful to better\\n delineate the abnormality.\\n ______________________________________________________________________________\\n FINAL REPORT\\n FRONTAL CHEST RADIOGRAPH\\n\\n INDICATION: 67-year-old woman with respiratory distress possibly in the\\n setting of mucus plugging.\\n\\n COMPARISON: Multiple prior studies, most recent dated .\\n\\n FINDINGS: The patient remains intubated, support devices are in unchanged\\n positions. Moderate-to-severe interstitial edema has significantly worsened\\n compared to the most recent prior study. Additionally, there is a patchy\\n right basal opacity, developing pneumonia is not excluded. Left retrocardiac\\n opacity has a more linear shape and may be due to atelectasis. Small pleural\\n effusions are present. There is no pneumothorax.\\n\\n IMPRESSION:\\n 1. Significant worsening of moderate-to-severe interstitial edema.\\n 2. Right basal patchy opacity, developing pneumonia is not excluded, repeat\\n radiograph after resolution of pulmonary edema would help to better delineate\\n the abnormality.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1031969,\n \"text\": \", D. MED MICU-7 4:12 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o infiltrate\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with respiratory distress possibly in setting of mucous\\n plugging with\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate\\n ______________________________________________________________________________\\n PFI REPORT\\n 1. Interval worsening of moderate-to-severe interstitial edema.\\n 2. Right basal opacity, developing pneumonia or aspiration are not excluded,\\n repeat radiograph after improvement of edema would be helpful to better\\n delineate the abnormality.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-23 00:00:00.000\",\n \"description\": \"ESOPHAGUS\",\n \"row_id\": 1031675,\n \"text\": \", C. MED MICU-7 2:40 PM\\n ESOPHAGUS; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: ? evidence reflux, pls perform barium swallow.\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with imaging findings c/w aspiration\\n REASON FOR THIS EXAMINATION:\\n ? evidence reflux, pls perform barium swallow.\\n ______________________________________________________________________________\\n PFI REPORT\\n No evidence for gastroesophageal reflux. Small-to-moderate hiatal hernia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-23 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1031579,\n \"text\": \" 9:40 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: r dl picc 46cm\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with\\n REASON FOR THIS EXAMINATION:\\n r dl picc 46cm\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 10:55 AM\\n 1) Right PICC ends in the low superior vena cava.\\n\\n 2) Bibasal consolidations.\\n\\n 3) Interval improvement in pulmonary edema.\\n ______________________________________________________________________________\\n FINAL REPORT\\n FRONTAL CHEST RADIOGRAPH:\\n\\n INDICATION: 67-year-old woman with CHF, post-PICC placement.\\n\\n COMPARISON: Prior radiograph dated . Note is made of CTA\\n chest dated .\\n\\n FINDINGS: Right PICC ends in the distal superior vena cava. The degree of\\n interstitial edema has improved, area of consolidation in the right lower and\\n middle lobe persists. Left retrocardiac opacity is also present, could be\\n secondary to atelectasis or aspiration. The degree of pulmonary edema has\\n improved. There is no pneumothorax.\\n\\n The osseous structures are demineralized.\\n\\n IMPRESSION: Right PICC ends in the low superior vena cava.\\n\\n Interval decrease in interstitial edema.\\n\\n 3) Bibasal consolidations.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-23 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1031580,\n \"text\": \", C. MED MICU-7 9:40 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: r dl picc 46cm\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with\\n REASON FOR THIS EXAMINATION:\\n r dl picc 46cm\\n ______________________________________________________________________________\\n PFI REPORT\\n 1) Right PICC ends in the low superior vena cava.\\n\\n 2) Bibasal consolidations.\\n\\n 3) Interval improvement in pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1032155,\n \"text\": \" 10:02 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: OGT placement\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman s/p bronch. new OGT placement\\n REASON FOR THIS EXAMINATION:\\n OGT placement\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld 12:51 PM\\n PFI: NG tube tip is out of view below the diaphragm likely in the stomach.\\n Improved interstitial pulmonary edema and improved right lower lobe aeration.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Assess NG tube.\\n\\n NG tube tip is out of view below the diaphragm likely in the stomach. ET tube\\n is in the standard position. Right PICC remains in place. There is no\\n pneumothorax or enlarging pleural effusions. Improved still mild interstitial\\n pulmonary edema. Mild cardiomegaly is stable. Mediastinal wires are aligned.\\n Residual barium is in the colon.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1031423,\n \"text\": \" 8:42 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? chf too\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with sob, on bipap, Rll pna,\\n REASON FOR THIS EXAMINATION:\\n ? chf too\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRX MON 11:28 AM\\n _____ worsening of interstitial edema.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST\\n\\n HISTORY: Short of breath, pneumonia. Possible CHF.\\n\\n One view. Comparison with . Diffusely increased interstitial markings\\n consistent with edema. This finding appears slightly worse. A more focal\\n zone of increased density at the right lung base which may represent\\n pneumonia. The heart and mediastinal structures are unchanged in appearance.\\n The patient is status post median sternotomy as before. A left subclavian\\n line has been withdrawn.\\n\\n IMPRESSION: Increasing interstitial markings consistent with CHF. Asymmetric\\n density at the right base which may represent focal consolidation, unchanged.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1031424,\n \"text\": \", J. EU 8:42 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? chf too\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with sob, on bipap, Rll pna,\\n REASON FOR THIS EXAMINATION:\\n ? chf too\\n ______________________________________________________________________________\\n PFI REPORT\\n _____ worsening of interstitial edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-23 00:00:00.000\",\n \"description\": \"VIDEO OROPHARYNGEAL SWALLOW\",\n \"row_id\": 1031673,\n \"text\": \" 2:38 PM\\n VIDEO OROPHARYNGEAL SWALLOW Clip # \\n Reason: ? silent aspiration\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with imaging findings c/w aspiration\\n REASON FOR THIS EXAMINATION:\\n ? silent aspiration\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Patient is a 67-year-old female with imaging findings consistent\\n with aspiration. Please evaluate for possible aspiration.\\n\\n EXAMINATION: Oropharyngeal video fluoroscopic swallowing evaluation.\\n\\n TECHNIQUE: An oral and pharyngeal swallowing video fluoroscopy was performed\\n today in collaboration with the speech pathology department. Barium of\\n various consistencies were administered to the patient under continuous video\\n fluoroscopic surveillance. Results are as follows.\\n\\n ORAL PHASE: Bolus formation and bolus control were mildly reduced. Premature\\n spillage was noted into the pharynx.\\n\\n PHARYNGEAL PHASE: Velar elevation and upper esophageal sphincter relaxation\\n were within functional limits. Laryngeal elevation and laryngeal valve\\n closure were mild to moderately reduced. Epiglottic deflection was complete.\\n\\n ASPIRATION/PENETRATION: Penetration was noted to occur one time before the\\n swallow secondary to premature spillage inconsistently during the swallow of\\n nectar-thick liquids and thin liquids. The majority of the penetration was\\n able to be cleared spontaneously; however, trace residue still remained, which\\n was effectively cleared by a cued cough.\\n\\n IMPRESSION: Mild-to-moderate oropharyngeal dysphagia with episodes of\\n penetration on nectar thick and thin liquids.\\n\\n Please refer to speech pathology note in OMR from for full report,\\n assessment, and further recommendations.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-23 00:00:00.000\",\n \"description\": \"ESOPHAGUS\",\n \"row_id\": 1031674,\n \"text\": \" 2:40 PM\\n ESOPHAGUS; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: ? evidence reflux, pls perform barium swallow.\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with imaging findings c/w aspiration\\n REASON FOR THIS EXAMINATION:\\n ? evidence reflux, pls perform barium swallow.\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc TUE 4:56 PM\\n No evidence for gastroesophageal reflux. Small-to-moderate hiatal hernia.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Patient is a 67-year-old female with imaging findings consistent\\n with aspiration. With oropharyngeal video swallowing study, _____ no evidence\\n of significant aspiration. Please perform barium swallow to evaluate for\\n possible gastroesophageal reflux.\\n\\n EXAMINATION: Barium esophagram.\\n\\n FINDINGS: Secondary to patient's limited mobility, this study was technically\\n limited, and the patient was placed in a modified AP position. A single\\n contrast barium esophagram was obtained. Barium passes freely through the\\n esophagus. There is no significant aspiration into the airway and no\\n significant retention in the valleculae. No structural abnormalities are\\n detected in the region of the pharynx and cervical esophagus. There were\\n normal primary peristaltic contractions; however, proximal escape was noted.\\n There is a moderate-sized hiatal hernia. There is no associated free\\n gastroesophageal reflux demonstrated.\\n\\n IMPRESSION: No evidence for gastroesophageal reflux. Small- to moderate-\\n sized hiatal hernia.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1031759,\n \"text\": \" 5:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? et tube placement, ? pulm edema, ? evidence new collapse\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with resp distetress s/p intubation\\n REASON FOR THIS EXAMINATION:\\n ? et tube placement, ? pulm edema, ? evidence new collapse\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf WED 11:50 AM\\n Interval development of moderate to severe pulmonary edema and increase in\\n degree of cardiomegaly.\\n ______________________________________________________________________________\\n FINAL REPORT\\n FRONTAL CHEST RADIOGRAPH:\\n\\n INDICATION: 67-year-old woman with respiratory distress post-intubation.\\n\\n COMPARISON: at 9:50.\\n\\n FINDINGS: Since prior study, moderate to severe pulmonary edema has\\n developed. Bilateral small pleural effusions are present. The cardiac\\n silhouette is moderately enlarged. The endotracheal tube ends at the level of\\n the thoracic inlet. Right PICC ends in the mid SVC.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1031760,\n \"text\": \", C. MED MICU-7 5:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? et tube placement, ? pulm edema, ? evidence new collapse\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with resp distetress s/p intubation\\n REASON FOR THIS EXAMINATION:\\n ? et tube placement, ? pulm edema, ? evidence new collapse\\n ______________________________________________________________________________\\n PFI REPORT\\n Interval development of moderate to severe pulmonary edema and increase in\\n degree of cardiomegaly.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1031784,\n \"text\": \" 8:39 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: OGT placement.\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with new OGT placed.\\n REASON FOR THIS EXAMINATION:\\n OGT placement.\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf WED 11:46 AM\\n Significant improvement in now moderate pulmonary edema. Orogastric tube\\n reaches the stomach.\\n ______________________________________________________________________________\\n FINAL REPORT\\n FRONTAL CHEST RADIOGRAPH:\\n\\n INDICATION: 67-year-old woman with new orogastric tube placed.\\n\\n COMPARISON: @ 5:22 a.m.\\n\\n FINDINGS: Now moderate interstitial pulmonary edema has improved in the\\n interval. Patient remains intubated, with the endotracheal tube just below\\n the level of the thoracic inlet. Right PICC ends in the SVC. The enteric\\n tube reaches the stomach. Tiny pleural effusions are present.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1031785,\n \"text\": \", C. MED MICU-7 8:39 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: OGT placement.\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with new OGT placed.\\n REASON FOR THIS EXAMINATION:\\n OGT placement.\\n ______________________________________________________________________________\\n PFI REPORT\\n Significant improvement in now moderate pulmonary edema. Orogastric tube\\n reaches the stomach.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-22 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1031475,\n \"text\": \", C. MED MICU-7 12:17 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: Please perform CTA to eval for PE.\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with h/o recent PNA, s/p trach, tracheomalacia, who presents\\n w/ hypoxemia & respiratory distress. CXR relatively unchanged. Recent\\n surgery.\\n REASON FOR THIS EXAMINATION:\\n Please perform CTA to eval for PE.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n Minimal subcutaneous emphysema along both anterior chest walls. No PE.\\n Aspiration, with fluid in the right lower lobe and right middle lobe bronchi,\\n with atelectasis and patchy consolidation suspicious for pneumonia. There are\\n also findings suspicious for interstitial edema. Discussed with clinical\\n service.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-22 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1031474,\n \"text\": \" 12:17 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: Please perform CTA to eval for PE.\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman with h/o recent PNA, s/p trach, tracheomalacia, who presents\\n w/ hypoxemia & respiratory distress. CXR relatively unchanged. Recent\\n surgery.\\n REASON FOR THIS EXAMINATION:\\n Please perform CTA to eval for PE.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): TKCb MON 3:27 PM\\n Minimal subcutaneous emphysema along both anterior chest walls. No PE.\\n Aspiration, with fluid in the right lower lobe and right middle lobe bronchi,\\n with atelectasis and patchy consolidation suspicious for pneumonia. There are\\n also findings suspicious for interstitial edema. Discussed with clinical\\n service.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CTA OF THE CHEST WITHOUT AND WITH CONTRAST, \\n\\n INDICATION: 67-year-old with history of recent pneumonia, status post\\n tracheostomy. Please evaluate for pulmonary embolism.\\n\\n TECHNIQUE: Initial non-contrast CT of the chest was performed using 5-mm\\n contiguous axial sections. Following the uneventful administration of\\n intravenous contrast, CTA was performed using 2.5-mm contiguous axial\\n sections.\\n\\n Multiplanar reformations were created.\\n\\n FINDINGS: There is no filling defect within the main, right, left, lobar, or\\n segmental branches of the pulmonary artery to suggest the presence of\\n pulmonary embolism.\\n\\n There is fluid within the right lower lobe bronchus, with distal\\n atelectasis/consolidation. Most of the right lower lobe is involved.\\n Similarly, there is fluid within the right middle lobe bronchus. Patchy\\n atelectasis/consolidation is also present within the right middle lobe. Within\\n the posterior segment of the right upper lobe, there are small patches of\\n consolidation, consistent with pneumonia. There is minimal patchy\\n atelectasis/consolidation within the left lower lobe. There is a calcified\\n granuloma within the right upper lobe.\\n\\n There is diffuse interstitial thickening as well as foci of hazy ground glass\\n attenuation, likely representing interstitial edema. There are bilateral,\\n right greater than left small to moderate effusions. Background pattern of\\n emphysema is noted.\\n\\n As described on the previous CT of , there is mediastinal and\\n hilar lymphadenopathy. Subcentimeter axillary nodes are identified.\\n (Over)\\n\\n 12:17 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: Please perform CTA to eval for PE.\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n Postoperative changes from CABG are present. Heart remains enlarged. There\\n is no pericardial effusion.\\n\\n OSSEOUS STRUCTURES: There are no suspicious osseous lesions. Multilevel\\n degenerative changes are noted. There is subcutaneous emphysema along the\\n chest wall bilaterally. Clinical correlation suggested.\\n\\n IMPRESSION:\\n 1. No PE.\\n 2. Findings compatible with aspiration within the right lower and middle lobe\\n bronchi, with atelectasis and airspace consolidation suspicious for pneumonia.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-09-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1032395,\n \"text\": \" 4:14 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old woman recently extubated after episode of flash pulmonary edema.\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH FROM AT 0428 HOURS.\\n\\n HISTORY: Recently extubated after pulmonary edema. Assess for change.\\n\\n COMMENT: AP view of the chest provided. Comparison is made with .\\n\\n Previously seen pulmonary edema has improved. Minimal residual pulmonary\\n vascular congestion. Cardiac silhouette is mildly enlarged. Calcification of\\n aortic arch. Sternotomy wires. The patient's lung apices are obscured by the\\n chin.\\n\\n IMPRESSION: Improvement in pulmonary edema.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2138-09-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 293035,\n \"text\": \"Sinus rhythm. Occasional premature atrial contractions. Compared to the\\nprevious tracing of no change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2138-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 293036,\n \"text\": \"Sinus rhythm\\nShort P-R interval\\nConsider old inferior myocardial infarction\\nExtensive ST-T changes\\nSince previous tracing of the same date, heart rate slower, ventricular ectopic\\nactivity less, ST-T wave abnormalities more apparent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2138-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 293037,\n \"text\": \"Sinus tachycardia with frequent ventricular ectopy. Prior inferior myocardial\\ninfarction. Compared to the previous tracing of the rate has increased.\\nFrequent ventricular ectopy has appeared. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2138-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 293038,\n \"text\": \"Sinus tachycardia with increase in rate as compared with prior tracing\\nof . Prior inferior myocardial infarction. Compared to the previous\\ntracing of there is variation in precordial lead placement. The lateral\\nST-T wave changes have improved. Atrial ectopy persists. No diagnostic\\ninterim change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2138-09-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 293039,\n \"text\": \"Sinus rhythm and frequent atrial ectopy. Prominent Q waves in\\nleads II, III and aVF as recorded on tracing of with\\nST-T wave flattening in these leads. Biphasic T waves in leads V4-V6\\nas previously recorded. However, there has been improvement in\\nthe anterior ischemic appearing ST-T wave changes. Clinical correlation is\\nsuggested.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":23592,"cells":{"subject_id":{"kind":"number","value":15175,"string":"15,175"},"hadm_id":{"kind":"number","value":182061,"string":"182,061"},"target_text":{"kind":"string","value":"48 year old female with history of HIV (last CD4 114 in ) HCV, polysubstance abuse, tobacco use, and multiple admissions for pneumonia over the last few years, who presented to ED from her methadone clinic with lethargy, found here to have a RLL consolidation. In the ICU she was started on Zosyn and azithromycin, and her course was uneventful, with discontinuation of pressors by the following morning. She was transfused 1 U PRBC on after a drop of hematocrit from 26-22 which was likely dilutional. Her hematocrit rose appropriately."},"extractive_notes_summ":{"kind":"string","value":" 1:29 PM CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: Any change in RLL consolidation, evidence of empyema. (Over) 1:29 PM CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: Any change in RLL consolidation, evidence of empyema. PRESEPT CATH IN RIGHT SUBCLAVIAN WITH SCANT AMOUNT BLEEDING AT SITE. SENT TO EW AND WAS FOUND TO BE FEBRILE, HYPOTNESIVE WITH ELEVATED WBC. Interval development of a dependent moderate size left pleural effusion. FINDINGS: Cardiac, mediastinal, and hilar contours are within normal limits. Admitting Diagnosis: HYPOTENSION Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) SINGLE FRONTAL VIEW OF THE CHEST: There is interval placement of a right subclavian line that terminates in the SVC. Small right sided hydropneumothorax. Sinus rhythmIndeterminate frontal QRS axisLow QRS voltages in limb leadsNonspecific ST-T abnormalitiesSince previous tracing of , no significant change PT X3.CV--ARRIVED ON LEVOPHED GTT, 0.33MC/KG/MIN, ATTEMPTED TO WEAN OFF, BUT UNSUCCESSFUL AT THIS TIME. The patchy right lower lung zone opacity is again identified, unchanged compared to the study done three hours prior. HR 60'S, SR, NO ECTOPY NOTED. Shift NotePt had emesis after 1800 methadone and benadryl given. IMPRESSION: Patchy parenchymal opacity at the right lung base which appears improved in the interval. Loculated right sided pleural effusion with enhancing pleural margins suggestive of an empyema. There is a tiny right pleural effusion as well as pleural thickening along the right chest wall. TECHNIQUE: PA & lateral chest. PT WAS RECENTLY D/C' FROM HOSPITAL AND WAS TREATED FOR PNX. Previously evident right basilar parenchymal opacities are again noted, but they appear less confluent in the interval. These appear unchanged from the prior study. Small right pleural effusion and right pleural thickening. There is a small pericardial effusion. O2 via NC on because sat was dropping when pt very sleepy.GI - Tolerating PO's well. Amt is increasing slowly as pt recieved a substantial amt of IVF over the course of the night.Endocrine - BS stable - no insulin coverage needed.Neuro - Initially very lethargic but arousible and X2. There is a small right hydropneumothorax as well. Aware to watch for methadone withdraw. ABD SOFT NONTENDER WITH GOOD BS IN ALL 4 QUDS. R SC TLC intact and patent.Resp - BS cl bilat but course to bases. Methadone quickly absorbed in GI tract, but prior shift nurse unsure of how much might have been absorb before emesis...Pill not noted in emesis. REASON FOR THIS EXAMINATION: Any change in RLL consolidation, evidence of empyema. PT ENROLLED IN MUST PROTOCOL, PRESEPT CATH PLACED AND TRANS TO MICU FOR MONITORING.ALLERGIES--LAMICTALROSNEURO--PT LETHARGIC, SLEEPING WHEN NOT BE STIMULATED. Nsg Progress Note 1900-0700CV - Pt in NSR most of night - had a very short episode of vent bigeminy which resolved itself. CT OF THE CHEST WITH IV CONTRAST: Please note that the study has been presented for redictation on . LACTATE WNL SINCE ARRIVAL TO MICU. Report called to floor nurse and aware that meds held d/t upset stomach. The degree of consolidation in the right lower lobe remains unchanged. No significant change in right lower lobe consolidation. Hypoactive BS and no bowel activity noted.GU - Foley cath draining adequate amt cl yellow urine. INR 1.5.GI--NPO EXCPET FOR MEDS. DENIES N/V AT THIS TIME, STATES HAD SEVERAL EPISODES IN PAST FEW DAYS.RESP--ON 2L NC, LUNGS WITH RHONCI IN BASES, EXPECTORATING SM AMOUNTS THICK YELLOW SECRETIONS, SPEC SNET FOR GS, AND CX, WILL NEED INDUCED SPUTUM FOR PCP IN AM. RECEIVED PO MAG OXIDE FOR MAG 1.4, WILL ALSO RECEIVE IV MAG WHEN AVAILABLE, CA 6.5, WILL RECIEVE IV CALCIUM WHEN AVAILABLE. There is enhancement of the visceral and parietal pleura (a split pleural sign) suggestive of an empyema. No further vent ectopy noted. 11:48 AM CHEST (PORTABLE AP) Clip # Reason: infiltrate, effusion, edema MEDICAL CONDITION: 48 year old HIVpos woman with remote pmh pcp pna, recent adm for pna, now with klonopin intox, temp 101, rhonchorous RLL BS REASON FOR THIS EXAMINATION: infiltrate, effusion, edema WET READ: CCqc TUE 12:32 PM right basilar parenchymal opacity, slightly improved since prior; small right pleural effusion FINAL REPORT HISTORY: 48 y/o HIV+ female with recent history of pneumonia, here with fevers and decreased breath sounds at the right lung base. There is a dependent new left pleural effusion as well. MICU team aware and decided not to given another does of methadone. Again seen are an enlarged right hilar and precarinal lymph nodes. PT WENT TO CLINIC THIS AM AND WAS FOUND TO BE LETHARGIC, PT HAD ADMITTED TO TAKING 3 EXTRA KLONIPIN THIS AM. No new parenchymal opacities are seen. Compared to the prior study, the right sided pleural effusion has slightly increased in size with loculated components. The osseous structures demonstrate old healed right 12th rib fracture. To be transferred to 716 via bed accompanied by RN and co-worker. SVO2 ~80%, CATH CALIBRATED. CREAT 1.5 IN EW.SOCIAL--PT ARRIVED FROM EW WITH CLOTHES, BUT NOT HER PURSE."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2118-10-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":844662,"text":" 11:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate, effusion, edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old HIVpos woman with remote pmh pcp pna, recent adm for pna, now with\n klonopin intox, temp 101, rhonchorous RLL BS\n REASON FOR THIS EXAMINATION:\n infiltrate, effusion, edema\n ______________________________________________________________________________\n WET READ: CCqc TUE 12:32 PM\n right basilar parenchymal opacity, slightly improved since prior; small right\n pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 48 y/o HIV+ female with recent history of pneumonia, here with fevers\n and decreased breath sounds at the right lung base.\n\n TECHNIQUE: PA & lateral chest.\n\n COMPARISON: .\n\n FINDINGS: Cardiac, mediastinal, and hilar contours are within normal limits.\n Previously evident right basilar parenchymal opacities are again noted, but\n they appear less confluent in the interval. No new parenchymal opacities are\n seen. There is a tiny right pleural effusion as well as pleural thickening\n along the right chest wall. Visualized osseous structures are unremarkable.\n\n IMPRESSION: Patchy parenchymal opacity at the right lung base which appears\n improved in the interval. Small right pleural effusion and right\n pleural thickening.\n\n\n"},{"category":"Radiology","chartdate":"2118-10-13 00:00:00.000","description":"CT CHEST W/CONTRAST","row_id":844892,"text":" 1:29 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Any change in RLL consolidation, evidence of empyema.\n Admitting Diagnosis: HYPOTENSION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with RLL pneumonia, recurrent, with previous evidence of\n effusion on chest CT done on , here with fever, rhonchi on R on exam.\n REASON FOR THIS EXAMINATION:\n Any change in RLL consolidation, evidence of empyema.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 48 year-old woman with right lower lobe pneumonia, evaluate for\n empyemia.\n\n COMPARISON: .\n\n TECHNIQUE: Multiple axial images of the chest were obtained following the\n administration of 100 cc of Optiray.\n\n CT OF THE CHEST WITH IV CONTRAST: Please note that the study has been\n presented for redictation on . Compared to the prior study,\n the right sided pleural effusion has slightly increased in size with loculated\n components. There is enhancement of the visceral and parietal pleura (a split\n pleural sign) suggestive of an empyema. There is a small right\n hydropneumothorax as well. There is a dependent new left pleural effusion as\n well.\n\n The degree of consolidation in the right lower lobe remains unchanged. Again\n seen are an enlarged right hilar and precarinal lymph nodes. These appear\n unchanged from the prior study. There is a small pericardial effusion.\n\n A few images through the abdomen demonstrate some fluid in the gallbladder\n fossa. The adrenal glands are not enlarged.\n\n The osseous structures demonstrate old healed right 12th rib fracture.\n\n IMPRESSION: 1. Interval development of a dependent moderate size left pleural\n effusion.\n\n 2. Loculated right sided pleural effusion with enhancing pleural margins\n suggestive of an empyema.\n\n 3. Small right sided hydropneumothorax.\n\n 4. No significant change in right lower lobe consolidation.\n (Over)\n\n 1:29 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Any change in RLL consolidation, evidence of empyema.\n Admitting Diagnosis: HYPOTENSION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2118-10-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":844676,"text":" 1:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check catheter placement\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with low bp and fever\n REASON FOR THIS EXAMINATION:\n check catheter placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status-post new catheter placement.\n\n COMPARISON: Radiograph dated at 12 P.M.\n\n SINGLE FRONTAL VIEW OF THE CHEST: There is interval placement of a right\n subclavian line that terminates in the SVC. There is no pneumothorax. The\n patchy right lower lung zone opacity is again identified, unchanged compared\n to the study done three hours prior. No other interval change.\n\n"},{"category":"ECG","chartdate":"2118-10-11 00:00:00.000","description":"Report","row_id":314164,"text":"Sinus rhythm\nIndeterminate frontal QRS axis\nLow QRS voltages in limb leads\nNonspecific ST-T abnormalities\nSince previous tracing of , no significant change\n\n"},{"category":"Nursing/other","chartdate":"2118-10-12 00:00:00.000","description":"Report","row_id":1459680,"text":"Shift Note\nPt had emesis after 1800 methadone and benadryl given. Methadone quickly absorbed in GI tract, but prior shift nurse unsure of how much might have been absorb before emesis...Pill not noted in emesis. MICU team aware and decided not to given another does of methadone. Report called to floor nurse and aware that meds held d/t upset stomach. Aware to watch for methadone withdraw. Pt currently resting comfortably. To be transferred to 716 via bed accompanied by RN and co-worker.\n"},{"category":"Nursing/other","chartdate":"2118-10-11 00:00:00.000","description":"Report","row_id":1459677,"text":"MICU A ADMIT NOTE\naddendum--Ordered for 1u pc's and hung at 1845, premed with tylenol 650mg po.\n"},{"category":"Nursing/other","chartdate":"2118-10-11 00:00:00.000","description":"Report","row_id":1459678,"text":"MICU A ADMIT NOTE\nPLEASE SEE \nPT SI A 48 YO WOMAN WITH PMED HX OF HIV, HCV, IVDA, NEUROPATHY, ANXIETY, CURRENTLY IN A METHADONE PROGRAM. PT WAS RECENTLY D/C' FROM HOSPITAL AND WAS TREATED FOR PNX. PT WENT TO CLINIC THIS AM AND WAS FOUND TO BE LETHARGIC, PT HAD ADMITTED TO TAKING 3 EXTRA KLONIPIN THIS AM. SENT TO EW AND WAS FOUND TO BE FEBRILE, HYPOTNESIVE WITH ELEVATED WBC. PT ENROLLED IN MUST PROTOCOL, PRESEPT CATH PLACED AND TRANS TO MICU FOR MONITORING.\nALLERGIES--LAMICTAL\n\nROS\nNEURO--PT LETHARGIC, SLEEPING WHEN NOT BE STIMULATED. AWOKE AT 4PM, REQUESTING HER METHADONE DOSE, DOSE CONFIRMED BY HOUSE STAFF, AND GIVEN AT 1700. PT ABLE TO MOVE ALL EXTREMITES EQUALLY AND STRONG, INTACT GAG AND COUGH, PERRL AT 3MM AND BRISK. PT X3.\n\nCV--ARRIVED ON LEVOPHED GTT, 0.33MC/KG/MIN, ATTEMPTED TO WEAN OFF, BUT UNSUCCESSFUL AT THIS TIME. HR 60'S, SR, NO ECTOPY NOTED. CVP 6-12, RECEIVED NS IVF BOLUS 500CC FOR CVP 6, STARTED ON LR GTT AT 150CC/HR X2L. NO SKIN BREAKDOWN NOTED. PRESEPT CATH IN RIGHT SUBCLAVIAN WITH SCANT AMOUNT BLEEDING AT SITE. SVO2 ~80%, CATH CALIBRATED. RECEIVED PO MAG OXIDE FOR MAG 1.4, WILL ALSO RECEIVE IV MAG WHEN AVAILABLE, CA 6.5, WILL RECIEVE IV CALCIUM WHEN AVAILABLE. REPEAT HCT 22, WILL NEED REPEAT LABS AT 10PM. LACTATE WNL SINCE ARRIVAL TO MICU. INR 1.5.\n\nGI--NPO EXCPET FOR MEDS. ABD SOFT NONTENDER WITH GOOD BS IN ALL 4 QUDS. DENIES N/V AT THIS TIME, STATES HAD SEVERAL EPISODES IN PAST FEW DAYS.\n\nRESP--ON 2L NC, LUNGS WITH RHONCI IN BASES, EXPECTORATING SM AMOUNTS THICK YELLOW SECRETIONS, SPEC SNET FOR GS, AND CX, WILL NEED INDUCED SPUTUM FOR PCP IN AM. C/O RIGHT SIDE CHEST PAIN WITH COUGH.\n\nGU--FOLEY CATH IN PLACE, DRAINING CLEAR YELLOW URINE QS. CREAT 1.5 IN EW.\n\nSOCIAL--PT ARRIVED FROM EW WITH CLOTHES, BUT NOT HER PURSE. EW STATES NOT IN THEIR SAFE. AMBULANCE COMPANY CONTACT AND NOT FOUND IN AMBULANCE. CURRENTLY EW STAFF LOOKING FOR PURSE. PT CONCERNED ABOUT CAT AND WHO WILL CARE FOR IT, ATTEMPTING TO CONTACT NEIGHBOR, BUT ADDRESS BOOK IS IN THE PURSE. STATES WOULD LIKE HER SISTER TO BE HER HEALTH CARE PROXY, FORMS PROVIDED.\n"},{"category":"Nursing/other","chartdate":"2118-10-12 00:00:00.000","description":"Report","row_id":1459679,"text":"Nsg Progress Note 1900-0700\n\nCV - Pt in NSR most of night - had a very short episode of vent bigeminy which resolved itself. No further vent ectopy noted. Unable to wean levo off. Given bolus of IVF and kept on 150/hr all night but still requiring levo. Afebrile. Venous sat remained in the 80's throughout the night with no changes. Hct increased to 26.6 after one unit PC's. Mg WNL after recieving Mg last night. R SC TLC intact and patent.\n\nResp - BS cl bilat but course to bases. Strong spont prod cough of thick yellowish phlegm - mod to large amt. O2 via NC on because sat was dropping when pt very sleepy.\n\nGI - Tolerating PO's well. Took all of her evening meds without problem. Hypoactive BS and no bowel activity noted.\n\nGU - Foley cath draining adequate amt cl yellow urine. Amt is increasing slowly as pt recieved a substantial amt of IVF over the course of the night.\n\nEndocrine - BS stable - no insulin coverage needed.\n\nNeuro - Initially very lethargic but arousible and X2. Presently very awake and alert and X3. MAE. Very pleasant and cooperative. Concerned about lost purse. This RN has not heard any news on its whereabouts. Pt also concerned about contacting appropriate people on where she is and how long she will be here.\n\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2118-10-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 844662,\n \"text\": \" 11:48 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: infiltrate, effusion, edema\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old HIVpos woman with remote pmh pcp pna, recent adm for pna, now with\\n klonopin intox, temp 101, rhonchorous RLL BS\\n REASON FOR THIS EXAMINATION:\\n infiltrate, effusion, edema\\n ______________________________________________________________________________\\n WET READ: CCqc TUE 12:32 PM\\n right basilar parenchymal opacity, slightly improved since prior; small right\\n pleural effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 48 y/o HIV+ female with recent history of pneumonia, here with fevers\\n and decreased breath sounds at the right lung base.\\n\\n TECHNIQUE: PA & lateral chest.\\n\\n COMPARISON: .\\n\\n FINDINGS: Cardiac, mediastinal, and hilar contours are within normal limits.\\n Previously evident right basilar parenchymal opacities are again noted, but\\n they appear less confluent in the interval. No new parenchymal opacities are\\n seen. There is a tiny right pleural effusion as well as pleural thickening\\n along the right chest wall. Visualized osseous structures are unremarkable.\\n\\n IMPRESSION: Patchy parenchymal opacity at the right lung base which appears\\n improved in the interval. Small right pleural effusion and right\\n pleural thickening.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2118-10-13 00:00:00.000\",\n \"description\": \"CT CHEST W/CONTRAST\",\n \"row_id\": 844892,\n \"text\": \" 1:29 PM\\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \\n Reason: Any change in RLL consolidation, evidence of empyema.\\n Admitting Diagnosis: HYPOTENSION\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old woman with RLL pneumonia, recurrent, with previous evidence of\\n effusion on chest CT done on , here with fever, rhonchi on R on exam.\\n REASON FOR THIS EXAMINATION:\\n Any change in RLL consolidation, evidence of empyema.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 48 year-old woman with right lower lobe pneumonia, evaluate for\\n empyemia.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Multiple axial images of the chest were obtained following the\\n administration of 100 cc of Optiray.\\n\\n CT OF THE CHEST WITH IV CONTRAST: Please note that the study has been\\n presented for redictation on . Compared to the prior study,\\n the right sided pleural effusion has slightly increased in size with loculated\\n components. There is enhancement of the visceral and parietal pleura (a split\\n pleural sign) suggestive of an empyema. There is a small right\\n hydropneumothorax as well. There is a dependent new left pleural effusion as\\n well.\\n\\n The degree of consolidation in the right lower lobe remains unchanged. Again\\n seen are an enlarged right hilar and precarinal lymph nodes. These appear\\n unchanged from the prior study. There is a small pericardial effusion.\\n\\n A few images through the abdomen demonstrate some fluid in the gallbladder\\n fossa. The adrenal glands are not enlarged.\\n\\n The osseous structures demonstrate old healed right 12th rib fracture.\\n\\n IMPRESSION: 1. Interval development of a dependent moderate size left pleural\\n effusion.\\n\\n 2. Loculated right sided pleural effusion with enhancing pleural margins\\n suggestive of an empyema.\\n\\n 3. Small right sided hydropneumothorax.\\n\\n 4. No significant change in right lower lobe consolidation.\\n (Over)\\n\\n 1:29 PM\\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \\n Reason: Any change in RLL consolidation, evidence of empyema.\\n Admitting Diagnosis: HYPOTENSION\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2118-10-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 844676,\n \"text\": \" 1:05 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: check catheter placement\\n Admitting Diagnosis: HYPOTENSION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 48 year old woman with low bp and fever\\n REASON FOR THIS EXAMINATION:\\n check catheter placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status-post new catheter placement.\\n\\n COMPARISON: Radiograph dated at 12 P.M.\\n\\n SINGLE FRONTAL VIEW OF THE CHEST: There is interval placement of a right\\n subclavian line that terminates in the SVC. There is no pneumothorax. The\\n patchy right lower lung zone opacity is again identified, unchanged compared\\n to the study done three hours prior. No other interval change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2118-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 314164,\n \"text\": \"Sinus rhythm\\nIndeterminate frontal QRS axis\\nLow QRS voltages in limb leads\\nNonspecific ST-T abnormalities\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1459680,\n \"text\": \"Shift Note\\nPt had emesis after 1800 methadone and benadryl given. Methadone quickly absorbed in GI tract, but prior shift nurse unsure of how much might have been absorb before emesis...Pill not noted in emesis. MICU team aware and decided not to given another does of methadone. Report called to floor nurse and aware that meds held d/t upset stomach. Aware to watch for methadone withdraw. Pt currently resting comfortably. To be transferred to 716 via bed accompanied by RN and co-worker.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1459677,\n \"text\": \"MICU A ADMIT NOTE\\naddendum--Ordered for 1u pc's and hung at 1845, premed with tylenol 650mg po.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1459678,\n \"text\": \"MICU A ADMIT NOTE\\nPLEASE SEE \\nPT SI A 48 YO WOMAN WITH PMED HX OF HIV, HCV, IVDA, NEUROPATHY, ANXIETY, CURRENTLY IN A METHADONE PROGRAM. PT WAS RECENTLY D/C' FROM HOSPITAL AND WAS TREATED FOR PNX. PT WENT TO CLINIC THIS AM AND WAS FOUND TO BE LETHARGIC, PT HAD ADMITTED TO TAKING 3 EXTRA KLONIPIN THIS AM. SENT TO EW AND WAS FOUND TO BE FEBRILE, HYPOTNESIVE WITH ELEVATED WBC. PT ENROLLED IN MUST PROTOCOL, PRESEPT CATH PLACED AND TRANS TO MICU FOR MONITORING.\\nALLERGIES--LAMICTAL\\n\\nROS\\nNEURO--PT LETHARGIC, SLEEPING WHEN NOT BE STIMULATED. AWOKE AT 4PM, REQUESTING HER METHADONE DOSE, DOSE CONFIRMED BY HOUSE STAFF, AND GIVEN AT 1700. PT ABLE TO MOVE ALL EXTREMITES EQUALLY AND STRONG, INTACT GAG AND COUGH, PERRL AT 3MM AND BRISK. PT X3.\\n\\nCV--ARRIVED ON LEVOPHED GTT, 0.33MC/KG/MIN, ATTEMPTED TO WEAN OFF, BUT UNSUCCESSFUL AT THIS TIME. HR 60'S, SR, NO ECTOPY NOTED. CVP 6-12, RECEIVED NS IVF BOLUS 500CC FOR CVP 6, STARTED ON LR GTT AT 150CC/HR X2L. NO SKIN BREAKDOWN NOTED. PRESEPT CATH IN RIGHT SUBCLAVIAN WITH SCANT AMOUNT BLEEDING AT SITE. SVO2 ~80%, CATH CALIBRATED. RECEIVED PO MAG OXIDE FOR MAG 1.4, WILL ALSO RECEIVE IV MAG WHEN AVAILABLE, CA 6.5, WILL RECIEVE IV CALCIUM WHEN AVAILABLE. REPEAT HCT 22, WILL NEED REPEAT LABS AT 10PM. LACTATE WNL SINCE ARRIVAL TO MICU. INR 1.5.\\n\\nGI--NPO EXCPET FOR MEDS. ABD SOFT NONTENDER WITH GOOD BS IN ALL 4 QUDS. DENIES N/V AT THIS TIME, STATES HAD SEVERAL EPISODES IN PAST FEW DAYS.\\n\\nRESP--ON 2L NC, LUNGS WITH RHONCI IN BASES, EXPECTORATING SM AMOUNTS THICK YELLOW SECRETIONS, SPEC SNET FOR GS, AND CX, WILL NEED INDUCED SPUTUM FOR PCP IN AM. C/O RIGHT SIDE CHEST PAIN WITH COUGH.\\n\\nGU--FOLEY CATH IN PLACE, DRAINING CLEAR YELLOW URINE QS. CREAT 1.5 IN EW.\\n\\nSOCIAL--PT ARRIVED FROM EW WITH CLOTHES, BUT NOT HER PURSE. EW STATES NOT IN THEIR SAFE. AMBULANCE COMPANY CONTACT AND NOT FOUND IN AMBULANCE. CURRENTLY EW STAFF LOOKING FOR PURSE. PT CONCERNED ABOUT CAT AND WHO WILL CARE FOR IT, ATTEMPTING TO CONTACT NEIGHBOR, BUT ADDRESS BOOK IS IN THE PURSE. STATES WOULD LIKE HER SISTER TO BE HER HEALTH CARE PROXY, FORMS PROVIDED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1459679,\n \"text\": \"Nsg Progress Note 1900-0700\\n\\nCV - Pt in NSR most of night - had a very short episode of vent bigeminy which resolved itself. No further vent ectopy noted. Unable to wean levo off. Given bolus of IVF and kept on 150/hr all night but still requiring levo. Afebrile. Venous sat remained in the 80's throughout the night with no changes. Hct increased to 26.6 after one unit PC's. Mg WNL after recieving Mg last night. R SC TLC intact and patent.\\n\\nResp - BS cl bilat but course to bases. Strong spont prod cough of thick yellowish phlegm - mod to large amt. O2 via NC on because sat was dropping when pt very sleepy.\\n\\nGI - Tolerating PO's well. Took all of her evening meds without problem. Hypoactive BS and no bowel activity noted.\\n\\nGU - Foley cath draining adequate amt cl yellow urine. Amt is increasing slowly as pt recieved a substantial amt of IVF over the course of the night.\\n\\nEndocrine - BS stable - no insulin coverage needed.\\n\\nNeuro - Initially very lethargic but arousible and X2. Presently very awake and alert and X3. MAE. Very pleasant and cooperative. Concerned about lost purse. This RN has not heard any news on its whereabouts. Pt also concerned about contacting appropriate people on where she is and how long she will be here.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":23593,"cells":{"subject_id":{"kind":"number","value":25259,"string":"25,259"},"hadm_id":{"kind":"number","value":171245,"string":"171,245"},"target_text":{"kind":"string","value":"He was admitted to the Trauma Service. Orthopedics was consulted for his bilateral femur fractures for which he underwent intramedullary nail of both. There were no intraoperative complications. He remained in the Trauma ICU for several days for close monitoring and was eventually transferred to the regular nursing unit. He was started on Lovenox postoperatively. A Physical therapy consultation was placed and it was recommended that he be discharged home with services. An Otolaryngology consult was placed for glass in his nose, no surgical intervention was warranted. Saline nasal spray was ordered and he will follow up in clinic as an outpatient. He was also seen by Social work for emotional support and counseling."},"extractive_notes_summ":{"kind":"string","value":"TECHNIQUE: Contiguous axial imaging was performed from the thoracic inlet to the pubic symphysis following the uneventful administration of IV contrast. Proximal thoracic trachea demonstrates 2 discrete foci of air at its right lateral surface. TECHNIQUE: Contiguous axial imaging was performed from the cranial vertex to the foramen magnum without IV contrast. FINDINGS: The heart, lungs, and mediastinum are within normal limits with no evidence of acute cardiopulmonary disease. On the right, there is a comminuted segmental fracture of the proximal femoral diaphysis. Bilateral proximal femoral fractures, no other fracture identified. TRAUMA VIEWS OF THE CHEST AND PELVIS: The cardiomediastinal contour is normal. ; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST BILAT IN O.R.Clip # Reason: BILAT FEMUR FX Admitting Diagnosis: BLUNT TRAUMA;TELEMETRY FINAL REPORT HISTORY: Trauma. The sacroiliac joints are unremarkable. The rectum, prostate, and sigmoid colon are unremarkable. CT ABDOMEN WITH IV CONTRAST: No intra-abdominal hemorrhage, free fluid, or air. FINDINGS: The collapsed bladder with contrast is noted within the pelvis. CT CERVICAL SPINE WITHOUT IV CONTRAST: The skull base to the superior aspect of the T1 vertebral body are imaged. Otherwise, no diagnostic interimchange. No displaced rib fractures or pneumothorax is identified. HEAD CT WITHOUT IV CONTRAST: There is no fracture or hemorrhage. The proximal femurs demonstrate comminuted fractures bilaterally. left ring finger lac, dressing intact.plan- monitor crit, ? On the right, the distal fracture fragments demonstrate lateral displacement of approximately one shaft width. Mucosal thickening in the ethmoid air cells bilaterally is not accompanied by any fracture. The normal cervical lordosis is maintained. No fracture involving the femoral heads, acetabula bilaterally, or remainder of pelvis are identified. Bilateral femoral heads are appropriately located. COMPARISON: Concurrent trauma radiographs. The heart, aorta, and great vessels are unremarkable. Bilateral proximal femoral fractures. Arising from the right lateral aspect of the proximal thoracic trachea, two foci of air within the mediastinum are identified (2:6, 2:9). IMPRESSION: 1) No evidence of fracture, hemorrhage, or other acute traumatic injury. On the left, there is an oblique fracture involving the proximal femoral diaphysis. The anterior superior aspect of the C3 vertebral body demonstrates an osteophyte or ossific density which could possibly relate to prior trauma. There is approximately one shaft width of lateral and posterior displacement of the major distal fracture fragment. The bony thorax is unremarkable. There is a comminuted left proximal femur fracture with medial displacement of the distal fracture fragment. lytes wnl.Skin- bilat femur dsg, D&I, original surgical dsg not to be changed untill POD 2. abrasions to head, and left arm. In the setting of trauma, tracheal injury cannot be entirely excluded, though this injury does not typically occur in isolation either. No rib fractures are identified. There is no pleural or pericardial effusion. There is no evidence of traumatic injury to the more inferior trachea, or bronchi. IMPRESSION: No evidence of acute fracture, alignment abnormality, or other acute traumatic injury. The esophagus follows a normal course on the left anterior surface of the spine. No significant displacement or angulation noted. The distal femur is intact. IMPRESSION: Comminuted fractures of the proximal femurs as detailed above. There is no edema or shift of normally midline structures. There is no mesenteric or retroperitoneal lymphadenopathy. There is no evidence of solid parenchymal organ injury. Incidental note is made of a tiny splenule in the left upper quadrant (2:57). The heart is not enlarged. Although a common site for tracheal diverticula, the size of these foci and their multiplicity are atypical. b/p 138/62. The pelvis and sacrum are intact. There is no fracture, alignment abnormality, or evidence of prevertebral soft tissue swelling. A tiny hypoattenuating lesion in segment 7 of the liver (2:46) is too small to characterize, but likely a cyst. No cervical lymphadenopathy or hematoma is identified. There is no pelvic hemorrhage or fluid collection. CT CHEST WITH IV CONTRAST: There is no evidence of traumatic aortic injury or hematoma or hemorrhage within the mediastinum. 1:19 PM CT C-SPINE W/O CONTRAST Clip # Reason: assess for traumatic injury MEDICAL CONDITION: 43 yo M restrained driver w/ severe pelvis pain, internally rotated R thigh, ext rotated L; seatbelt sign REASON FOR THIS EXAMINATION: assess for traumatic injury No contraindications for IV contrast WET READ: RSRc TUE 2:07 PM No fracture or acute alignment abnormality. 2) Multiple fragments of glass in left naris/proximal nasal cavity. No other fracture identified in the pelvis, sacrum, or bony thorax. The maxillary sinuses bilaterally demonstrate small polyps or mucous retention cysts. No trochanteric fracture, femoral head fracture, acetabular fracture, or other pelvic or sacral fracture is identified. Comminuted bilateral proximal femoral fractures with lateral displacement of the distal fracture fragment on the right, and medial displacement of the distal fracture fragment on the left. 1:18 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: trauma protocol, please obtain images through mid femur give MEDICAL CONDITION: 43 yo M restrained driver w/ severe pelvis pain, internally rotated R thigh, ext rotated L; seatbelt sign REASON FOR THIS EXAMINATION: trauma protocol, please obtain images through mid femur given likelihood of pelvis and/or femur fractures No contraindications for IV contrast WET READ: RSRc TUE 2:06 PM Two foci of air possibly continuous with right lateral aspect of proximal thoracic trachea."},"n_notes":{"kind":"number","value":9,"string":"9"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2144-04-15 00:00:00.000","description":"Report","row_id":1592091,"text":"Admit note\n\n43 yr male involved in MVC. pt stated in ED that his breaks locked and car slid into a pole. pt medflighted to . Ct head- neg, CT-c-spine- neg, Ct torso- bilat femur fx.\n\npmh- MVC C2-C3 fx and Halo, + ETOH, + Cocaine, +smoker.\n\nNKDA\n\n pt had bilat ORIF with IM nailling.\n\nFrom OR at .\n\nneuro- pt alert and oriented X3, consistantly. on CIWA scale, highest score 9. pt has anxiety and some aggiation. is able to be talked down for short periods. very short attention span and short term memory. ativan given TID, and prn. pt on dilaudid PCA .25/6/2.5. states he is having pain but it is much exaggerated by \"aggitation from not being able to drink water\". is able to MAE, but does not lift bilat LE due to pain, and refuses to be turned. c-collar d/c.\n\nCV- HR SR- ST 80's to low 100's. b/p 138/62. + peripheral pulses. skin warm and dry. P-boots and SQ heparin. crit down to 26.4 from 29.5. EKG shows some Q waves, ? old infarct or from cocaine use.\n\nresp- lung sounds clear to coarse. + smoker. o2 weaned off sat mid to high 90's. encouraged to cough and deep breathe, IS given and instructed on use.\n\nGI- NPO but taking lots of ice chips. abd soft, + BS.\n\nGU- foley clear yellow urine. avg 45cc/hr. IVF cont 100cc/hr. lytes wnl.\n\nSkin- bilat femur dsg, D&I, original surgical dsg not to be changed untill POD 2. abrasions to head, and left arm. left ring finger lac, dressing intact.\n\nplan- monitor crit, ? OOB with PT, pt is full weight bearing on bilat LE. ? transfer to floor.\n\n"},{"category":"Radiology","chartdate":"2144-04-18 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1015734,"text":" 8:27 PM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for sources of fever\n Admitting Diagnosis: BLUNT TRAUMA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with fever POD 3 s/p ORIF bilateral femur fx's\n REASON FOR THIS EXAMINATION:\n Please evaluate for sources of fever\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON AT 20:32\n\n INDICATION: Fevers.\n\n FINDINGS: The heart, lungs, and mediastinum are within normal limits with no\n evidence of acute cardiopulmonary disease.\n\n\n"},{"category":"Radiology","chartdate":"2144-04-14 00:00:00.000","description":"BO FEMUR (AP & LAT) BILAT IN O.R.","row_id":1015237,"text":" 9:05 PM\n FEMUR (AP & LAT) BILAT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST BILAT IN O.R.Clip # \n Reason: BILAT FEMUR FX\n Admitting Diagnosis: BLUNT TRAUMA;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n These two examinations consist of eighteen intraoperative radiographs during\n fixation of bilateral femoral fractures. On both sides there are poorly\n assessed intertrochanteric and subtrochanteric fractures which are fixated by\n long intramedullary rods with interlocking nails extending into each femoral\n head as well as distal interlocking screws. This patient has no preoperative\n radiographs on PACS.\n\n"},{"category":"Radiology","chartdate":"2144-04-14 00:00:00.000","description":"B FEMUR (AP & LAT) BILAT","row_id":1015183,"text":" 1:48 PM\n FEMUR (AP & LAT) BILAT; KNEE (2 VIEWS) BILAT Clip # \n Reason: please evaluate fractures\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with gross deformity bilateral thighs\n REASON FOR THIS EXAMINATION:\n please evaluate fractures\n ______________________________________________________________________________\n FINAL REPORT\n AP PELVIS, MULTIPLE VIEWS OF BILATERAL FEMURS, AT 13:53 HOURS:\n\n HISTORY: Question deformity of bilateral thighs.\n\n COMPARISON: None.\n\n FINDINGS:\n\n The collapsed bladder with contrast is noted within the pelvis. There is an\n intraluminal Foley catheter. The pelvis and sacrum are intact. The\n sacroiliac joints are unremarkable. Bilateral femoral heads are appropriately\n located. On the right, there is a comminuted segmental fracture of the\n proximal femoral diaphysis. There is approximately one shaft width of lateral\n and posterior displacement of the major distal fracture fragment. The knee\n joint is grossly aligned. The distal femur is intact. On the left, there is\n an oblique fracture involving the proximal femoral diaphysis. Femoral\n comminution is also noted on this side as well. No significant displacement\n or angulation noted. The left knee joint is grossly appropriately aligned as\n well.\n\n IMPRESSION: Comminuted fractures of the proximal femurs as detailed above.\n\n"},{"category":"Radiology","chartdate":"2144-04-14 00:00:00.000","description":"TRAUMA #2 (AP CXR & PELVIS PORT)","row_id":1015163,"text":" 12:51 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MVC, trauma.\n\n COMPARISON: None available.\n\n TRAUMA VIEWS OF THE CHEST AND PELVIS: The cardiomediastinal contour is\n normal. The heart is not enlarged. The lungs are clear. The bony thorax is\n unremarkable. No displaced rib fractures or pneumothorax is identified.\n\n There is a comminuted left proximal femur fracture with medial displacement of\n the distal fracture fragment. The right femur demonstrates an oblique\n fracture of the proximal femur with lateral angulation of the distal fracture\n fragment. No trochanteric fracture, femoral head fracture, acetabular\n fracture, or other pelvic or sacral fracture is identified.\n\n IMPRESSION:\n 1. Bilateral proximal femoral fractures.\n 2. No other fracture identified in the pelvis, sacrum, or bony thorax.\n\n"},{"category":"Radiology","chartdate":"2144-04-14 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":1015173,"text":" 1:19 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: assess for traumatic injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 yo M restrained driver w/ severe pelvis pain, internally rotated R thigh,\n ext rotated L; seatbelt sign\n REASON FOR THIS EXAMINATION:\n assess for traumatic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc TUE 2:07 PM\n No fracture or acute alignment abnormality.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 43-year-old male restrained driver with pelvic pain. Please\n evaluate for cervical injury.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial imaging was performed from the skull base to the\n cervicothoracic junction. Coronal and sagittal reformations were provided.\n\n CT CERVICAL SPINE WITHOUT IV CONTRAST: The skull base to the superior aspect\n of the T1 vertebral body are imaged. There is no fracture, alignment\n abnormality, or evidence of prevertebral soft tissue swelling. The normal\n cervical lordosis is maintained. The anterior superior aspect of the C3\n vertebral body demonstrates an osteophyte or ossific density which could\n possibly relate to prior trauma. No cervical lymphadenopathy or hematoma is\n identified.\n\n IMPRESSION: No evidence of acute fracture, alignment abnormality, or other\n acute traumatic injury. These findings were posted to the ED dashboard at 2\n p.m., .\n\n\n"},{"category":"Radiology","chartdate":"2144-04-14 00:00:00.000","description":"CT CHEST W/CONTRAST","row_id":1015171,"text":" 1:18 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: trauma protocol, please obtain images through mid femur give\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 yo M restrained driver w/ severe pelvis pain, internally rotated R thigh,\n ext rotated L; seatbelt sign\n REASON FOR THIS EXAMINATION:\n trauma protocol, please obtain images through mid femur given likelihood of\n pelvis and/or femur fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc TUE 2:06 PM\n Two foci of air possibly continuous with right lateral aspect of proximal\n thoracic trachea. Though these may be tracheal diverticula, in setting of\n trauma, and especially before positive pressure ventilation, tracheoscopy for\n tracheal rupture is recommended.\n\n Flattening of IVC and small spleen likely due to intravascular depletion. No\n evidence of solid organ injury or intraabdominal gas or hemorrhage.\n\n Bilateral proximal femoral fractures, no other fracture identified.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 43-year-old male restrained driver with severe pelvic pain and\n bilateral femoral fractures identified on pelvic radiograph. Please evaluate\n for traumatic injury to chest, abdomen, and pelvis.\n\n COMPARISON: Concurrent trauma radiographs.\n\n TECHNIQUE: Contiguous axial imaging was performed from the thoracic inlet to\n the pubic symphysis following the uneventful administration of IV contrast.\n Coronal and sagittal reformations were provided.\n\n CT CHEST WITH IV CONTRAST: There is no evidence of traumatic aortic injury or\n hematoma or hemorrhage within the mediastinum. Arising from the right lateral\n aspect of the proximal thoracic trachea, two foci of air within the\n mediastinum are identified (2:6, 2:9). The esophagus follows a normal course\n on the left anterior surface of the spine. There is no evidence of traumatic\n injury to the more inferior trachea, or bronchi. There is no pleural or\n pericardial effusion. Incidental note is made of subsegmental atelectasis. The\n lungs are otherwise clear. There is no supraclavicular, mediastinal, or\n axillary lymphadenopathy. The heart, aorta, and great vessels are\n unremarkable.\n\n CT ABDOMEN WITH IV CONTRAST: No intra-abdominal hemorrhage, free fluid, or\n air. There is no evidence of solid parenchymal organ injury. A tiny\n hypoattenuating lesion in segment 7 of the liver (2:46) is too small to\n characterize, but likely a cyst. Incidental note is made of a tiny splenule\n in the left upper quadrant (2:57). The remainder of liver, spleen, pancreas,\n adrenal glands, kidneys, ureters, large bowel, and small bowel are\n unremarkable. There is no mesenteric or retroperitoneal lymphadenopathy.\n (Over)\n\n 1:18 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: trauma protocol, please obtain images through mid femur give\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT PELVIS WITH IV CONTRAST: A Foley catheter is in place, and the bladder is\n collapsed. The rectum, prostate, and sigmoid colon are unremarkable. There\n is no pelvic hemorrhage or fluid collection.\n\n The proximal femurs demonstrate comminuted fractures bilaterally. On the\n right, the distal fracture fragments demonstrate lateral displacement of\n approximately one shaft width. On the left, there is medial displacement of\n the distal fracture fragment. No fracture involving the femoral heads,\n acetabula bilaterally, or remainder of pelvis are identified. No rib\n fractures are identified.\n\n IMPRESSION:\n\n 1. Comminuted bilateral proximal femoral fractures with lateral displacement\n of the distal fracture fragment on the right, and medial displacement of the\n distal fracture fragment on the left.\n\n 2. Proximal thoracic trachea demonstrates 2 discrete foci of air at its right\n lateral surface. Although a common site for tracheal diverticula, the size of\n these foci and their multiplicity are atypical. In the setting of trauma,\n tracheal injury cannot be entirely excluded, though this injury does not\n typically occur in isolation either. Given the inevitability of positive\n pressure ventilation for orthopedic surgery, tracheal injury must be assumed\n until proven otherwise. likely by direct visualization (tracheoscopy).\n\n These findings were posted to the ED dashboard and discussed with Dr. \n at 2:00 p.m. and 2:25 p.m. respectively, .\n\n"},{"category":"Radiology","chartdate":"2144-04-14 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1015172,"text":" 1:19 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for traumatic injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 yo M restrained driver w/ severe pelvis pain, internally rotated R thigh,\n ext rotated L; seatbelt sign\n REASON FOR THIS EXAMINATION:\n assess for traumatic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc TUE 2:07 PM\n No hemorrhage, edema, or cranial fracture. Left nares demonstrates multiple\n fragments of glass.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 43-year-old male restrained driver with severe pelvic pain. Please\n evaluate for traumatic injury.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial imaging was performed from the cranial vertex to\n the foramen magnum without IV contrast.\n\n HEAD CT WITHOUT IV CONTRAST: There is no fracture or hemorrhage. There is no\n edema or shift of normally midline structures. The ventricles and sulci are\n normal in size and configuration. Mucosal thickening in the ethmoid air cells\n bilaterally is not accompanied by any fracture. The maxillary sinuses\n bilaterally demonstrate small polyps or mucous retention cysts. The left\n naris demonstrates approximately 5 square or rectangular 3 mm fragments of\n apparently leaded glass.\n\n IMPRESSION:\n 1) No evidence of fracture, hemorrhage, or other acute traumatic injury.\n 2) Multiple fragments of glass in left naris/proximal nasal cavity. These\n findings were discussed with the trauma surgery resident and entered into the\n ED dashboard at 2 p.m., .\n\n\n"},{"category":"ECG","chartdate":"2144-04-14 00:00:00.000","description":"Report","row_id":184768,"text":"Sinus rhythm. Baseline artifact. Normal tracing. Compared to the previous\ntracing of the rate is increased. Otherwise, no diagnostic interim\nchange.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1592091,\n \"text\": \"Admit note\\n\\n43 yr male involved in MVC. pt stated in ED that his breaks locked and car slid into a pole. pt medflighted to . Ct head- neg, CT-c-spine- neg, Ct torso- bilat femur fx.\\n\\npmh- MVC C2-C3 fx and Halo, + ETOH, + Cocaine, +smoker.\\n\\nNKDA\\n\\n pt had bilat ORIF with IM nailling.\\n\\nFrom OR at .\\n\\nneuro- pt alert and oriented X3, consistantly. on CIWA scale, highest score 9. pt has anxiety and some aggiation. is able to be talked down for short periods. very short attention span and short term memory. ativan given TID, and prn. pt on dilaudid PCA .25/6/2.5. states he is having pain but it is much exaggerated by \\\"aggitation from not being able to drink water\\\". is able to MAE, but does not lift bilat LE due to pain, and refuses to be turned. c-collar d/c.\\n\\nCV- HR SR- ST 80's to low 100's. b/p 138/62. + peripheral pulses. skin warm and dry. P-boots and SQ heparin. crit down to 26.4 from 29.5. EKG shows some Q waves, ? old infarct or from cocaine use.\\n\\nresp- lung sounds clear to coarse. + smoker. o2 weaned off sat mid to high 90's. encouraged to cough and deep breathe, IS given and instructed on use.\\n\\nGI- NPO but taking lots of ice chips. abd soft, + BS.\\n\\nGU- foley clear yellow urine. avg 45cc/hr. IVF cont 100cc/hr. lytes wnl.\\n\\nSkin- bilat femur dsg, D&I, original surgical dsg not to be changed untill POD 2. abrasions to head, and left arm. left ring finger lac, dressing intact.\\n\\nplan- monitor crit, ? OOB with PT, pt is full weight bearing on bilat LE. ? transfer to floor.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-18 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1015734,\n \"text\": \" 8:27 PM\\n CHEST (PA & LAT) Clip # \\n Reason: Please evaluate for sources of fever\\n Admitting Diagnosis: BLUNT TRAUMA;TELEMETRY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with fever POD 3 s/p ORIF bilateral femur fx's\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for sources of fever\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL CHEST ON AT 20:32\\n\\n INDICATION: Fevers.\\n\\n FINDINGS: The heart, lungs, and mediastinum are within normal limits with no\\n evidence of acute cardiopulmonary disease.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-14 00:00:00.000\",\n \"description\": \"BO FEMUR (AP & LAT) BILAT IN O.R.\",\n \"row_id\": 1015237,\n \"text\": \" 9:05 PM\\n FEMUR (AP & LAT) BILAT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST BILAT IN O.R.Clip # \\n Reason: BILAT FEMUR FX\\n Admitting Diagnosis: BLUNT TRAUMA;TELEMETRY\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Trauma.\\n\\n These two examinations consist of eighteen intraoperative radiographs during\\n fixation of bilateral femoral fractures. On both sides there are poorly\\n assessed intertrochanteric and subtrochanteric fractures which are fixated by\\n long intramedullary rods with interlocking nails extending into each femoral\\n head as well as distal interlocking screws. This patient has no preoperative\\n radiographs on PACS.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-14 00:00:00.000\",\n \"description\": \"B FEMUR (AP & LAT) BILAT\",\n \"row_id\": 1015183,\n \"text\": \" 1:48 PM\\n FEMUR (AP & LAT) BILAT; KNEE (2 VIEWS) BILAT Clip # \\n Reason: please evaluate fractures\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 year old man with gross deformity bilateral thighs\\n REASON FOR THIS EXAMINATION:\\n please evaluate fractures\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP PELVIS, MULTIPLE VIEWS OF BILATERAL FEMURS, AT 13:53 HOURS:\\n\\n HISTORY: Question deformity of bilateral thighs.\\n\\n COMPARISON: None.\\n\\n FINDINGS:\\n\\n The collapsed bladder with contrast is noted within the pelvis. There is an\\n intraluminal Foley catheter. The pelvis and sacrum are intact. The\\n sacroiliac joints are unremarkable. Bilateral femoral heads are appropriately\\n located. On the right, there is a comminuted segmental fracture of the\\n proximal femoral diaphysis. There is approximately one shaft width of lateral\\n and posterior displacement of the major distal fracture fragment. The knee\\n joint is grossly aligned. The distal femur is intact. On the left, there is\\n an oblique fracture involving the proximal femoral diaphysis. Femoral\\n comminution is also noted on this side as well. No significant displacement\\n or angulation noted. The left knee joint is grossly appropriately aligned as\\n well.\\n\\n IMPRESSION: Comminuted fractures of the proximal femurs as detailed above.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-14 00:00:00.000\",\n \"description\": \"TRAUMA #2 (AP CXR & PELVIS PORT)\",\n \"row_id\": 1015163,\n \"text\": \" 12:51 PM\\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \\n Reason: TRAUMA\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: MVC, trauma.\\n\\n COMPARISON: None available.\\n\\n TRAUMA VIEWS OF THE CHEST AND PELVIS: The cardiomediastinal contour is\\n normal. The heart is not enlarged. The lungs are clear. The bony thorax is\\n unremarkable. No displaced rib fractures or pneumothorax is identified.\\n\\n There is a comminuted left proximal femur fracture with medial displacement of\\n the distal fracture fragment. The right femur demonstrates an oblique\\n fracture of the proximal femur with lateral angulation of the distal fracture\\n fragment. No trochanteric fracture, femoral head fracture, acetabular\\n fracture, or other pelvic or sacral fracture is identified.\\n\\n IMPRESSION:\\n 1. Bilateral proximal femoral fractures.\\n 2. No other fracture identified in the pelvis, sacrum, or bony thorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-14 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 1015173,\n \"text\": \" 1:19 PM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: assess for traumatic injury\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 yo M restrained driver w/ severe pelvis pain, internally rotated R thigh,\\n ext rotated L; seatbelt sign\\n REASON FOR THIS EXAMINATION:\\n assess for traumatic injury\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: RSRc TUE 2:07 PM\\n No fracture or acute alignment abnormality.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 43-year-old male restrained driver with pelvic pain. Please\\n evaluate for cervical injury.\\n\\n COMPARISON: None available.\\n\\n TECHNIQUE: Contiguous axial imaging was performed from the skull base to the\\n cervicothoracic junction. Coronal and sagittal reformations were provided.\\n\\n CT CERVICAL SPINE WITHOUT IV CONTRAST: The skull base to the superior aspect\\n of the T1 vertebral body are imaged. There is no fracture, alignment\\n abnormality, or evidence of prevertebral soft tissue swelling. The normal\\n cervical lordosis is maintained. The anterior superior aspect of the C3\\n vertebral body demonstrates an osteophyte or ossific density which could\\n possibly relate to prior trauma. No cervical lymphadenopathy or hematoma is\\n identified.\\n\\n IMPRESSION: No evidence of acute fracture, alignment abnormality, or other\\n acute traumatic injury. These findings were posted to the ED dashboard at 2\\n p.m., .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-14 00:00:00.000\",\n \"description\": \"CT CHEST W/CONTRAST\",\n \"row_id\": 1015171,\n \"text\": \" 1:18 PM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: trauma protocol, please obtain images through mid femur give\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 yo M restrained driver w/ severe pelvis pain, internally rotated R thigh,\\n ext rotated L; seatbelt sign\\n REASON FOR THIS EXAMINATION:\\n trauma protocol, please obtain images through mid femur given likelihood of\\n pelvis and/or femur fractures\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: RSRc TUE 2:06 PM\\n Two foci of air possibly continuous with right lateral aspect of proximal\\n thoracic trachea. Though these may be tracheal diverticula, in setting of\\n trauma, and especially before positive pressure ventilation, tracheoscopy for\\n tracheal rupture is recommended.\\n\\n Flattening of IVC and small spleen likely due to intravascular depletion. No\\n evidence of solid organ injury or intraabdominal gas or hemorrhage.\\n\\n Bilateral proximal femoral fractures, no other fracture identified.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 43-year-old male restrained driver with severe pelvic pain and\\n bilateral femoral fractures identified on pelvic radiograph. Please evaluate\\n for traumatic injury to chest, abdomen, and pelvis.\\n\\n COMPARISON: Concurrent trauma radiographs.\\n\\n TECHNIQUE: Contiguous axial imaging was performed from the thoracic inlet to\\n the pubic symphysis following the uneventful administration of IV contrast.\\n Coronal and sagittal reformations were provided.\\n\\n CT CHEST WITH IV CONTRAST: There is no evidence of traumatic aortic injury or\\n hematoma or hemorrhage within the mediastinum. Arising from the right lateral\\n aspect of the proximal thoracic trachea, two foci of air within the\\n mediastinum are identified (2:6, 2:9). The esophagus follows a normal course\\n on the left anterior surface of the spine. There is no evidence of traumatic\\n injury to the more inferior trachea, or bronchi. There is no pleural or\\n pericardial effusion. Incidental note is made of subsegmental atelectasis. The\\n lungs are otherwise clear. There is no supraclavicular, mediastinal, or\\n axillary lymphadenopathy. The heart, aorta, and great vessels are\\n unremarkable.\\n\\n CT ABDOMEN WITH IV CONTRAST: No intra-abdominal hemorrhage, free fluid, or\\n air. There is no evidence of solid parenchymal organ injury. A tiny\\n hypoattenuating lesion in segment 7 of the liver (2:46) is too small to\\n characterize, but likely a cyst. Incidental note is made of a tiny splenule\\n in the left upper quadrant (2:57). The remainder of liver, spleen, pancreas,\\n adrenal glands, kidneys, ureters, large bowel, and small bowel are\\n unremarkable. There is no mesenteric or retroperitoneal lymphadenopathy.\\n (Over)\\n\\n 1:18 PM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: trauma protocol, please obtain images through mid femur give\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n CT PELVIS WITH IV CONTRAST: A Foley catheter is in place, and the bladder is\\n collapsed. The rectum, prostate, and sigmoid colon are unremarkable. There\\n is no pelvic hemorrhage or fluid collection.\\n\\n The proximal femurs demonstrate comminuted fractures bilaterally. On the\\n right, the distal fracture fragments demonstrate lateral displacement of\\n approximately one shaft width. On the left, there is medial displacement of\\n the distal fracture fragment. No fracture involving the femoral heads,\\n acetabula bilaterally, or remainder of pelvis are identified. No rib\\n fractures are identified.\\n\\n IMPRESSION:\\n\\n 1. Comminuted bilateral proximal femoral fractures with lateral displacement\\n of the distal fracture fragment on the right, and medial displacement of the\\n distal fracture fragment on the left.\\n\\n 2. Proximal thoracic trachea demonstrates 2 discrete foci of air at its right\\n lateral surface. Although a common site for tracheal diverticula, the size of\\n these foci and their multiplicity are atypical. In the setting of trauma,\\n tracheal injury cannot be entirely excluded, though this injury does not\\n typically occur in isolation either. Given the inevitability of positive\\n pressure ventilation for orthopedic surgery, tracheal injury must be assumed\\n until proven otherwise. likely by direct visualization (tracheoscopy).\\n\\n These findings were posted to the ED dashboard and discussed with Dr. \\n at 2:00 p.m. and 2:25 p.m. respectively, .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-14 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1015172,\n \"text\": \" 1:19 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: assess for traumatic injury\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 43 yo M restrained driver w/ severe pelvis pain, internally rotated R thigh,\\n ext rotated L; seatbelt sign\\n REASON FOR THIS EXAMINATION:\\n assess for traumatic injury\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: RSRc TUE 2:07 PM\\n No hemorrhage, edema, or cranial fracture. Left nares demonstrates multiple\\n fragments of glass.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 43-year-old male restrained driver with severe pelvic pain. Please\\n evaluate for traumatic injury.\\n\\n COMPARISON: None available.\\n\\n TECHNIQUE: Contiguous axial imaging was performed from the cranial vertex to\\n the foramen magnum without IV contrast.\\n\\n HEAD CT WITHOUT IV CONTRAST: There is no fracture or hemorrhage. There is no\\n edema or shift of normally midline structures. The ventricles and sulci are\\n normal in size and configuration. Mucosal thickening in the ethmoid air cells\\n bilaterally is not accompanied by any fracture. The maxillary sinuses\\n bilaterally demonstrate small polyps or mucous retention cysts. The left\\n naris demonstrates approximately 5 square or rectangular 3 mm fragments of\\n apparently leaded glass.\\n\\n IMPRESSION:\\n 1) No evidence of fracture, hemorrhage, or other acute traumatic injury.\\n 2) Multiple fragments of glass in left naris/proximal nasal cavity. These\\n findings were discussed with the trauma surgery resident and entered into the\\n ED dashboard at 2 p.m., .\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 184768,\n \"text\": \"Sinus rhythm. Baseline artifact. Normal tracing. Compared to the previous\\ntracing of the rate is increased. Otherwise, no diagnostic interim\\nchange.\\n\\n\"\n }\n]"}}},{"rowIdx":23594,"cells":{"subject_id":{"kind":"number","value":69469,"string":"69,469"},"hadm_id":{"kind":"number","value":179397,"string":"179,397"},"target_text":{"kind":"string","value":"82 y/o F with hypertension, atrial fibrillation, remote seizure disorder and thyroidectomy, past episodes of self-neglect, presenting to ED after several days of immobilization fall at home. . #. Atrial fibrillation: Likely withdrawal of dual rate control with diltiazem and metoprolol in addition to significant dehydration while the patient was on the floor of her home. The patient was transferred to the ICU for rate control with a diltiazem drip, to which she responded. Ultimately was able to control rate on the drip, with hemodynamic stablitiy (mildly elevated blood pressures). Was transferred to the floor on a PO regimen of diltiazem and metoprolol similar to her home regimen. On telemetry, patient was noted to have atrial fibrillation, mostly in 50s-60s, with occasional asymptomatic bradycardia to 40s. The patient did not have any further episodes of Afib with RVR on the floor. She was hemodynamically stable, and was discharged on her home dose of diltiazem and 50 mg of metoprolol , as opposed to 100 mg , given her asymptomatic bradycardia."},"extractive_notes_summ":{"kind":"string","value":"Patchy retrocardiac opacity is noted. Consider left ventricularhypertrophy with repolarization abnormality. There is right-sided bullosa with left nasal septum deviation. There is mild left-sided nasal septum deviation. Enlarged left thyroid gland. Nonspecidfic sub-cm hypodense skull lesions in the frontal bone (pls compare to prior if available). Multilevel degenerative changes with moderate-to-severe neural foraminal narrowing, disc space narrowing and minimal anterior and posterior disc osteophyte complexes causing minimal narrowing of the spinal canal are noted. There is a lacunar infarct in the left basal ganglia, just adjacent to the left lateral ventricle (2:18). Enlarged left thyroid gland, likely multinodular goiter, but clinical correlation recommended. Atrial fibrillation. Mild prominence of the ventricles and cerebral sulci is compatible with age-appropriate atrophy. Mild mucosal sinus disease is again noted. Mild mucosal thickening in the maxillary sinuses, left more than right, is noted. A subcentimeter hypodense skull lesion in the left frontal bone just superior to the orbit (3:19) is nonspecific. osteopenia. Minimal anterolisthesis of C4 on C5 is likely degenerative. Normal cervical spine lordosis is preserved. Nonspecific hypodense bony lesions in the frontal bone. The aorta is calcified and tortuous. l thyroid mass. Fibrotic changes in bilateral lung apices, most likely related to prior granulomatous disease. Large left thyroid lobe and clips in the right thyroid bed are again noted. Periventricular and subcortical white matter hypodensities are compatible with chronic small vessel ischemic disease. Moderate mucosal thickening in the ethmoid sinus air cells is also noted. SINGLE FRONTAL VIEW OF THE CHEST: Please note that this exam is limited as the left costophrenic angle was not included in the image. NON-CONTRAST CT OF THE CERVICAL SPINE: Bones are osteopenic. Prevertebral soft tissues are not thickened. The patient is status post right thyroid lobe resection with enlargement of the left lobe and coarse calcifications. There is right-sided bullosa containing some mucosal secretions. Correlation with history of malignancy and comparison with prior CTs if available is recommended. Fibrotic changes with bronchiectasis and calcification in both lung apices, possibly related to prior granulomatous disease are noted. COMPARISON: Thyroid ultrasound from . fibrotic changes in lung apices. IMPRESSION: 1. IMPRESSION: 1. Known fibrotic changes are again noted within bilateral lung apices, better seen on cervical spine CT from same date. IMPRESSION: Retrocardiac atelectasis or pneumonia. Atrial fibrillation with rapid ventricular response. Cardiomegaly. No evidence of acute intracranial injury. COMPARISON: None. COMPARISON: None. Clinical correlationis suggested.TRACING #2 Atherosclerotic calcifications of the carotid artery are severe. No evidence of acute injury to the cervical spine. change. No previous tracing available forcomparison.TRACING #1 Since the previous tracing the rate has decreased.QRS voltage has increased and is probably more apparent. There is no pneumothorax or right-sided pleural effusion. There is also mild mucosal thickening in the sphenoid sinuses. 2. 2. NON-CONTRAST HEAD CT: There is no intracranial hemorrhage, mass effect, or -white matter differentiation abnormality. Orbits and globes are unremarkable. There is no vertebral body height loss. 3. Imaged mastoid air cells are clear. Heart is severely enlarged. There is no fracture. There is no evidence of fracture. mucosal sinus dz FINAL REPORT REASON FOR EXAM: Status post fall. 3:51 PM CHEST (SINGLE VIEW) Clip # Reason: eval for infiltrate MEDICAL CONDITION: 82 year old woman found down REASON FOR THIS EXAMINATION: eval for infiltrate FINAL REPORT REASON FOR EXAM: Found down. FINAL REPORT REASON FOR EXAM: Status post fall. 12:29 PM CT C-SPINE W/O CONTRAST Clip # Reason: fx MEDICAL CONDITION: 82 year old woman with s/p fall REASON FOR THIS EXAMINATION: fx No contraindications for IV contrast WET READ: 4:18 PM No fx."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2119-11-09 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1158090,"text":" 12:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 4:03 PM\n No ICH. Nonspecidfic sub-cm hypodense skull lesions in the frontal bone (pls\n compare to prior if available). mucosal sinus dz\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Status post fall.\n\n COMPARISON: None.\n\n NON-CONTRAST HEAD CT: There is no intracranial hemorrhage, mass effect, or\n -white matter differentiation abnormality. Mild prominence of the\n ventricles and cerebral sulci is compatible with age-appropriate atrophy.\n Periventricular and subcortical white matter hypodensities are compatible with\n chronic small vessel ischemic disease. There is a lacunar infarct in the left\n basal ganglia, just adjacent to the left lateral ventricle (2:18). There is\n no fracture. There is right-sided bullosa containing some mucosal\n secretions. There is mild left-sided nasal septum deviation. Mild mucosal\n thickening in the maxillary sinuses, left more than right, is noted. There is\n also mild mucosal thickening in the sphenoid sinuses. Moderate mucosal\n thickening in the ethmoid sinus air cells is also noted. Orbits and globes\n are unremarkable. Imaged mastoid air cells are clear. A subcentimeter\n hypodense skull lesion in the left frontal bone just superior to the orbit\n (3:19) is nonspecific.\n\n IMPRESSION:\n 1. No evidence of acute intracranial injury.\n 2. Nonspecific hypodense bony lesions in the frontal bone. Correlation with\n history of malignancy and comparison with prior CTs if available is\n recommended.\n\n"},{"category":"Radiology","chartdate":"2119-11-09 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":1158092,"text":" 12:29 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 4:18 PM\n No fx. osteopenia. change. l thyroid mass. fibrotic changes in lung\n apices.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Status post fall.\n\n COMPARISON: Thyroid ultrasound from .\n\n NON-CONTRAST CT OF THE CERVICAL SPINE: Bones are osteopenic. There is no\n evidence of fracture. Minimal anterolisthesis of C4 on C5 is likely\n degenerative. Normal cervical spine lordosis is preserved. There is no\n vertebral body height loss. Multilevel degenerative changes with\n moderate-to-severe neural foraminal narrowing, disc space narrowing and\n minimal anterior and posterior disc osteophyte complexes causing minimal\n narrowing of the spinal canal are noted. Prevertebral soft tissues are not\n thickened. Mild mucosal sinus disease is again noted. The patient is status\n post right thyroid lobe resection with enlargement of the left lobe and coarse\n calcifications. Fibrotic changes with bronchiectasis and calcification in\n both lung apices, possibly related to prior granulomatous disease are noted.\n Atherosclerotic calcifications of the carotid artery are severe. There is\n right-sided bullosa with left nasal septum deviation.\n\n\n IMPRESSION:\n 1. No evidence of acute injury to the cervical spine.\n\n 2. Enlarged left thyroid gland, likely multinodular goiter, but clinical\n correlation recommended.\n\n 3. Fibrotic changes in bilateral lung apices, most likely related to prior\n granulomatous disease.\n\n"},{"category":"Radiology","chartdate":"2119-11-09 00:00:00.000","description":"CHEST (SINGLE VIEW)","row_id":1158132,"text":" 3:51 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman found down\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Found down.\n\n COMPARISON: None.\n\n SINGLE FRONTAL VIEW OF THE CHEST: Please note that this exam is limited as\n the left costophrenic angle was not included in the image. Heart is severely\n enlarged. The aorta is calcified and tortuous. Patchy retrocardiac opacity\n is noted. Known fibrotic changes are again noted within bilateral lung\n apices, better seen on cervical spine CT from same date. Large left thyroid\n lobe and clips in the right thyroid bed are again noted. There is no\n pneumothorax or right-sided pleural effusion.\n\n IMPRESSION: Retrocardiac atelectasis or pneumonia. Cardiomegaly. Enlarged left\n thyroid gland.\n\n\n"},{"category":"ECG","chartdate":"2119-11-09 00:00:00.000","description":"Report","row_id":142897,"text":"Atrial fibrillation. Since the previous tracing the rate has decreased.\nQRS voltage has increased and is probably more apparent. Clinical correlation\nis suggested.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2119-11-09 00:00:00.000","description":"Report","row_id":142898,"text":"Atrial fibrillation with rapid ventricular response. Consider left ventricular\nhypertrophy with repolarization abnormality. No previous tracing available for\ncomparison.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2119-11-09 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1158090,\n \"text\": \" 12:26 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ICH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with s/p fall\\n REASON FOR THIS EXAMINATION:\\n ICH\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 4:03 PM\\n No ICH. Nonspecidfic sub-cm hypodense skull lesions in the frontal bone (pls\\n compare to prior if available). mucosal sinus dz\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Status post fall.\\n\\n COMPARISON: None.\\n\\n NON-CONTRAST HEAD CT: There is no intracranial hemorrhage, mass effect, or\\n -white matter differentiation abnormality. Mild prominence of the\\n ventricles and cerebral sulci is compatible with age-appropriate atrophy.\\n Periventricular and subcortical white matter hypodensities are compatible with\\n chronic small vessel ischemic disease. There is a lacunar infarct in the left\\n basal ganglia, just adjacent to the left lateral ventricle (2:18). There is\\n no fracture. There is right-sided bullosa containing some mucosal\\n secretions. There is mild left-sided nasal septum deviation. Mild mucosal\\n thickening in the maxillary sinuses, left more than right, is noted. There is\\n also mild mucosal thickening in the sphenoid sinuses. Moderate mucosal\\n thickening in the ethmoid sinus air cells is also noted. Orbits and globes\\n are unremarkable. Imaged mastoid air cells are clear. A subcentimeter\\n hypodense skull lesion in the left frontal bone just superior to the orbit\\n (3:19) is nonspecific.\\n\\n IMPRESSION:\\n 1. No evidence of acute intracranial injury.\\n 2. Nonspecific hypodense bony lesions in the frontal bone. Correlation with\\n history of malignancy and comparison with prior CTs if available is\\n recommended.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2119-11-09 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 1158092,\n \"text\": \" 12:29 PM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with s/p fall\\n REASON FOR THIS EXAMINATION:\\n fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 4:18 PM\\n No fx. osteopenia. change. l thyroid mass. fibrotic changes in lung\\n apices.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Status post fall.\\n\\n COMPARISON: Thyroid ultrasound from .\\n\\n NON-CONTRAST CT OF THE CERVICAL SPINE: Bones are osteopenic. There is no\\n evidence of fracture. Minimal anterolisthesis of C4 on C5 is likely\\n degenerative. Normal cervical spine lordosis is preserved. There is no\\n vertebral body height loss. Multilevel degenerative changes with\\n moderate-to-severe neural foraminal narrowing, disc space narrowing and\\n minimal anterior and posterior disc osteophyte complexes causing minimal\\n narrowing of the spinal canal are noted. Prevertebral soft tissues are not\\n thickened. Mild mucosal sinus disease is again noted. The patient is status\\n post right thyroid lobe resection with enlargement of the left lobe and coarse\\n calcifications. Fibrotic changes with bronchiectasis and calcification in\\n both lung apices, possibly related to prior granulomatous disease are noted.\\n Atherosclerotic calcifications of the carotid artery are severe. There is\\n right-sided bullosa with left nasal septum deviation.\\n\\n\\n IMPRESSION:\\n 1. No evidence of acute injury to the cervical spine.\\n\\n 2. Enlarged left thyroid gland, likely multinodular goiter, but clinical\\n correlation recommended.\\n\\n 3. Fibrotic changes in bilateral lung apices, most likely related to prior\\n granulomatous disease.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2119-11-09 00:00:00.000\",\n \"description\": \"CHEST (SINGLE VIEW)\",\n \"row_id\": 1158132,\n \"text\": \" 3:51 PM\\n CHEST (SINGLE VIEW) Clip # \\n Reason: eval for infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman found down\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Found down.\\n\\n COMPARISON: None.\\n\\n SINGLE FRONTAL VIEW OF THE CHEST: Please note that this exam is limited as\\n the left costophrenic angle was not included in the image. Heart is severely\\n enlarged. The aorta is calcified and tortuous. Patchy retrocardiac opacity\\n is noted. Known fibrotic changes are again noted within bilateral lung\\n apices, better seen on cervical spine CT from same date. Large left thyroid\\n lobe and clips in the right thyroid bed are again noted. There is no\\n pneumothorax or right-sided pleural effusion.\\n\\n IMPRESSION: Retrocardiac atelectasis or pneumonia. Cardiomegaly. Enlarged left\\n thyroid gland.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2119-11-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 142897,\n \"text\": \"Atrial fibrillation. Since the previous tracing the rate has decreased.\\nQRS voltage has increased and is probably more apparent. Clinical correlation\\nis suggested.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2119-11-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 142898,\n \"text\": \"Atrial fibrillation with rapid ventricular response. Consider left ventricular\\nhypertrophy with repolarization abnormality. No previous tracing available for\\ncomparison.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":23595,"cells":{"subject_id":{"kind":"number","value":11204,"string":"11,204"},"hadm_id":{"kind":"number","value":183293,"string":"183,293"},"target_text":{"kind":"string","value":"1. CARDIOVASCULAR: A. CORONARY ARTERY DISEASE: The patient had previous cardiac catheterization five years ago that was within normal limits. The patient had his cardiac enzymes cycled and he ruled out for myocardial infarction. He had a cardiac catheterization on which showed normal coronary arteries. At this time, aspirin was discontinued."},"extractive_notes_summ":{"kind":"string","value":"ABG 7.44/39/93. STARTED ON ATROVENT MDIS. Since the previous tracing sinus rhythm is now seen.Borderline Q-T interval prolongation is noted. There is nopericardial effusion. SGOT,SGPT, T. BILI UP.RESP- CONT. ABG pnd. t/f held for extubation. levoquin IVHR 95-109 AF. He came in at 1.0. LS course lower airways.neuro: pt. (-)1.7liter for . FREQ BOLUSES. ECHO done, EKG done. Since the previous tracing multifocal atrial prematurebeats are seen. EDEMA. ?TRY WEAN VENT AGAIN IN AM. Was given Ativan, MSO4 and Vec. Suction prn. PT WITH SM. K+ 4.2. Mild (1+) mitral regurgitation is seen. DiffuseSt-T wave abnormalities are seen.TRACING #1 Was placed on Hep gtt after bolus, T.L placed. U/O LOW, DRIFTED DOWN TO 1-6CC/HR. WILL WITHDRAW TO DEEP TACTILE STIUMLATION UPPER EXT. ativan weaned off gradually and d/c'd for extubation. SVO2 69. k-3.6, replaced with 40meq iv, repeat 4.0. Consideralso left ventricular hypertrophy. for day.gi- ogt clamped and d/c'd prior to extubation. OCC. sedation decreased.P: change to PSV and assess wakefullness. Chest CT priliminary, neg for PE, disection. follow PAP's, u/o. CHF, RESP FAILURECCU NPNO- TEMP UP TO 102.3 PO, RE'D TYLENOL. ON PROPOFOL AND REQ. BCx2 sent, given rocephin and Vanco. To be ruled out for MI. X4.PULM: PT CONTINUES ON VENT. CCU NPN 2300-0700O: afeb. PAP 52-60/30-34. BP dropped to 80's/50's, MAP 64-66, cont with good diuresis. BLD C+S SENT X1, PERIPHERAL STICK. CCU NPN 3-11PMCV: remains off pressors, BP 90-100/60, HR 120-140 A.fib. LS with fine crackles at bases bilaterally.ID: afebrile. MAP 65-71. milrinone at .38mcq/kg/min. REINFORCE PRN.PLAN- FOLLOW TEMPS, ?WILL NEED ABX. reinforce prn. PT. Sinus rhythm, rate 99. SATS 95-99. Echo done showing systolic dysfunction, no shunt.PMH: HTN, previously on atenolol, stopped himself ~1mo ago.ALL: NKDACV: on Dopa BP 90-110/, weaned from 6ug to 5ug/kg/min. FOLLOW U/O, BUN, CREAT, LFTS. C.O. fent. cont. cont. ABD SOFT/DIST. 5.3/2.2/1200. SBP 80-90S. PAD's up since last diuresis. 40 KCL IV given this am with repeat K+ 4.2. Consider prior anterior myocardial infarction. HR 110-90 NSR. recieved second dose of dig. TITRATION OF DIPRIVAN TO SEDATION. Atrial fibrillation. suctioned for small amt. A rare ventricular premature beat is noted. Sinus rhythm, rate 78. ORDERS TO KEEP MEAN >65. Cont on Milrinone at .38ug/kg/min and amiodarone at .5mg/min. WITH B. K-5.1, RECHECK IN PM 4.6. Since the previous tracing of lateral T waveinversions are less. CCU NSG NOTE: ALT IN CVO: For complete VS see CCU flow sheet.ID: T-max 100R. on milrinone, amiodarone, heparin- same doses. Left axisdeviation. TO MOD. U/O IMPROVED SLIGHTLY THIS PM. PAD 19-22.CVP 7-10 and WEDge 18. u/o 50-60cc/hr.heparin 1000u/hr. Intraventricular conduction delay. PTT HIGH, HEPARIN DECREASED X2 AND HELD FOR 1HR WITH 1ST CHANGE. heart failure, afccu npno- t max 99.3. c+s pnd/neg. Specimen sent for lytes. 30CC/HR. fentanyl d/c'd prior to extubation. DOPA CURRENTLY AT 3.6 MCGS. OGT CLAMPED. ATTEMPT TO WEAN OFF. SEDATED ON DIPRIVAN (SEE VS SCREEN). Coarse atrial fibrillation with a moderate ventricular response. D/C'D AT MIDNOC & NPO-> ? LEVOPHED 4.5MCG/MIN-> CO 4.5/1.95/1227. ECTOPY RESOLVED. wbc 11.5. c+s pnd, sputum oroph. addendumstarted on captopril, tol well. recheck ptt. in and pnd. ON IV LEVOFLOX.ENDO: BS 130->111. A right IJ line is present, tip overlying proximal SVC. abg adeq, later po2 down 68, peep up to 7.5 and abg- 79,39,7.41,0. sats 92-96. l/s sl. CHF and bilateral effusions. k- 4.3. creat 1.0. hct 46.7, plts 93. lfts improved, still elevated. chf, resp failure, afccu npno- t max 100.8 po. however, pt. LEVOPHED STARTED & DOPA WEANED TO OFF. HO AWARE OF HEMODYNAMICS.GI: TF: FS NEPRO 10CC/HR. PTT 61.3. (+) BSA: confusion after extubation good diuresis. BS+. AMTS. gaze traks.TM 100.2R. INTUBATED. EXTUBATION. wakes slightly with repos or sx'ing. HO AWARE.ID: AFEBRILE. contin, gtts per plan. contins. edematous. on levo IV for presumed pnxHR 95-116 AF. follow u/o, lytes. 1.2l u/o responce. BP high, req. bp 80s-90s/. A right- sided central line is identified with tip at the proximal superior vena cava. pt. IMPRESSION: Mild chf with effusions and bibasilar collpase/consolidation. SX FOR SM.-MOD. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. cont. cont. cont. cont. cont. CONT. CONT. CCU NSG NOTE: ALT IN CVS: I'm in the \".O: For complete VS see ccu flow sheet.ID: T-max 100.4R. SVO2 71. HO CALLED->WEAN DOPA AS TOL. Probable residual small right pleural effusion. C.O. An endotracheal tube is identified in place. CA,MG,PO4 SENT. Held further fluid boluses. k-4.7. When pt awake, is out of sinc with vent, RR in 30's. ABG 7.43/38/91/26 97% SAT.CARDIAC: HR 93-110 AF. prod. pt consult to eval strength, etc. MG 1.6->TREATED WITH MGS04 2GMS PB X1. No bm.RENAL: Creat down to 1.1. PAD 21-27, CVP 9-14, W 23, CO 6.1/2.64/866. bp maintained at 90s-100s. flora.cv- hr max 122 in am, afib, down to 90s-100s, no vea. ATTEMPTS TO OPEN EYES.RESP: ON VENT: FIO2 WEANED FROM .60->.40 X 700 + AC 10 & 7.5 PEEP. Compared with one day earlier, a right IJ Swan-Ganz catheter is now in place. Will need repeat ABG. BS COURSE AND DIMINISHED AT BASES. co improved to 5.9, ci 2.55, svr down to 719. pa 57/35 down to low 43/20, wedge down to 20. cvp 22-11. cvp changed to rv pattern x2, pa line withdrawn x2 by mds, cvp now with ra trace, pa cont. CVP transduced via T.L., 24. Heparin was also d/c and lovenox begun. CCU NPN 7P-7ACV: Pt has remained in A.fib, rate 140's on Amiodarone gtt at 1mg/min, given another bolus of 150mg at MN, HR down a bit to 120's a.fib, BP has been 80-90/70, MAP 65-75. sat 98. pt calm/sedated at time of rhythm conversion."},"n_notes":{"kind":"number","value":37,"string":"37"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2121-07-02 00:00:00.000","description":"ABDOMEN U.S. (COMPLETE STUDY)","row_id":760334,"text":" 8:15 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: HEP C NEWLY DIAGNOSED CHECK FOR HEPATOMA ASCITES AND CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with new HCV dx.\n REASON FOR THIS EXAMINATION:\n eval for hepatoma, ascites, cirrhosis\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL ULTRASOUND:\n\n INDICATION: Hepatitis C virus.\n\n FINDINGS:\n\n The hepatic parenchyma is coarsened and nodular compatible with cirrhosis. A\n few tiny cysts are visualized in segment 4 measuring up to 7 mm. A tiny\n echogenic focus is seen in the right hepatic lobe, probably representing a\n granuloma. No solid liver lesions are identified. The main portal vein is\n patent with appropriate directional flow. There is no ascites, evidence of\n varices or splenomegaly. The gallbladder is normal in appearance. The common\n duct is not dilated. The visualized pancreas is unremarkable. The kidneys\n are normal in size and architecture with the right kidney measuring 11.7 cm in\n length and the left kidney measuring 11.5 cm in length. There is no\n hydronephrosis, renal mass or calculus.\n\n IMPRESSION:\n\n Cirrhotic liver with no complications of chronic liver disease.\n\n"},{"category":"Echo","chartdate":"2121-06-20 00:00:00.000","description":"Report","row_id":71437,"text":"PATIENT/TEST INFORMATION:\nIndication: Cyanosis on ventilator. R/o large right-left shunt\nBP (mm Hg): 112/76\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 16:39\nTest: Portable TTE(Focused views)\nDoppler: Focused pulse and color flow\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nLEFT VENTRICLE: There is severe global left ventricular hypokinesis.\n\nRIGHT VENTRICLE: There is severe global right ventricular free wall\nhypokinesis.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with one iv injection of 8 ccs\nof agitated normal saline at rest.\n\nConclusions:\nThe left atrium is mildly dilated. There is severe global left ventricular\nhypokinesis. There is severe global right ventricular free wall hypokinesis.\nThe aortic valve leaflets are mildly thickened. The mitral valve leaflets are\nmildly thickened. Mild (1+) mitral regurgitation is seen. There is no\npericardial effusion. A contrast injection at rest did not reveal any right to\nleft shunting.\n\n\n"},{"category":"ECG","chartdate":"2121-06-21 00:00:00.000","description":"Report","row_id":176676,"text":"Sinus rhythm, rate 99. Since the previous tracing the heart rate is somewhat\nfaster. No significant ectopy is noted. The T wave inversions previously seen\nare somewhat less impressive.\nTRACING #4\n\n"},{"category":"ECG","chartdate":"2121-06-20 00:00:00.000","description":"Report","row_id":176677,"text":"Sinus rhythm, rate 88. Since the previous tracing multifocal atrial premature\nbeats are seen. A rare ventricular premature beat is noted. No other\nsignificant changes have occurred.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2121-06-20 00:00:00.000","description":"Report","row_id":176678,"text":"Sinus rhythm, rate 78. Since the previous tracing sinus rhythm is now seen.\nBorderline Q-T interval prolongation is noted. Deep T wave inversions are\npresent in leads I, aVL and across the precordium.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2121-06-20 00:00:00.000","description":"Report","row_id":176679,"text":"Atrial fibrillation, average ventricular rate 148. Left axis deviation. Diffuse\nSt-T wave abnormalities are seen.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2121-07-02 00:00:00.000","description":"Report","row_id":176436,"text":"Atrial fibrillation with a controlled ventricular response. Left axis\ndeviation. Intraventricular conduction delay. Left ventricular hypertrophy.\nDeep T wave inversions in leads V3-V6 and T wave inversions in leads I and aVL.\nCompared to the previous tracing of T wave inversions in the lateral\nleads are much more prominent and the rate is slower. Cannot rule out an\nischemic process. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2121-06-27 00:00:00.000","description":"Report","row_id":176437,"text":"Atrial fibrillation. Since the previous tracing of lateral T wave\ninversions are less. Other abnormalities as previously described persist.\n\n"},{"category":"ECG","chartdate":"2121-06-24 00:00:00.000","description":"Report","row_id":176438,"text":"Coarse atrial fibrillation with a moderate ventricular response. Q-T interval\nis long for rate. Left axis deviation - consider left anterior fascicular\nblock. Anterolateral and lateral ST-T wave abnormalities concerning for\nmyocardial ischemia. Consider prior anterior myocardial infarction. Consider\nalso left ventricular hypertrophy. Compared to the previous tracing of \nthe ventricular response is slower and the ST-T wave abnormalities persist.\nClinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2121-06-21 00:00:00.000","description":"Report","row_id":176439,"text":"Atrial fibrillation with a rapid ventricular response. Left axis deviation.\nConsider left anterior fascicular block. Anterolateral and lateral ST-T wave\nabnormalities concerning for myocardial ischemia. Compared to the previous\ntracing of the atrial fibrillation is new and the ST-T wave\nabnormalities persist. Clinical correlation is suggested.\n\n"},{"category":"Nursing/other","chartdate":"2121-06-24 00:00:00.000","description":"Report","row_id":1409936,"text":"CCU NPN 2300-0700\nO: afeb. levoquin IV\nHR 95-109 AF. no VEA. amiodarone .5mg/min. recieved second dose of dig. .25mg IV. to start QD dose today.\n\nBP 89-95/60's. MAP 65-71. milrinone at .38mcq/kg/min. PAD 19-22.CVP 7-10 and WEDge 18. u/o 50-60cc/hr.\n\nheparin 1000u/hr. PTT 90.(within range) AM pnd.\n\nresp: for overnight rest, placed on AC in eve: rate 10/700/.40/7.5peep. sats 97-99%. ABG 7.44/39/93. no overbreathing vent. suctioned for small amt. thick yellow/tan secretions. LS course lower airways.\n\nneuro: pt. sedated when left alone, no spont. movement. but arouses with any stimulation. trys to open eyes, moving arms, coughing becomes very red in face. settles down on own if left alone. ativan at 4mg/hr. decreased to 3mg during night. no change in sedaton level noted. fent. gtt at 50mcq.\n\nA: no change in VS/C.O. numbers. good diurses in eve.\n stable on AC. no spont. breathing. sedation decreased.\nP: change to PSV and assess wakefullness. . sedation slowly.\nfollow swan numbers. monitor HR/rythym for change. dig. today.\n\n"},{"category":"Nursing/other","chartdate":"2121-06-24 00:00:00.000","description":"Report","row_id":1409937,"text":"heart failure, af\nccu npn\no- t max 99.3. c+s pnd/neg. cont. on abx.\ncv- hr 120s to 90s af, no vea. bp 100s to 130s/. cont. on milrinone, amiodarone, heparin- same doses. k-3.6, replaced with 40meq iv, repeat 4.0. 2 amps mgso4 also given x1. ptt 90.7. plts 93.\nresp- weaned to psv and extubated at 4:30pm. on 50% cool neb, sats 98-100. abg- 113,46,7.39,29. no sob noted after extubation. sx'd for sm amts white to tan sputum, bld tinged. coughing well after extubation with encouragement, orally sx'd or ?swallows sputum. l/s sl. coarse/dim. lasix 20mg iv given x1 in am with good response. i+o about 500cc neg. for day.\ngi- ogt clamped and d/c'd prior to extubation. t/f held for extubation. no bm.\nskin- intact, repos side to back with skin/oral care.\nms- awake and reponsive all day, most time interactive- nodding and following commands. also agitated and anxious at times. fentanyl d/c'd prior to extubation. ativan weaned off gradually and d/c'd for extubation. unable to speak, mouthing words, then able to speak in hoarse voice, difficult to understand.\nsocial- fx, friends visited most day, supportive to pt. fx updated on status, plan and understand. reinforce prn.\n"},{"category":"Nursing/other","chartdate":"2121-06-23 00:00:00.000","description":"Report","row_id":1409934,"text":"CCU NSG NOTE: ALT IN CV\nO: For complete VS see CCU flow sheet.\nID: T-max 100R. Pt conts on abx.\nCV: HR increased from low 100s to 120s a-fib. 40 KCL IV given this am with repeat K+ 4.2. Levophed weaned off at 11:15 with BP staying in 90-low 100s. He continues on milrinone at .32 mic/kilo, amiodarone at .5mg and heparin with theraputic PTT. PAP has ranged 40-50s/28-32 with wedge of 23, ra 13-16 and last CO/CI off levophed for 45 minutes was 4.8/2.08/ 1133. He was started on 12.5 aldactone NG.\nRESP: Pt has been weaned to C-PAP with gas on 40% 7.5 PEEP 10 PS with RR 8-15 was 7.40/ 39/ 127/ 25. PEEP has since been weaned to 5 with 02 sats 98-100%. He is being suctioned ~Q2 for thick yellow secretions. He has a strong cough. Breath sounds are decreased and occasional wheezes are heard. He is getting MDIs from resp. Pt has been observed to have periods of apnea followed by increased resp rate and pt jerking awake. Wife states she has noted this at home.\nRENAL: Creatinine decreased from 2.5 yesterday ato 1.5 today. He came in at 1.0. Urine appears very consentrated and cloudy. Specimen sent for lytes. He is ~600cc positive for the day but k~2800cc neg LOS.\nGI: Nepro was restarted at 10cc/hr at 10am. Pt had residual of 50cc at noon but it was mostly bile and G-. No BM.\nENDO: FS at noon 128 and no ss reg insulin given.\nMS/SEDATION: Pt has been rouseable to verbal stimuli, as well as startling awake on his own. He has followed simple commands and seems to recognise and respond to family members. is moving all extremities. He continues on ativan 5mg/hr and fentanyl 50mic/min.\nA: Contd elevated filling pressures/marginal BP off levo/poor u/o/tolerating c-pap\nP: If bp drops too low try neo to maintain bp. Suction prn. 5pm labs. Support pt and family.\n"},{"category":"Nursing/other","chartdate":"2121-06-23 00:00:00.000","description":"Report","row_id":1409935,"text":"CCU NPN 3-11PM\nCV: remains off pressors, BP 90-100/60, HR 120-140 A.fib. Given .25mg Dig, 20mg Lasix IV, diuresed ~1L over next few hours. BP dropped to 80's/50's, MAP 64-66, cont with good diuresis. K+ 4.2. HR has dropped to 110-120. Cont on Milrinone at .38ug/kg/min and amiodarone at .5mg/min. Heparin adjusted for PTT of 58 at 8 PM, will need PTT at 2AM. CO 6.5, CI 2.8\n\nNeuro: sedated on Fent 50ug, Ativan 5mg, decreased to 4mg. Responds to voice, nods appropriately at times.\n\nResp: on PS 10/5 PEEP, after getting 50ug bolus of fent x2 for agitation, was having periods of apnea, placed back on AC rate of 10, VT 700 for the night, will changed back to PS early AM. Suctioned for scant pale yellow secretions x2. LS with fine crackles at bases bilaterally.\n\nID: afebrile. cont on levofloxacin q 24hrs.\n\nEndo: BS 108, no ins required.\n\nGI:Kept TF, Nepro at 10cc for high residul at 4PM, 30cc residual at 10PM, increased TF to 20cc. Nutrition saw pt, check chart for recommendations.\n\nSoc: wife and children in, updated by Dr. .\n\nA: Showing improvement in CO on Milrinone and off pressors, diuresing well.\n\nP: Cont hemodynamic monitoring, cont vent support, change back to PS in AM, diurese as tolerated with hopes of weaning in next few days.\n"},{"category":"Nursing/other","chartdate":"2121-06-21 00:00:00.000","description":"Report","row_id":1409926,"text":"END OF SHIFT/NURSE CLINICAL UPDATE\nPT ADMITTED FOR CHF/SOB WITH PULM. EDEMA. AFIB-CARDIOVERTED BACK INTO SINUS (SEE MD HISTORY)\n\nNEURO: PT DOES NOT FOLLOW COMMANDS AT THIS TIME. SEDATED ON DIPRIVAN (SEE VS SCREEN). WILL WITHDRAW TO DEEP TACTILE STIUMLATION UPPER EXT. PEARL. PT VERY AGITATED WITH LOW DOSE SEDATION. TITRATION OF DIPRIVAN TO SEDATION. COUGHING WITH DECREASING SATS WHEN AGITATED. X4.\n\nPULM: PT CONTINUES ON VENT. PT WITH SM. TO MOD. AMTS OF THICK WHITE SECRETIONS FROM ET TUBE. BS COARSE BILATERAL BUT CLEARS SOME WITH SUCTION. PT PO >90% ON VENT.\n\nCV: PT . ON LOW DOSE DOPAMINE (RENAL DOSE). ATTEMPT TO WEAN OFF. ORDERS TO KEEP MEAN >65. DOPA CURRENTLY AT 3.6 MCGS. SBP 80-90S. HR <100, SINUS WITH FREQUENT PAC'S (SEE STRIP POSTED).\n\nGI/GU: PT WITH LARGE URINE OUTPUT BEGINNING OF SHIFT BUT HAS SINCE TAPPERED TO APPROX. 30CC/HR. MD UPDATED ON URINE OUTPUT. ORDER FOR LASIX GIVEN (SEE MED SHEET). PT CONTINUES TO HAVE POOR URINE OUTPUT. NO BM NOTED.\n\nLINES: CENTRAL LINE WITH SLIGHT BLOODY DRAINAGE TO PT AGITATION. A-LINE INTACT WITH FAIR WAVE FORM.\n\nFAMILY: GENERAL UPDATE GIVEN DAUGHTER OVER TELEPHONE. VERABLIZES UNDERSTANDING.\n\nPLEASE SEE CLINICAL INFORMATION SCREENS FOR HOURLY TRENDS.\n"},{"category":"Nursing/other","chartdate":"2121-06-21 00:00:00.000","description":"Report","row_id":1409927,"text":"Respiratory Care Note\n\nPt currently on AC 700*10 +5 40%. Pt tol current settings well. Pt on CPAP for ~ 1 hour today...pt became very agitated and had periods of apnea with Increasing sedation. Will cont to suport and change to PSV when pt ready\n"},{"category":"Nursing/other","chartdate":"2121-06-20 00:00:00.000","description":"Report","row_id":1409925,"text":"CCU Nursing Admission Note:\n61 yr old admitted from EW today with CHF. Pt has had increased leg edema and SOB for past 10 days. On arrival to EW was found to be in rapid A.fib at 140, BP initially 90/70, was cyanotic and SOB in EW, sat 99% on 2L, EKG with rate related changes. Cardioverted after receiving sedation, back to NSR, cont to have SOB, BP dropping to 70-80/, started Dopamine 15ug/kg/min and was intubated. Dopa able to be weaned to 5ug. Was given Ativan, MSO4 and Vec. BCx2 sent, given rocephin and Vanco. Chest CT priliminary, neg for PE, disection. Was placed on Hep gtt after bolus, T.L placed. Echo done showing systolic dysfunction, no shunt.\n\nPMH: HTN, previously on atenolol, stopped himself ~1mo ago.\n\nALL: NKDA\n\nCV: on Dopa BP 90-110/, weaned from 6ug to 5ug/kg/min. HR 110-90 NSR. ECHO done, EKG done. To be ruled out for MI. Cath potentially next week. On hep gtt at 1800U/hr.\n\nResp: Vented, AC 700x12, 100%, 10 PEEP. Suctioned for scant blood tinged sputum. ABG pnd. Sats 99-100%.\n\nGI: NGT in place, BS present, abd soft, no stool. HCT 47.6\n\nGU: aggressively diuresing from lasix given in EW.\n\nMS: Sedated on IV Ativan, given 1x bolus of vecuronium. Given MSO4x1 also.\n\nID: T 99 po, WBC 6.8, given AB in EW, BC sent.\n\nSoc: wife and children in, updated by RN/MD.\n"},{"category":"Nursing/other","chartdate":"2121-06-21 00:00:00.000","description":"Report","row_id":1409928,"text":"CHF, RESP FAILURE\nCCU NPN\nO- TEMP UP TO 102.3 PO, RE'D TYLENOL. BLD C+S SENT X1, PERIPHERAL STICK. URINE AND SPUTUM SENT ALSO. WBC 10.1.\nCV- HR 101 TO 90S SR, NO VEA. BP 80-90S IN MA, MAPS 70S. DOPA WEANED TO OFF BY 2:30PM. BP 90S-100S LATER IN DAY. K-5.1, RECHECK IN PM 4.6. PTT HIGH, HEPARIN DECREASED X2 AND HELD FOR 1HR WITH 1ST CHANGE. LAST PTT 118 AND HEPARIN DOWN TO 1000UNITS/HR AT 4:15PM, CHECK PTT TONOCT. BLEEDING SMALL AMTS FROM TLC AND ALINE SITE. PLTS 122. CK 93 TODAY. SGOT,SGPT, T. BILI UP.\nRESP- CONT. ON A/C 10, TV 700, 60% WEANED X2 TO 40% WITH 5PEP. SATS 95-99. LAST ABG ON 40%- 100,29,7.42,19.\nHAD PSV TRIAL, AT 1ST TV 500S, RATE 21 ON PSV 12, BUT BECAME APNEIC WHEN AGITATED AND BACK ON A/C. L/S COARSE/JUNKY WITH SCAT WHEEZES TO SL. COARSE, DIM THRUOUT. STARTED ON ATROVENT MDIS. SX'D FOR THICK TAN X1, THEN WHITE TO BLOODY/BLD TINGED SEC. U/O LOW, DRIFTED DOWN TO 1-6CC/HR. HO AWARE AND RE'D 3 BOLUSES OF 250CC N/S WITHOUT CHANGE IN U/O. U/O IMPROVED SLIGHTLY THIS PM. POS. ABOUT 1100CC TODAY (NEG 4700CC ).\nGI- NPO. OGT CLAMPED. ABD SOFT/DIST. WITH B. SOUNDS. NO BM.\nMS- AGITATED OFF/ON. ON PROPOFOL AND REQ. FREQ BOLUSES. CHANGED TO ATIVAN IN HOPES OF RAISING HIS BP. REQUIRED DRIP TO BE TITRATED TO 4MG/HR WITH SEVERAL 2-3MG BOLUSES TO SEDATE. STILL AGITATED WITH SX'ING. OCC. FOLLOWS COMMANDS SUCH AS OPENING EYES OR SQUEEZING HANDS. IN BED. HANDS RESTRAINED FOR RISK OF EXTUBATION. RELEASED FREQ.\nSOCIAL- FX IN MOST DAY, SUPPORTIVE TO PT. STATUS, PLAN EXPLAINED TO FX MEMBERS, UNDERSTAND. REINFORCE PRN.\nPLAN- FOLLOW TEMPS, ?WILL NEED ABX. ?TRY WEAN VENT AGAIN IN AM. FOLLOW U/O, BUN, CREAT, LFTS.\n"},{"category":"Nursing/other","chartdate":"2121-06-26 00:00:00.000","description":"Report","row_id":1409942,"text":"CCU NPN 1900-0700\nS: \" I'm in , \"\nO: pt. confused on place/time. sometimes will state or hosp. able to state name. moving all extrem. on bed and able to lift arms up toward face. having spatial difficulties. able to hold up 2 fingers. speech slow and very soft.\nno agitation. sleeps most of time when left alone.\n\nHR 87-94AF. BP 130-140/80's. PAP 52-60/30-34. CVP 13-15. unable to wedge catheter. SVO2 69. C.O. 5.3/2.2/1200. unchanged from days.\ngiven 37.5 captopril in eve. increased to 50mg for 0600.\n\n\nno diuresis since . u/o 50cc/hr. (-)1.7liter for . currently 100cc neg.\n\nLS crackles bases. sat 95-98% 2lnc. RR 20-28.\n\ntaking pills with water. does better without straw.\n\nA: C.O. unchanged. PAD's up since last diuresis.\n no change in MS\nP: follow MS for change. follow PAP's, u/o. PT. ? try to dangle with PT.\n"},{"category":"Nursing/other","chartdate":"2121-06-26 00:00:00.000","description":"Report","row_id":1409943,"text":"heart failure, af\nccu npn\no- id- afebrile.\nms- lethargic, arouses to voice, at times needs loud voice, stimulation to arouse. mae. oriented to self, knows year, not month or place. does not remember when reoriented. cooperative.\ncv- hr 87-98 af, no vea. bp 130-140s/. k- 4.3. creat 1.0. hct 46.7, plts 93. lfts improved, still elevated. pa line d/c'd.\nresp- on 2l n/c, sats 96-98. no sob. prod. cough thin clear, bld tinged sputum. good u/o, with i+o neg. 730cc at 6pm. l/s dim thruout.\norder in to eval for cpt.\ngi- taking sips juice, water and pills with encouragement, tol fairly well, occ coughs after taking on pos. had few bites pudding, refused rest. increase diet as tol when more awake, asp. precautions. no bm.\nactivity- repos side to back in bed. oob to chair (slide). oob for 4.5hrs, tol well. pt consult to eval strength, etc. in and pnd. s/b ot.\nskin- intact. has some generalized edema.\nsocial- fx in, updated on pt status, procedures and plan.\naccess- i iv infiltrated, second patent. attempted iv insertion x2, unsuccessful, iv rn called and try for 2nd line.\n"},{"category":"Nursing/other","chartdate":"2121-06-27 00:00:00.000","description":"Report","row_id":1409944,"text":"nursing progress note 7p-7a\nS\" I WANT TO GO TO \"\n\nO: NEURO: PT. ORIENTED TO PERSON ONLY. MOVING ALL EXTREMITIES, HAS SOME DIFFICULTIES WITH SPATIAL RELATIONS, IE UNABLE TO DIRECT YANKAUR CATH TO MOUTH. TAKING SIPS OF WATER BY STRAW WELL. SPEECH SLOW AND SOFT.\n\nRESP: LUNGS DIMINISHED. O2 SATS ON 2L 96%-98%. COUGHING AND RAISING THICK WHITE SPUTUM.\n\nCV: CONTINUES IN A-FIB RATE 80-90'S. NO VEA NOTED. BP STABLE, TOL INCREASED DOSE OF CAPTOPRIL. DIGOXIN CHANGED TO PO DIG LEVEL PENDING THIS AM.\n\nGI: ABD SOFT DISTENDED, NO BM TAKING SIPS OF WATER ONLY. PT STATES JUICE IS TO SWEET.\n\nGU: URINE ADEQUATE. AMBER COLORED.\n\nSLEPT IN SHORT NAPS OVERNIGHT. MORE AWAKE THIS AM\n"},{"category":"Nursing/other","chartdate":"2121-06-24 00:00:00.000","description":"Report","row_id":1409938,"text":"addendum\nstarted on captopril, tol well. increase as tol, as ordered.\n"},{"category":"Nursing/other","chartdate":"2121-06-25 00:00:00.000","description":"Report","row_id":1409939,"text":"CCU NPN 1900-0700\nADDENDUM\n\n0600: pt. alert, Oriented to place and person. able to speak louder. continues to refuse to take any meds po. MD spoke to pt. without effect. BP 160/90 when awake. given hydralazine 20mg IV at 0630 with good effect. BP coming down to 130/60 by 0700.\n"},{"category":"Nursing/other","chartdate":"2121-06-25 00:00:00.000","description":"Report","row_id":1409940,"text":"CCU NPN 1900-0700\nS: \" Where am I \"\nO: pt. confused to place and time. able to state name only. only speaks in very low whisper voice. follows commands but very weak. trying to get hands towards face and neck. hands restrained for safety with invasive lines in place. pt. restless in early eve, putting legs over bed, getting mildly anxious when telling pt. of recent events. later in eve, pt. refusing to take captopril po (he took it at 2130). sleeps when left alone. arouses to name and/or light shaking. eyes open spont. gaze traks.\n\nTM 100.2R. contins. on levo IV for presumed pnx\nHR 95-116 AF. BP 130-150/70-90. captopril inc. to 12.5, given at 2130. BP remaining high 140-150/80. captopril inc. to 25mg and additional dose of 12.5mg orderd. however, pt. refused to take, not agitated but refusing to take water or meds. instead , given hydralazine 10mg IV, only minimal effect.\n\nPAP 60/33, wedge 26, CVP 16 prior to lasix and when pt. more restless. down to PAD 23-27, CVP 13-15. SVO2 71. C.O. 5.8/2.5/1100.\n\nheparin 1000u/hr. amio .5mg/min. milrinone .32mcq/kg/min.\n\nLS diminished throughout. FIO2 weaned to 4lnc. sats 97-99%. RR 20-24, unlabored.\n\nGU: 20 lasix IV at 2100. 1.2l u/o responce. currently 100cc/hr.\nGI: took small sips of water in early eve, no issues. (+) BS\n\nA: confusion after extubation\n good diuresis.\n BP high, req. titration up captopril\nP: follow MS for change/improvement. follow u/o, lytes. contin, gtts per plan.\n"},{"category":"Nursing/other","chartdate":"2121-06-25 00:00:00.000","description":"Report","row_id":1409941,"text":"CCU NSG NOTE: ALT IN CV\nS: I'm in the \".\nO: For complete VS see ccu flow sheet.\nID: T-max 100.4R. Pt conts on abx.\nCV: PT continues to improve. HR on digoxin has come down to 80-90s Afib. He continues on IV amiodarone at .5mic. He was able to take pills and captopril was increased this afternoon from 25mg to 37.5mg and bp is now in low 100s. Milrinone was d/c at 10:30 and c/o-ci decreased to 5.1/2.2 with svr 1286. Heparin was also d/c and lovenox begun. PAP has been stable in 40s/23-26 wedge of 12 and RA of . Swan and a-line will remain in overnight and probably be removed tomorrow.\nRESP: RR 16-22 with 02 sat on 2L NP 96-97%. He does have some creacles at bases. he has a strong cough.\nGI: Pt was able to take pills and some jello with encouragement, but would not be safe to attempt anything more at this time due to decreased mental status. No bm.\nRENAL: Creat down to 1.1. He was autodiuresing earlier and u/o has now dropped off to 40-60cc/hr. He is ~1600cc neg for the day.\nMS: Pt sleeps when left alone and can be roused with vebal stimuli and wet wash cloth to face. He knows he is in hospital, knows his name, but speach is slurred. He will follow simple commands and is moving all extremities. He seems to be swallowing safely, but needs to be watched and kept awake to ensure he swallows.\nA: Stable of milrinone/autodiuresing/slowly waking up\nP: Monitor for changes. Check CO/CI at 8p and in am. Increase captopril as tolerated. pt frequently. Increase diet as tolerated\n"},{"category":"Radiology","chartdate":"2121-06-20 00:00:00.000","description":"CT CHEST W/CONTRAST","row_id":759463,"text":" 1:27 PM\n CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: R/O PE , EVALUATION OF RESPIRATORY DISTRESS.\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with RESPIRATORY DISTRESS AND AFIB. INTUBATED.\n REASON FOR THIS EXAMINATION:\n R/O PE\n EVALUATION OF RESPIRATORY DISTRESS.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n 61 year old respiratory distress and atrial fibrillation.\n\n CT OF THE CHEST WITH CONTRAST\n\n CONTRAST:\n 150 cc of IV Optiray.\n\n TECHNIQUE:\n Multiple axial images of the entire chest was obtained with the use of\n intravenous contrast.\n\n CT CHEST WITH CONTRAST:\n There is no evidence of pulmonary embolus. The great vessels are normal. The\n heart is moderately enlarged. Bilateral pleural effusions with associated\n atelectasis is noted. Prevascular lymphadenopathy is identified. There are no\n focal consolidations. The osseous structures demonstrate degenerative changes.\n An endotracheal tube is identified in place.\n\n The unenhanced abdominal organs are unremarkable.\n Reconstructed images demonstrate no evidence of pulmonary embolus.\n\n IMPRESSION:\n 1. No pulmonary embolus.\n 2. Moderate bilateral pleural effusions with associated atelectasis.\n 3. Marked cardiomegaly.\n\n"},{"category":"Radiology","chartdate":"2121-06-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":759934,"text":" 9:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval CHF/ PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with RESPIRATORY DISTRESS S/P swan.\n\n REASON FOR THIS EXAMINATION:\n eval CHF/ PNA\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE CHEST, is compared to 4 days earlier.\n\n INDICATION: Respiratory distress.\n\n A SG catheter is present, with the distal tip terminating in the main\n pulmonary artery region. No pneumothorax is identified.\n\n The heart is enlarged. There has been improvement in the previously reported\n findings of congestive heart failure, with associated pleural effusions.\n\n No new or progressive abnormalities are identified.\n\n IMPRESSION:\n 1) SG catheter in satisfactory position.\n\n 2) Near complete resolution of heart failure findings. Probable residual\n small right pleural effusion.\n\n\n"},{"category":"Nursing/other","chartdate":"2121-06-21 00:00:00.000","description":"Report","row_id":1409929,"text":"addendum\nccu npn\npt into afib about 6:30pm, rate 140s-160s. bp maintained at 90s-100s. sat 98. pt calm/sedated at time of rhythm conversion. ho made aware. started on amiodarone at 7pm with 150mg bolus to 1mg/min drip. cont. for 6hrs, then down to .5mg/min as ordered.\nhr staying in 140s after bolus, cont. in af. bp 80s-90s/. fx in, aware of rhythm change and treatment.\n"},{"category":"Nursing/other","chartdate":"2121-06-22 00:00:00.000","description":"Report","row_id":1409930,"text":"CCU NPN 7P-7A\nAddendum:TL changed to cortis and pt swaned at 6AM, opening pressures: PAP 57/30, CVP 21, PCWP 30, CO 4.6, CI 1.99, SVR 1148 these #'s on 5ug/kg/min of dopamine, with BP 100/60. UO improved since Dopa started 40-80cc/hr. Cardioverted at 6:20 with 200J, briefly went into NSR, then back to a.fib. Given another amiodarone 150mg bolus over 10min and attempted cardioversion with 300J, same thing happened, NSR briefly than back into a.fib. Tried to decreased dopa to 3ug, BP falling to 80's/, increased back to 5ug/kg/min. During line change sats dropped to 90%, increased FIO@ to 60%, CXR done. Will need repeat ABG.\n"},{"category":"Nursing/other","chartdate":"2121-06-22 00:00:00.000","description":"Report","row_id":1409931,"text":"CCU NPN 7P-7A\nCV: Pt has remained in A.fib, rate 140's on Amiodarone gtt at 1mg/min, given another bolus of 150mg at MN, HR down a bit to 120's a.fib, BP has been 80-90/70, MAP 65-75. UO cont to be minimal. Attempted 500cc NS bolus with transient improvement in BP, no increase in UO. CVP transduced via T.L., 24. Held further fluid boluses. Plan to place swan-ganz catheter to aid evaluation of volume status and C.O.\n\nResp: suctioned q 3-4 for scant white secretions, LS clear. When pt awake, is out of sinc with vent, RR in 30's. Changed to IMV with 12 PS, but has not made no differance in his comfort when awake. ABG sent at time of agitation was good, has maintained sats of 99-100%.\n\nNeuro: Difficult to sedate pt, Ativan has been increased to 6mg after several 2 mg boluses. Given 25ug of fent at a time, does drop pressure to 80/60. Haldol given, 2.5mg x2 followed by 5mg IV. Pt cont to intermittently wake up, will calm somewhat to verbal reassurances. Has at times followed commands and nodded appropriately. Awakens startled and delerious.\n\nID: T 100-97, given 1x dose of Levaquin, awaiting ID approval for q 24hr dosing. Has been diaphoretic, with breaking of T.\n\nGI: no stool, BS present. NPO.\n\nSoc: wife called about swan and possible cardioversion.\n"},{"category":"Nursing/other","chartdate":"2121-06-22 00:00:00.000","description":"Report","row_id":1409932,"text":"chf, resp failure, af\nccu npn\no- t max 100.8 po. cont. on levoquin. wbc 11.5. c+s pnd, sputum oroph. flora.\ncv- hr max 122 in am, afib, down to 90s-100s, no vea. cont. on amiodarone decreased to .5mg/min at 4pm. systolic bp 90-100s, occ 80s in am. maps 66-80s. cont. on dopamine at 5mic. milrinone started 10:30am with bolus given over 1/2hr to .38mic/kg/min. co improved to 5.9, ci 2.55, svr down to 719. pa 57/35 down to low 43/20, wedge down to 20. cvp 22-11. cvp changed to rv pattern x2, pa line withdrawn x2 by mds, cvp now with ra trace, pa cont. to wedge. heparin on 1000units/hr, ptt 99.8, heparin down to 800units/hr at 2:30pm, recheck ptt this eve. inr 2.2, ho aware. k-4.7. hct 47.8, plts 115.\nresp- cont intubated a/c 10, rarely overbreaths, tv 700, 60% with 5 peep. abg adeq, later po2 down 68, peep up to 7.5 and abg- 79,39,7.41,0. sats 92-96. l/s sl. coarse thruout, rare scat. wheeze.\nu/o improved with milrinone to 130-230cc/hr. sx'd infreq for small white sputum.\nrenal- creat up to 2.5 (1.3).\ngi- abd soft with b. sounds. ogt with small dk green bile. started on nepro at 10cc/hr, increase as tol to 30cc/hr. hold at 12am for possible extubation . no bm.\nms/neuro- sedated well on ativan 6mg/hr and 50mic fentanyl in am, not waking to sx'ing or movement. ativan decreased to 5mg/hr. wakes slightly with repos or sx'ing. able to follow commands and nod/shake head appropriately when sl. awake. mae.\nskin- intact repos side to side to back q3hrs with skin/oral care. hands sl. edematous. 2 rings removed with wife's permission and given to fx.\nsocial- fx in, supportive to each other and pt. enc to talk/interact with pt. status, plan explained to fx, understand. reinforce, update prn.\na/p- diuresing with improved hemodynamics on milrinone. sats gradually improving, ?try to decrease to 50% this eve if sats cont. to rise. would start with low dose lasix if used (20mg). cont. on ativan/fentanyl. hold t/f at 12am. recheck ptt.\n"},{"category":"Nursing/other","chartdate":"2121-06-23 00:00:00.000","description":"Report","row_id":1409933,"text":"NEURO: SEDATED WITH ATIVAN 5MG/HR & FENTANYL 50MCG/HR. RESPONDS TO\n PAINFUL STIMULI. MAE. ATTEMPTS TO OPEN EYES.\nRESP: ON VENT: FIO2 WEANED FROM .60->.40 X 700 + AC 10 & 7.5 PEEP.\n BS COURSE AND DIMINISHED AT BASES. O2 SAT 94-98%. RR 10/10.\n SX FOR SM.-MOD. AMTS. THICK YELLOW SPUTUM. ABG 7.43/38/91/26\n 97% SAT.\nCARDIAC: HR 93-110 AF. BP 90-117/50-60'S. PAD 21-27, CVP 9-14, W 23,\n CO 6.1/2.64/866. ~0100 HR 120'S AF WITH INCREASED VEA. HO\n CALLED->WEAN DOPA AS TOL. LEVOPHED STARTED & DOPA WEANED TO\n OFF. CA,MG,PO4 SENT. MG 1.6->TREATED WITH MGS04 2GMS PB X1.\n HR BACK TO 90-100'S. ECTOPY RESOLVED. LEVOPHED 4.5MCG/MIN->\n CO 4.5/1.95/1227. CONT. ON AMIODARONE .5MG/HR, MILRINONE\n .38MCG/KG, & HEPARIN GTT AT 800U/HR. PTT 61.3. HO AWARE OF\n HEMODYNAMICS.\nGI: TF: FS NEPRO 10CC/HR. MINIMAL RESIDUALS. D/C'D AT MIDNOC & NPO->\n ? EXTUBATION. ABD. SL. DISTENDED. BS+. NO STOOL.\nGU: FOLEY->CD PATENT & DRAINING CLEAR AMBER URINE. U/O 50-170CC/HR\n DOWN TO 20-30CC/HR THIS AM. HO AWARE.\nID: AFEBRILE. CONT. ON IV LEVOFLOX.\nENDO: BS 130->111. NO INSULIN REQUIRED.\nLABS: WBC 11.4, HCT 40.9, PLAT CT 106K, CHEMISTRIES PENDING.\nNEED TO ADDRESS DECREASED CI & LOW U/O.\n"},{"category":"Radiology","chartdate":"2121-06-20 00:00:00.000","description":"CHEST (PA & LAT)","row_id":759448,"text":" 10:49 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with SOB, bilateral pedal edema\n REASON FOR THIS EXAMINATION:\n r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n Shortness of breath, pedal edema.\n\n CHEST PA AND LATERAL:\n The cardiomediastinal silhouette is stable. Acute fracture of the posterior\n 4th rib is identified. There are no focal consolidations. There is mild\n prominence of the interstitial markings. There is a small left-sided pleural\n effusion.\n\n IMPRESSION:\n 1. Minimal CHF.\n 2. Acute 4th posterior rib fracture.\n\n"},{"category":"Radiology","chartdate":"2121-06-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":759520,"text":" 8:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with RESPIRATORY DISTRESS S/P TRIPLE LUMEN CL PLACEMENT\n REASON FOR THIS EXAMINATION:\n evaluate chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: SOB, S/P triple lumen placement.\n\n CHEST, SINGLE PORTABLE VIEW:\n\n The right portion of the chest is not included on this supine film. An ET\n tube is present, the tip 5.6 cm above the carina. An NG tube is present, tip\n partially obscured, but thought to overlie the stomach. A right IJ line is\n present, tip overlying proximal SVC.\n\n The cardiomediastinal silhouette is prominent. There is hazy opacity in both\n lungs, suggesting layering effusions. I suspect the presence of underlying\n vascular plethora/CHF. There is also left lower lobe collapse and/or\n consolidation and atelectasis in the visualized portion of the right base. No\n supine film evidence of pneumothorax is identified.\n\n Healed left 4th rib fracture noted.\n\n IMPRESSION: Mild chf with effusions and bibasilar collpase/consolidation. No\n pneumothorax detected.\n\n"},{"category":"Radiology","chartdate":"2121-06-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":759462,"text":" 1:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O PNEUMO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with RESPIRATORY DISTRESS S/P TRIPLE LUMEN CL PLACEMENT\n REASON FOR THIS EXAMINATION:\n R/O PNEUMO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old with respiratory distress S/P triple lumen central\n line placement.\n\n AP VIEW OF THE CHEST:\n\n Comparison made to examination from the same day at 12:57pm.\n\n Endotracheal tube identified at the level of the superior clavicles. A right-\n sided central line is identified with tip at the proximal superior vena cava.\n There is no pneumothorax. Heart and lungs are unchanged.\n\n IMPRESSION: Right central line catheter with tip in the proximal superior\n vena cava.\n\n"},{"category":"Radiology","chartdate":"2121-06-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":759459,"text":" 12:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CHECK OGT AND ETT PLACEMENT. , EVALUATION OF RESPIRATORY DI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with RESPIRATORY DISTRESS\n REASON FOR THIS EXAMINATION:\n CHECK OGT AND ETT PLACEMENT.\n EVALUATION OF RESPIRATORY DISTRESS.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress, evaluate endotracheal tube placement.\n\n PORTABLE AP VIEW OF THE CHEST:\n\n Comparison made to same-day examination performed at 10:59AM.\n\n Endotracheal tube is identified with the tip at the level of the superior\n portion of the clavicles. There is no pneumothorax. There is bilateral hilar\n vascular congestion consistent with congestive heart failure. The cardiac\n silhouette and osseous structures are unchanged.\n\n IMPRESSION: Endotracheal tube in satisfactory position.\n 2) mild CHF\n\n"},{"category":"Radiology","chartdate":"2121-06-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":759571,"text":" 5:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval swan placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with RESPIRATORY DISTRESS S/P swan.\n REASON FOR THIS EXAMINATION:\n eval swan placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress status post Swan.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Compared with one day earlier, a right IJ Swan-Ganz catheter is now in place.\n The tip lies relatively distal in the right pulmonary artery and retraction of\n the tip should be considered. There is marked prominence of the\n cardiomediastinal silhouette, unchanged compared with one day earlier. There\n is upper zone redistribution and diffuse vascular blurring, consistent with\n CHF. There are bilateral pleural effusions, greater on the right, with\n underlying collapse and/or consolidation. The extreme left costophrenic angle\n is not included on this film.\n\n IMPRESSION:\n\n 1. Interval placement of right IJ Swan-Ganz catheter with tip relatively\n distal in right pulmonary artery. Retraction of the tip should be considered.\n\n 2. Prominence of the cardiomediastinal silhouette. This is similar to the\n appearance on the portable film, but more pronounced than on the PA view.\n This appearance is likely accentuated by AP supine technique. However,\n clinical correlation is requested. (Scattered nodes are present in the\n mediastinum on the CTA from and there was mediastinal lipomatosis but no\n hemorrhage within the mediastinum was identified at that time.)\n\n 3. CHF and bilateral effusions.\n\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-07-02 00:00:00.000\",\n \"description\": \"ABDOMEN U.S. (COMPLETE STUDY)\",\n \"row_id\": 760334,\n \"text\": \" 8:15 AM\\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \\n Reason: HEP C NEWLY DIAGNOSED CHECK FOR HEPATOMA ASCITES AND CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with new HCV dx.\\n REASON FOR THIS EXAMINATION:\\n eval for hepatoma, ascites, cirrhosis\\n ______________________________________________________________________________\\n FINAL REPORT\\n ABDOMINAL ULTRASOUND:\\n\\n INDICATION: Hepatitis C virus.\\n\\n FINDINGS:\\n\\n The hepatic parenchyma is coarsened and nodular compatible with cirrhosis. A\\n few tiny cysts are visualized in segment 4 measuring up to 7 mm. A tiny\\n echogenic focus is seen in the right hepatic lobe, probably representing a\\n granuloma. No solid liver lesions are identified. The main portal vein is\\n patent with appropriate directional flow. There is no ascites, evidence of\\n varices or splenomegaly. The gallbladder is normal in appearance. The common\\n duct is not dilated. The visualized pancreas is unremarkable. The kidneys\\n are normal in size and architecture with the right kidney measuring 11.7 cm in\\n length and the left kidney measuring 11.5 cm in length. There is no\\n hydronephrosis, renal mass or calculus.\\n\\n IMPRESSION:\\n\\n Cirrhotic liver with no complications of chronic liver disease.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2121-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 71437,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Cyanosis on ventilator. R/o large right-left shunt\\nBP (mm Hg): 112/76\\nHR (bpm): 81\\nStatus: Inpatient\\nDate/Time: at 16:39\\nTest: Portable TTE(Focused views)\\nDoppler: Focused pulse and color flow\\nContrast: Saline\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is mildly dilated.\\n\\nLEFT VENTRICLE: There is severe global left ventricular hypokinesis.\\n\\nRIGHT VENTRICLE: There is severe global right ventricular free wall\\nhypokinesis.\\n\\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\\nregurgitation is seen.\\n\\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nGENERAL COMMENTS: Contrast study was performed with one iv injection of 8 ccs\\nof agitated normal saline at rest.\\n\\nConclusions:\\nThe left atrium is mildly dilated. There is severe global left ventricular\\nhypokinesis. There is severe global right ventricular free wall hypokinesis.\\nThe aortic valve leaflets are mildly thickened. The mitral valve leaflets are\\nmildly thickened. Mild (1+) mitral regurgitation is seen. There is no\\npericardial effusion. A contrast injection at rest did not reveal any right to\\nleft shunting.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2121-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176676,\n \"text\": \"Sinus rhythm, rate 99. Since the previous tracing the heart rate is somewhat\\nfaster. No significant ectopy is noted. The T wave inversions previously seen\\nare somewhat less impressive.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2121-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176677,\n \"text\": \"Sinus rhythm, rate 88. Since the previous tracing multifocal atrial premature\\nbeats are seen. A rare ventricular premature beat is noted. No other\\nsignificant changes have occurred.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2121-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176678,\n \"text\": \"Sinus rhythm, rate 78. Since the previous tracing sinus rhythm is now seen.\\nBorderline Q-T interval prolongation is noted. Deep T wave inversions are\\npresent in leads I, aVL and across the precordium.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2121-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176679,\n \"text\": \"Atrial fibrillation, average ventricular rate 148. Left axis deviation. Diffuse\\nSt-T wave abnormalities are seen.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2121-07-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176436,\n \"text\": \"Atrial fibrillation with a controlled ventricular response. Left axis\\ndeviation. Intraventricular conduction delay. Left ventricular hypertrophy.\\nDeep T wave inversions in leads V3-V6 and T wave inversions in leads I and aVL.\\nCompared to the previous tracing of T wave inversions in the lateral\\nleads are much more prominent and the rate is slower. Cannot rule out an\\nischemic process. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2121-06-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176437,\n \"text\": \"Atrial fibrillation. Since the previous tracing of lateral T wave\\ninversions are less. Other abnormalities as previously described persist.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2121-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176438,\n \"text\": \"Coarse atrial fibrillation with a moderate ventricular response. Q-T interval\\nis long for rate. Left axis deviation - consider left anterior fascicular\\nblock. Anterolateral and lateral ST-T wave abnormalities concerning for\\nmyocardial ischemia. Consider prior anterior myocardial infarction. Consider\\nalso left ventricular hypertrophy. Compared to the previous tracing of \\nthe ventricular response is slower and the ST-T wave abnormalities persist.\\nClinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2121-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176439,\n \"text\": \"Atrial fibrillation with a rapid ventricular response. Left axis deviation.\\nConsider left anterior fascicular block. Anterolateral and lateral ST-T wave\\nabnormalities concerning for myocardial ischemia. Compared to the previous\\ntracing of the atrial fibrillation is new and the ST-T wave\\nabnormalities persist. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409936,\n \"text\": \"CCU NPN 2300-0700\\nO: afeb. levoquin IV\\nHR 95-109 AF. no VEA. amiodarone .5mg/min. recieved second dose of dig. .25mg IV. to start QD dose today.\\n\\nBP 89-95/60's. MAP 65-71. milrinone at .38mcq/kg/min. PAD 19-22.CVP 7-10 and WEDge 18. u/o 50-60cc/hr.\\n\\nheparin 1000u/hr. PTT 90.(within range) AM pnd.\\n\\nresp: for overnight rest, placed on AC in eve: rate 10/700/.40/7.5peep. sats 97-99%. ABG 7.44/39/93. no overbreathing vent. suctioned for small amt. thick yellow/tan secretions. LS course lower airways.\\n\\nneuro: pt. sedated when left alone, no spont. movement. but arouses with any stimulation. trys to open eyes, moving arms, coughing becomes very red in face. settles down on own if left alone. ativan at 4mg/hr. decreased to 3mg during night. no change in sedaton level noted. fent. gtt at 50mcq.\\n\\nA: no change in VS/C.O. numbers. good diurses in eve.\\n stable on AC. no spont. breathing. sedation decreased.\\nP: change to PSV and assess wakefullness. . sedation slowly.\\nfollow swan numbers. monitor HR/rythym for change. dig. today.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409937,\n \"text\": \"heart failure, af\\nccu npn\\no- t max 99.3. c+s pnd/neg. cont. on abx.\\ncv- hr 120s to 90s af, no vea. bp 100s to 130s/. cont. on milrinone, amiodarone, heparin- same doses. k-3.6, replaced with 40meq iv, repeat 4.0. 2 amps mgso4 also given x1. ptt 90.7. plts 93.\\nresp- weaned to psv and extubated at 4:30pm. on 50% cool neb, sats 98-100. abg- 113,46,7.39,29. no sob noted after extubation. sx'd for sm amts white to tan sputum, bld tinged. coughing well after extubation with encouragement, orally sx'd or ?swallows sputum. l/s sl. coarse/dim. lasix 20mg iv given x1 in am with good response. i+o about 500cc neg. for day.\\ngi- ogt clamped and d/c'd prior to extubation. t/f held for extubation. no bm.\\nskin- intact, repos side to back with skin/oral care.\\nms- awake and reponsive all day, most time interactive- nodding and following commands. also agitated and anxious at times. fentanyl d/c'd prior to extubation. ativan weaned off gradually and d/c'd for extubation. unable to speak, mouthing words, then able to speak in hoarse voice, difficult to understand.\\nsocial- fx, friends visited most day, supportive to pt. fx updated on status, plan and understand. reinforce prn.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409934,\n \"text\": \"CCU NSG NOTE: ALT IN CV\\nO: For complete VS see CCU flow sheet.\\nID: T-max 100R. Pt conts on abx.\\nCV: HR increased from low 100s to 120s a-fib. 40 KCL IV given this am with repeat K+ 4.2. Levophed weaned off at 11:15 with BP staying in 90-low 100s. He continues on milrinone at .32 mic/kilo, amiodarone at .5mg and heparin with theraputic PTT. PAP has ranged 40-50s/28-32 with wedge of 23, ra 13-16 and last CO/CI off levophed for 45 minutes was 4.8/2.08/ 1133. He was started on 12.5 aldactone NG.\\nRESP: Pt has been weaned to C-PAP with gas on 40% 7.5 PEEP 10 PS with RR 8-15 was 7.40/ 39/ 127/ 25. PEEP has since been weaned to 5 with 02 sats 98-100%. He is being suctioned ~Q2 for thick yellow secretions. He has a strong cough. Breath sounds are decreased and occasional wheezes are heard. He is getting MDIs from resp. Pt has been observed to have periods of apnea followed by increased resp rate and pt jerking awake. Wife states she has noted this at home.\\nRENAL: Creatinine decreased from 2.5 yesterday ato 1.5 today. He came in at 1.0. Urine appears very consentrated and cloudy. Specimen sent for lytes. He is ~600cc positive for the day but k~2800cc neg LOS.\\nGI: Nepro was restarted at 10cc/hr at 10am. Pt had residual of 50cc at noon but it was mostly bile and G-. No BM.\\nENDO: FS at noon 128 and no ss reg insulin given.\\nMS/SEDATION: Pt has been rouseable to verbal stimuli, as well as startling awake on his own. He has followed simple commands and seems to recognise and respond to family members. is moving all extremities. He continues on ativan 5mg/hr and fentanyl 50mic/min.\\nA: Contd elevated filling pressures/marginal BP off levo/poor u/o/tolerating c-pap\\nP: If bp drops too low try neo to maintain bp. Suction prn. 5pm labs. Support pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409935,\n \"text\": \"CCU NPN 3-11PM\\nCV: remains off pressors, BP 90-100/60, HR 120-140 A.fib. Given .25mg Dig, 20mg Lasix IV, diuresed ~1L over next few hours. BP dropped to 80's/50's, MAP 64-66, cont with good diuresis. K+ 4.2. HR has dropped to 110-120. Cont on Milrinone at .38ug/kg/min and amiodarone at .5mg/min. Heparin adjusted for PTT of 58 at 8 PM, will need PTT at 2AM. CO 6.5, CI 2.8\\n\\nNeuro: sedated on Fent 50ug, Ativan 5mg, decreased to 4mg. Responds to voice, nods appropriately at times.\\n\\nResp: on PS 10/5 PEEP, after getting 50ug bolus of fent x2 for agitation, was having periods of apnea, placed back on AC rate of 10, VT 700 for the night, will changed back to PS early AM. Suctioned for scant pale yellow secretions x2. LS with fine crackles at bases bilaterally.\\n\\nID: afebrile. cont on levofloxacin q 24hrs.\\n\\nEndo: BS 108, no ins required.\\n\\nGI:Kept TF, Nepro at 10cc for high residul at 4PM, 30cc residual at 10PM, increased TF to 20cc. Nutrition saw pt, check chart for recommendations.\\n\\nSoc: wife and children in, updated by Dr. .\\n\\nA: Showing improvement in CO on Milrinone and off pressors, diuresing well.\\n\\nP: Cont hemodynamic monitoring, cont vent support, change back to PS in AM, diurese as tolerated with hopes of weaning in next few days.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409926,\n \"text\": \"END OF SHIFT/NURSE CLINICAL UPDATE\\nPT ADMITTED FOR CHF/SOB WITH PULM. EDEMA. AFIB-CARDIOVERTED BACK INTO SINUS (SEE MD HISTORY)\\n\\nNEURO: PT DOES NOT FOLLOW COMMANDS AT THIS TIME. SEDATED ON DIPRIVAN (SEE VS SCREEN). WILL WITHDRAW TO DEEP TACTILE STIUMLATION UPPER EXT. PEARL. PT VERY AGITATED WITH LOW DOSE SEDATION. TITRATION OF DIPRIVAN TO SEDATION. COUGHING WITH DECREASING SATS WHEN AGITATED. X4.\\n\\nPULM: PT CONTINUES ON VENT. PT WITH SM. TO MOD. AMTS OF THICK WHITE SECRETIONS FROM ET TUBE. BS COARSE BILATERAL BUT CLEARS SOME WITH SUCTION. PT PO >90% ON VENT.\\n\\nCV: PT . ON LOW DOSE DOPAMINE (RENAL DOSE). ATTEMPT TO WEAN OFF. ORDERS TO KEEP MEAN >65. DOPA CURRENTLY AT 3.6 MCGS. SBP 80-90S. HR <100, SINUS WITH FREQUENT PAC'S (SEE STRIP POSTED).\\n\\nGI/GU: PT WITH LARGE URINE OUTPUT BEGINNING OF SHIFT BUT HAS SINCE TAPPERED TO APPROX. 30CC/HR. MD UPDATED ON URINE OUTPUT. ORDER FOR LASIX GIVEN (SEE MED SHEET). PT CONTINUES TO HAVE POOR URINE OUTPUT. NO BM NOTED.\\n\\nLINES: CENTRAL LINE WITH SLIGHT BLOODY DRAINAGE TO PT AGITATION. A-LINE INTACT WITH FAIR WAVE FORM.\\n\\nFAMILY: GENERAL UPDATE GIVEN DAUGHTER OVER TELEPHONE. VERABLIZES UNDERSTANDING.\\n\\nPLEASE SEE CLINICAL INFORMATION SCREENS FOR HOURLY TRENDS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409927,\n \"text\": \"Respiratory Care Note\\n\\nPt currently on AC 700*10 +5 40%. Pt tol current settings well. Pt on CPAP for ~ 1 hour today...pt became very agitated and had periods of apnea with Increasing sedation. Will cont to suport and change to PSV when pt ready\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409925,\n \"text\": \"CCU Nursing Admission Note:\\n61 yr old admitted from EW today with CHF. Pt has had increased leg edema and SOB for past 10 days. On arrival to EW was found to be in rapid A.fib at 140, BP initially 90/70, was cyanotic and SOB in EW, sat 99% on 2L, EKG with rate related changes. Cardioverted after receiving sedation, back to NSR, cont to have SOB, BP dropping to 70-80/, started Dopamine 15ug/kg/min and was intubated. Dopa able to be weaned to 5ug. Was given Ativan, MSO4 and Vec. BCx2 sent, given rocephin and Vanco. Chest CT priliminary, neg for PE, disection. Was placed on Hep gtt after bolus, T.L placed. Echo done showing systolic dysfunction, no shunt.\\n\\nPMH: HTN, previously on atenolol, stopped himself ~1mo ago.\\n\\nALL: NKDA\\n\\nCV: on Dopa BP 90-110/, weaned from 6ug to 5ug/kg/min. HR 110-90 NSR. ECHO done, EKG done. To be ruled out for MI. Cath potentially next week. On hep gtt at 1800U/hr.\\n\\nResp: Vented, AC 700x12, 100%, 10 PEEP. Suctioned for scant blood tinged sputum. ABG pnd. Sats 99-100%.\\n\\nGI: NGT in place, BS present, abd soft, no stool. HCT 47.6\\n\\nGU: aggressively diuresing from lasix given in EW.\\n\\nMS: Sedated on IV Ativan, given 1x bolus of vecuronium. Given MSO4x1 also.\\n\\nID: T 99 po, WBC 6.8, given AB in EW, BC sent.\\n\\nSoc: wife and children in, updated by RN/MD.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409928,\n \"text\": \"CHF, RESP FAILURE\\nCCU NPN\\nO- TEMP UP TO 102.3 PO, RE'D TYLENOL. BLD C+S SENT X1, PERIPHERAL STICK. URINE AND SPUTUM SENT ALSO. WBC 10.1.\\nCV- HR 101 TO 90S SR, NO VEA. BP 80-90S IN MA, MAPS 70S. DOPA WEANED TO OFF BY 2:30PM. BP 90S-100S LATER IN DAY. K-5.1, RECHECK IN PM 4.6. PTT HIGH, HEPARIN DECREASED X2 AND HELD FOR 1HR WITH 1ST CHANGE. LAST PTT 118 AND HEPARIN DOWN TO 1000UNITS/HR AT 4:15PM, CHECK PTT TONOCT. BLEEDING SMALL AMTS FROM TLC AND ALINE SITE. PLTS 122. CK 93 TODAY. SGOT,SGPT, T. BILI UP.\\nRESP- CONT. ON A/C 10, TV 700, 60% WEANED X2 TO 40% WITH 5PEP. SATS 95-99. LAST ABG ON 40%- 100,29,7.42,19.\\nHAD PSV TRIAL, AT 1ST TV 500S, RATE 21 ON PSV 12, BUT BECAME APNEIC WHEN AGITATED AND BACK ON A/C. L/S COARSE/JUNKY WITH SCAT WHEEZES TO SL. COARSE, DIM THRUOUT. STARTED ON ATROVENT MDIS. SX'D FOR THICK TAN X1, THEN WHITE TO BLOODY/BLD TINGED SEC. U/O LOW, DRIFTED DOWN TO 1-6CC/HR. HO AWARE AND RE'D 3 BOLUSES OF 250CC N/S WITHOUT CHANGE IN U/O. U/O IMPROVED SLIGHTLY THIS PM. POS. ABOUT 1100CC TODAY (NEG 4700CC ).\\nGI- NPO. OGT CLAMPED. ABD SOFT/DIST. WITH B. SOUNDS. NO BM.\\nMS- AGITATED OFF/ON. ON PROPOFOL AND REQ. FREQ BOLUSES. CHANGED TO ATIVAN IN HOPES OF RAISING HIS BP. REQUIRED DRIP TO BE TITRATED TO 4MG/HR WITH SEVERAL 2-3MG BOLUSES TO SEDATE. STILL AGITATED WITH SX'ING. OCC. FOLLOWS COMMANDS SUCH AS OPENING EYES OR SQUEEZING HANDS. IN BED. HANDS RESTRAINED FOR RISK OF EXTUBATION. RELEASED FREQ.\\nSOCIAL- FX IN MOST DAY, SUPPORTIVE TO PT. STATUS, PLAN EXPLAINED TO FX MEMBERS, UNDERSTAND. REINFORCE PRN.\\nPLAN- FOLLOW TEMPS, ?WILL NEED ABX. ?TRY WEAN VENT AGAIN IN AM. FOLLOW U/O, BUN, CREAT, LFTS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409942,\n \"text\": \"CCU NPN 1900-0700\\nS: \\\" I'm in , \\\"\\nO: pt. confused on place/time. sometimes will state or hosp. able to state name. moving all extrem. on bed and able to lift arms up toward face. having spatial difficulties. able to hold up 2 fingers. speech slow and very soft.\\nno agitation. sleeps most of time when left alone.\\n\\nHR 87-94AF. BP 130-140/80's. PAP 52-60/30-34. CVP 13-15. unable to wedge catheter. SVO2 69. C.O. 5.3/2.2/1200. unchanged from days.\\ngiven 37.5 captopril in eve. increased to 50mg for 0600.\\n\\n\\nno diuresis since . u/o 50cc/hr. (-)1.7liter for . currently 100cc neg.\\n\\nLS crackles bases. sat 95-98% 2lnc. RR 20-28.\\n\\ntaking pills with water. does better without straw.\\n\\nA: C.O. unchanged. PAD's up since last diuresis.\\n no change in MS\\nP: follow MS for change. follow PAP's, u/o. PT. ? try to dangle with PT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409943,\n \"text\": \"heart failure, af\\nccu npn\\no- id- afebrile.\\nms- lethargic, arouses to voice, at times needs loud voice, stimulation to arouse. mae. oriented to self, knows year, not month or place. does not remember when reoriented. cooperative.\\ncv- hr 87-98 af, no vea. bp 130-140s/. k- 4.3. creat 1.0. hct 46.7, plts 93. lfts improved, still elevated. pa line d/c'd.\\nresp- on 2l n/c, sats 96-98. no sob. prod. cough thin clear, bld tinged sputum. good u/o, with i+o neg. 730cc at 6pm. l/s dim thruout.\\norder in to eval for cpt.\\ngi- taking sips juice, water and pills with encouragement, tol fairly well, occ coughs after taking on pos. had few bites pudding, refused rest. increase diet as tol when more awake, asp. precautions. no bm.\\nactivity- repos side to back in bed. oob to chair (slide). oob for 4.5hrs, tol well. pt consult to eval strength, etc. in and pnd. s/b ot.\\nskin- intact. has some generalized edema.\\nsocial- fx in, updated on pt status, procedures and plan.\\naccess- i iv infiltrated, second patent. attempted iv insertion x2, unsuccessful, iv rn called and try for 2nd line.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409944,\n \"text\": \"nursing progress note 7p-7a\\nS\\\" I WANT TO GO TO \\\"\\n\\nO: NEURO: PT. ORIENTED TO PERSON ONLY. MOVING ALL EXTREMITIES, HAS SOME DIFFICULTIES WITH SPATIAL RELATIONS, IE UNABLE TO DIRECT YANKAUR CATH TO MOUTH. TAKING SIPS OF WATER BY STRAW WELL. SPEECH SLOW AND SOFT.\\n\\nRESP: LUNGS DIMINISHED. O2 SATS ON 2L 96%-98%. COUGHING AND RAISING THICK WHITE SPUTUM.\\n\\nCV: CONTINUES IN A-FIB RATE 80-90'S. NO VEA NOTED. BP STABLE, TOL INCREASED DOSE OF CAPTOPRIL. DIGOXIN CHANGED TO PO DIG LEVEL PENDING THIS AM.\\n\\nGI: ABD SOFT DISTENDED, NO BM TAKING SIPS OF WATER ONLY. PT STATES JUICE IS TO SWEET.\\n\\nGU: URINE ADEQUATE. AMBER COLORED.\\n\\nSLEPT IN SHORT NAPS OVERNIGHT. MORE AWAKE THIS AM\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409938,\n \"text\": \"addendum\\nstarted on captopril, tol well. increase as tol, as ordered.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409939,\n \"text\": \"CCU NPN 1900-0700\\nADDENDUM\\n\\n0600: pt. alert, Oriented to place and person. able to speak louder. continues to refuse to take any meds po. MD spoke to pt. without effect. BP 160/90 when awake. given hydralazine 20mg IV at 0630 with good effect. BP coming down to 130/60 by 0700.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409940,\n \"text\": \"CCU NPN 1900-0700\\nS: \\\" Where am I \\\"\\nO: pt. confused to place and time. able to state name only. only speaks in very low whisper voice. follows commands but very weak. trying to get hands towards face and neck. hands restrained for safety with invasive lines in place. pt. restless in early eve, putting legs over bed, getting mildly anxious when telling pt. of recent events. later in eve, pt. refusing to take captopril po (he took it at 2130). sleeps when left alone. arouses to name and/or light shaking. eyes open spont. gaze traks.\\n\\nTM 100.2R. contins. on levo IV for presumed pnx\\nHR 95-116 AF. BP 130-150/70-90. captopril inc. to 12.5, given at 2130. BP remaining high 140-150/80. captopril inc. to 25mg and additional dose of 12.5mg orderd. however, pt. refused to take, not agitated but refusing to take water or meds. instead , given hydralazine 10mg IV, only minimal effect.\\n\\nPAP 60/33, wedge 26, CVP 16 prior to lasix and when pt. more restless. down to PAD 23-27, CVP 13-15. SVO2 71. C.O. 5.8/2.5/1100.\\n\\nheparin 1000u/hr. amio .5mg/min. milrinone .32mcq/kg/min.\\n\\nLS diminished throughout. FIO2 weaned to 4lnc. sats 97-99%. RR 20-24, unlabored.\\n\\nGU: 20 lasix IV at 2100. 1.2l u/o responce. currently 100cc/hr.\\nGI: took small sips of water in early eve, no issues. (+) BS\\n\\nA: confusion after extubation\\n good diuresis.\\n BP high, req. titration up captopril\\nP: follow MS for change/improvement. follow u/o, lytes. contin, gtts per plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409941,\n \"text\": \"CCU NSG NOTE: ALT IN CV\\nS: I'm in the \\\".\\nO: For complete VS see ccu flow sheet.\\nID: T-max 100.4R. Pt conts on abx.\\nCV: PT continues to improve. HR on digoxin has come down to 80-90s Afib. He continues on IV amiodarone at .5mic. He was able to take pills and captopril was increased this afternoon from 25mg to 37.5mg and bp is now in low 100s. Milrinone was d/c at 10:30 and c/o-ci decreased to 5.1/2.2 with svr 1286. Heparin was also d/c and lovenox begun. PAP has been stable in 40s/23-26 wedge of 12 and RA of . Swan and a-line will remain in overnight and probably be removed tomorrow.\\nRESP: RR 16-22 with 02 sat on 2L NP 96-97%. He does have some creacles at bases. he has a strong cough.\\nGI: Pt was able to take pills and some jello with encouragement, but would not be safe to attempt anything more at this time due to decreased mental status. No bm.\\nRENAL: Creat down to 1.1. He was autodiuresing earlier and u/o has now dropped off to 40-60cc/hr. He is ~1600cc neg for the day.\\nMS: Pt sleeps when left alone and can be roused with vebal stimuli and wet wash cloth to face. He knows he is in hospital, knows his name, but speach is slurred. He will follow simple commands and is moving all extremities. He seems to be swallowing safely, but needs to be watched and kept awake to ensure he swallows.\\nA: Stable of milrinone/autodiuresing/slowly waking up\\nP: Monitor for changes. Check CO/CI at 8p and in am. Increase captopril as tolerated. pt frequently. Increase diet as tolerated\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-20 00:00:00.000\",\n \"description\": \"CT CHEST W/CONTRAST\",\n \"row_id\": 759463,\n \"text\": \" 1:27 PM\\n CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST Clip # \\n CT RECONSTRUCTION\\n Reason: R/O PE , EVALUATION OF RESPIRATORY DISTRESS.\\n Field of view: 40 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with RESPIRATORY DISTRESS AND AFIB. INTUBATED.\\n REASON FOR THIS EXAMINATION:\\n R/O PE\\n EVALUATION OF RESPIRATORY DISTRESS.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION:\\n 61 year old respiratory distress and atrial fibrillation.\\n\\n CT OF THE CHEST WITH CONTRAST\\n\\n CONTRAST:\\n 150 cc of IV Optiray.\\n\\n TECHNIQUE:\\n Multiple axial images of the entire chest was obtained with the use of\\n intravenous contrast.\\n\\n CT CHEST WITH CONTRAST:\\n There is no evidence of pulmonary embolus. The great vessels are normal. The\\n heart is moderately enlarged. Bilateral pleural effusions with associated\\n atelectasis is noted. Prevascular lymphadenopathy is identified. There are no\\n focal consolidations. The osseous structures demonstrate degenerative changes.\\n An endotracheal tube is identified in place.\\n\\n The unenhanced abdominal organs are unremarkable.\\n Reconstructed images demonstrate no evidence of pulmonary embolus.\\n\\n IMPRESSION:\\n 1. No pulmonary embolus.\\n 2. Moderate bilateral pleural effusions with associated atelectasis.\\n 3. Marked cardiomegaly.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 759934,\n \"text\": \" 9:54 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval CHF/ PNA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with RESPIRATORY DISTRESS S/P swan.\\n\\n REASON FOR THIS EXAMINATION:\\n eval CHF/ PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n PORTABLE CHEST, is compared to 4 days earlier.\\n\\n INDICATION: Respiratory distress.\\n\\n A SG catheter is present, with the distal tip terminating in the main\\n pulmonary artery region. No pneumothorax is identified.\\n\\n The heart is enlarged. There has been improvement in the previously reported\\n findings of congestive heart failure, with associated pleural effusions.\\n\\n No new or progressive abnormalities are identified.\\n\\n IMPRESSION:\\n 1) SG catheter in satisfactory position.\\n\\n 2) Near complete resolution of heart failure findings. Probable residual\\n small right pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409929,\n \"text\": \"addendum\\nccu npn\\npt into afib about 6:30pm, rate 140s-160s. bp maintained at 90s-100s. sat 98. pt calm/sedated at time of rhythm conversion. ho made aware. started on amiodarone at 7pm with 150mg bolus to 1mg/min drip. cont. for 6hrs, then down to .5mg/min as ordered.\\nhr staying in 140s after bolus, cont. in af. bp 80s-90s/. fx in, aware of rhythm change and treatment.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409930,\n \"text\": \"CCU NPN 7P-7A\\nAddendum:TL changed to cortis and pt swaned at 6AM, opening pressures: PAP 57/30, CVP 21, PCWP 30, CO 4.6, CI 1.99, SVR 1148 these #'s on 5ug/kg/min of dopamine, with BP 100/60. UO improved since Dopa started 40-80cc/hr. Cardioverted at 6:20 with 200J, briefly went into NSR, then back to a.fib. Given another amiodarone 150mg bolus over 10min and attempted cardioversion with 300J, same thing happened, NSR briefly than back into a.fib. Tried to decreased dopa to 3ug, BP falling to 80's/, increased back to 5ug/kg/min. During line change sats dropped to 90%, increased FIO@ to 60%, CXR done. Will need repeat ABG.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409931,\n \"text\": \"CCU NPN 7P-7A\\nCV: Pt has remained in A.fib, rate 140's on Amiodarone gtt at 1mg/min, given another bolus of 150mg at MN, HR down a bit to 120's a.fib, BP has been 80-90/70, MAP 65-75. UO cont to be minimal. Attempted 500cc NS bolus with transient improvement in BP, no increase in UO. CVP transduced via T.L., 24. Held further fluid boluses. Plan to place swan-ganz catheter to aid evaluation of volume status and C.O.\\n\\nResp: suctioned q 3-4 for scant white secretions, LS clear. When pt awake, is out of sinc with vent, RR in 30's. Changed to IMV with 12 PS, but has not made no differance in his comfort when awake. ABG sent at time of agitation was good, has maintained sats of 99-100%.\\n\\nNeuro: Difficult to sedate pt, Ativan has been increased to 6mg after several 2 mg boluses. Given 25ug of fent at a time, does drop pressure to 80/60. Haldol given, 2.5mg x2 followed by 5mg IV. Pt cont to intermittently wake up, will calm somewhat to verbal reassurances. Has at times followed commands and nodded appropriately. Awakens startled and delerious.\\n\\nID: T 100-97, given 1x dose of Levaquin, awaiting ID approval for q 24hr dosing. Has been diaphoretic, with breaking of T.\\n\\nGI: no stool, BS present. NPO.\\n\\nSoc: wife called about swan and possible cardioversion.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409932,\n \"text\": \"chf, resp failure, af\\nccu npn\\no- t max 100.8 po. cont. on levoquin. wbc 11.5. c+s pnd, sputum oroph. flora.\\ncv- hr max 122 in am, afib, down to 90s-100s, no vea. cont. on amiodarone decreased to .5mg/min at 4pm. systolic bp 90-100s, occ 80s in am. maps 66-80s. cont. on dopamine at 5mic. milrinone started 10:30am with bolus given over 1/2hr to .38mic/kg/min. co improved to 5.9, ci 2.55, svr down to 719. pa 57/35 down to low 43/20, wedge down to 20. cvp 22-11. cvp changed to rv pattern x2, pa line withdrawn x2 by mds, cvp now with ra trace, pa cont. to wedge. heparin on 1000units/hr, ptt 99.8, heparin down to 800units/hr at 2:30pm, recheck ptt this eve. inr 2.2, ho aware. k-4.7. hct 47.8, plts 115.\\nresp- cont intubated a/c 10, rarely overbreaths, tv 700, 60% with 5 peep. abg adeq, later po2 down 68, peep up to 7.5 and abg- 79,39,7.41,0. sats 92-96. l/s sl. coarse thruout, rare scat. wheeze.\\nu/o improved with milrinone to 130-230cc/hr. sx'd infreq for small white sputum.\\nrenal- creat up to 2.5 (1.3).\\ngi- abd soft with b. sounds. ogt with small dk green bile. started on nepro at 10cc/hr, increase as tol to 30cc/hr. hold at 12am for possible extubation . no bm.\\nms/neuro- sedated well on ativan 6mg/hr and 50mic fentanyl in am, not waking to sx'ing or movement. ativan decreased to 5mg/hr. wakes slightly with repos or sx'ing. able to follow commands and nod/shake head appropriately when sl. awake. mae.\\nskin- intact repos side to side to back q3hrs with skin/oral care. hands sl. edematous. 2 rings removed with wife's permission and given to fx.\\nsocial- fx in, supportive to each other and pt. enc to talk/interact with pt. status, plan explained to fx, understand. reinforce, update prn.\\na/p- diuresing with improved hemodynamics on milrinone. sats gradually improving, ?try to decrease to 50% this eve if sats cont. to rise. would start with low dose lasix if used (20mg). cont. on ativan/fentanyl. hold t/f at 12am. recheck ptt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1409933,\n \"text\": \"NEURO: SEDATED WITH ATIVAN 5MG/HR & FENTANYL 50MCG/HR. RESPONDS TO\\n PAINFUL STIMULI. MAE. ATTEMPTS TO OPEN EYES.\\nRESP: ON VENT: FIO2 WEANED FROM .60->.40 X 700 + AC 10 & 7.5 PEEP.\\n BS COURSE AND DIMINISHED AT BASES. O2 SAT 94-98%. RR 10/10.\\n SX FOR SM.-MOD. AMTS. THICK YELLOW SPUTUM. ABG 7.43/38/91/26\\n 97% SAT.\\nCARDIAC: HR 93-110 AF. BP 90-117/50-60'S. PAD 21-27, CVP 9-14, W 23,\\n CO 6.1/2.64/866. ~0100 HR 120'S AF WITH INCREASED VEA. HO\\n CALLED->WEAN DOPA AS TOL. LEVOPHED STARTED & DOPA WEANED TO\\n OFF. CA,MG,PO4 SENT. MG 1.6->TREATED WITH MGS04 2GMS PB X1.\\n HR BACK TO 90-100'S. ECTOPY RESOLVED. LEVOPHED 4.5MCG/MIN->\\n CO 4.5/1.95/1227. CONT. ON AMIODARONE .5MG/HR, MILRINONE\\n .38MCG/KG, & HEPARIN GTT AT 800U/HR. PTT 61.3. HO AWARE OF\\n HEMODYNAMICS.\\nGI: TF: FS NEPRO 10CC/HR. MINIMAL RESIDUALS. D/C'D AT MIDNOC & NPO->\\n ? EXTUBATION. ABD. SL. DISTENDED. BS+. NO STOOL.\\nGU: FOLEY->CD PATENT & DRAINING CLEAR AMBER URINE. U/O 50-170CC/HR\\n DOWN TO 20-30CC/HR THIS AM. HO AWARE.\\nID: AFEBRILE. CONT. ON IV LEVOFLOX.\\nENDO: BS 130->111. NO INSULIN REQUIRED.\\nLABS: WBC 11.4, HCT 40.9, PLAT CT 106K, CHEMISTRIES PENDING.\\nNEED TO ADDRESS DECREASED CI & LOW U/O.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-20 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 759448,\n \"text\": \" 10:49 AM\\n CHEST (PA & LAT) Clip # \\n Reason: r/o CHF\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with SOB, bilateral pedal edema\\n REASON FOR THIS EXAMINATION:\\n r/o CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION:\\n Shortness of breath, pedal edema.\\n\\n CHEST PA AND LATERAL:\\n The cardiomediastinal silhouette is stable. Acute fracture of the posterior\\n 4th rib is identified. There are no focal consolidations. There is mild\\n prominence of the interstitial markings. There is a small left-sided pleural\\n effusion.\\n\\n IMPRESSION:\\n 1. Minimal CHF.\\n 2. Acute 4th posterior rib fracture.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 759520,\n \"text\": \" 8:17 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate chf\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with RESPIRATORY DISTRESS S/P TRIPLE LUMEN CL PLACEMENT\\n REASON FOR THIS EXAMINATION:\\n evaluate chf\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: SOB, S/P triple lumen placement.\\n\\n CHEST, SINGLE PORTABLE VIEW:\\n\\n The right portion of the chest is not included on this supine film. An ET\\n tube is present, the tip 5.6 cm above the carina. An NG tube is present, tip\\n partially obscured, but thought to overlie the stomach. A right IJ line is\\n present, tip overlying proximal SVC.\\n\\n The cardiomediastinal silhouette is prominent. There is hazy opacity in both\\n lungs, suggesting layering effusions. I suspect the presence of underlying\\n vascular plethora/CHF. There is also left lower lobe collapse and/or\\n consolidation and atelectasis in the visualized portion of the right base. No\\n supine film evidence of pneumothorax is identified.\\n\\n Healed left 4th rib fracture noted.\\n\\n IMPRESSION: Mild chf with effusions and bibasilar collpase/consolidation. No\\n pneumothorax detected.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 759462,\n \"text\": \" 1:20 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: R/O PNEUMO\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with RESPIRATORY DISTRESS S/P TRIPLE LUMEN CL PLACEMENT\\n REASON FOR THIS EXAMINATION:\\n R/O PNEUMO\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 61-year-old with respiratory distress S/P triple lumen central\\n line placement.\\n\\n AP VIEW OF THE CHEST:\\n\\n Comparison made to examination from the same day at 12:57pm.\\n\\n Endotracheal tube identified at the level of the superior clavicles. A right-\\n sided central line is identified with tip at the proximal superior vena cava.\\n There is no pneumothorax. Heart and lungs are unchanged.\\n\\n IMPRESSION: Right central line catheter with tip in the proximal superior\\n vena cava.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 759459,\n \"text\": \" 12:50 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: CHECK OGT AND ETT PLACEMENT. , EVALUATION OF RESPIRATORY DI\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with RESPIRATORY DISTRESS\\n REASON FOR THIS EXAMINATION:\\n CHECK OGT AND ETT PLACEMENT.\\n EVALUATION OF RESPIRATORY DISTRESS.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Respiratory distress, evaluate endotracheal tube placement.\\n\\n PORTABLE AP VIEW OF THE CHEST:\\n\\n Comparison made to same-day examination performed at 10:59AM.\\n\\n Endotracheal tube is identified with the tip at the level of the superior\\n portion of the clavicles. There is no pneumothorax. There is bilateral hilar\\n vascular congestion consistent with congestive heart failure. The cardiac\\n silhouette and osseous structures are unchanged.\\n\\n IMPRESSION: Endotracheal tube in satisfactory position.\\n 2) mild CHF\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 759571,\n \"text\": \" 5:56 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval swan placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with RESPIRATORY DISTRESS S/P swan.\\n REASON FOR THIS EXAMINATION:\\n eval swan placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Respiratory distress status post Swan.\\n\\n CHEST, SINGLE AP PORTABLE VIEW.\\n\\n Compared with one day earlier, a right IJ Swan-Ganz catheter is now in place.\\n The tip lies relatively distal in the right pulmonary artery and retraction of\\n the tip should be considered. There is marked prominence of the\\n cardiomediastinal silhouette, unchanged compared with one day earlier. There\\n is upper zone redistribution and diffuse vascular blurring, consistent with\\n CHF. There are bilateral pleural effusions, greater on the right, with\\n underlying collapse and/or consolidation. The extreme left costophrenic angle\\n is not included on this film.\\n\\n IMPRESSION:\\n\\n 1. Interval placement of right IJ Swan-Ganz catheter with tip relatively\\n distal in right pulmonary artery. Retraction of the tip should be considered.\\n\\n 2. Prominence of the cardiomediastinal silhouette. This is similar to the\\n appearance on the portable film, but more pronounced than on the PA view.\\n This appearance is likely accentuated by AP supine technique. However,\\n clinical correlation is requested. (Scattered nodes are present in the\\n mediastinum on the CTA from and there was mediastinal lipomatosis but no\\n hemorrhage within the mediastinum was identified at that time.)\\n\\n 3. CHF and bilateral effusions.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":23596,"cells":{"subject_id":{"kind":"number","value":109,"string":"109"},"hadm_id":{"kind":"number","value":139061,"string":"139,061"},"target_text":{"kind":"string","value":"ICU course: EKG showed no change from prior, and CXR showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home medication regimen. The patient was found to by hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. . history: . 1. Hypertensive urgency: During the patient's stay, her SBPs ranged from 140s-160s during the day, which is her baseline systolic blood pressure. She was maintained on her home oral medication regimen. At night, she became more hypertensive, with SBP to the 170s-180s, which was controlled with both IV hydralazine and PO nifedipine. PO nifedipine was most successful at bringing her SBP back to her baseline. SBP at discharge was 140. Throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. The renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. Right leg pain: Upon arrival on the floor, the patient complained of pain in R buttock and posterior thigh, much exacerbated with standing. Of note, lumbar spine MRI and R hip XR on most recent admission were both negative. Her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. Her pain when she was symptomatic was controlled well with PO dilaudid. If the pain recurs, an MRI of the right hip can be considered to evaluate for osteonecrosis. . 3. UTI: The patient had a urinalysis suggestive of UTI, though she remained asymptomatic throughout. She was treated with a three day course of ciprofloxacin. Her urine culture showed mixed flora consistent with skin contamination. . 4. ESRD: The patient has end-stage renal disease due to her lupus. The patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. She was followed by the renal consult service. Her potassium remained stable. Her calcium was low during admission, and supplemental calcium was given in addition to starting Calcitriol. She was not dialyzed through her PD catheter secondary to discomfort, but may reinitiate PD as an outpatient. Her laboratories will be checked as an outpatient in renal clinic. . 5. Anemia: The patient's hematocrit remained near her baseline low 20s throughout her stay. She has anemia from chronic kidney disease and chronic disease. The patient is not on Epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. Prior SVC thrombus: The patient has a reported history of prior thrombus related to catheter placement in , and was maintained on warfarin with INR goal 2.5 to 3.0. . 7. Systemic lupus erythematosus: No active issues. The patient's home prednisone regimen was continued."},"extractive_notes_summ":{"kind":"string","value":"Action: Bp lower beginning of shift (120/70) Hydralazine, Labetalol Aliskiren held. - Thrombocytopenia. malignant hypertension, baseline sBPs 180s-120s. - Thrombotic events. 3) Right lower extremity pain: 4) Hyperkalemia: Kayexalate as refusing dialysis. ALLERGIES: Penicillins / Percocet . hct 24.7, pt with baseline anemia. hct 24.7, pt with baseline anemia. hct 24.7, pt with baseline anemia. Zofran prn nausea. Zofran prn nausea. Reason for MICU Admission: Malignant Hypertension. Response: Sbp lowering to as low as 160s via noninvasive cuff and 180s aline. Response: Sbp lowering to as low as 160s via noninvasive cuff and 180s aline. There is a trivial/physiologic pericardial effusion. - Anemia. .H/O hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: Labetolol gtt off on days. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on labetalol gtt. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on labetalol gtt. Previous treatment with cytoxan, cellcept; currently on prednisone. Repeat k 5.0 from 5.9( 5.9 was moderately hemolyzed). When getting VS in , pt noted to be very hypertensive at 263/176. When getting VS in , pt noted to be very hypertensive at 263/176. - Malignant hypertension. - CKD/ESRD. Pt admitted to 4 for malignant hypertension, was on Labetolol gtt. bun 51, cr 8.4, k 5.9, moderately hemolyzed. bun 51, cr 8.4, k 5.9, moderately hemolyzed. bun 51, cr 8.4, k 5.9, moderately hemolyzed. Sent up from the ED on labetolol drip. .H/O hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: Action: Response: Plan: .H/O hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: Action: Response: Plan: Labetalol drip weaned to as low as 1mg/hr but sbp still 170s-180s noninvasive cuff and 190s-200s aline. Labetalol drip weaned to as low as 1mg/hr but sbp still 170s-180s noninvasive cuff and 190s-200s aline. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on home regimen. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on home regimen. Prn Zofran for nausea. # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen . # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen . .H/O hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: Sbp in 230s on arrival to icu via aline. .H/O hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: Sbp in 230s on arrival to icu via aline. Tonsillectomy. Renal c/s initiated. - Thrombotic events. - Thrombocytopenia. malignant hypertension, baseline sBPs 180s-120s. malignant hypertension, baseline sBPs 180s-120s. There is a trivial/physiologic pericardial effusion. - Anemia. ALLERGIES: Penicillins / Percocet . Reason for MICU Admission: Malignant Hypertension. - CKD/ESRD. Left atrial enlargement. 8:54 AM UNILAT LOWER EXT VEINS RIGHT Clip # Reason: dvt? - Malignant hypertension. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on labetalol gtt. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on labetalol gtt. # Prior SVC thrombus: Related to catheter in . # Prior SVC thrombus: Related to catheter in . Previous treatment with cytoxan, cellcept; currently on prednisone. When getting VS in , pt noted to be very hypertensive at 263/176. Renal c/s initiated. TTP (got plasmapheresisis) versus malignant HTN. Tonsillectomy. Diagosed . Asymptomatic currently. Initiated dialysis . CV: mildly tachy, RR, +S4. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on home regimen. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on home regimen. RIGHT LOWER EXTREMITY ULTRASOUND -scale and Doppler son of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. CKD/ESRD, diagnosed in , initiated hemodialysis . CKD/ESRD, diagnosed in , initiated hemodialysis . TTP (got plasmapheresis) versus malignant HTN thrombotic events. TTP (got plasmapheresis) versus malignant HTN thrombotic events. GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted. GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted. Mild (1+) aortic regurgitation is seen. # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen . # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen . previous treatment with cytoxan, cellcept, currently on prednisone. previous treatment with cytoxan, cellcept, currently on prednisone. Negative lupus anticoagulant (, , 9/). Negative lupus anticoagulant (, , 9/). Negative lupus anticoagulant (, , 9/). Evaluate for DVT. # ACCESS: Peripheral IV, A-line . # ACCESS: Peripheral IV, A-line . PD site - c/d/i. PD site - c/d/i. Past transfusion requirement. Past transfusion requirement. FINAL REPORT HISTORY: Shortness of breath. Not on epo given hypertension. Not on epo given hypertension. SVC thrombosis (); related to a catheter. Denies any swelling of her RLE. Uses commode to void. Uses commode to void. Currently, she has RLE pain. Some increased haziness of RLL/R diaphragm from CXR. The patient reportedly has bseline SBPs in 130-170s."},"n_notes":{"kind":"number","value":21,"string":"21"},"notes":{"kind":"list like","value":[{"category":"General","chartdate":"2141-09-11 00:00:00.000","description":"Initial H&P","row_id":339012,"text":" ADMISSION NOTE\n .\n Reason for MICU Admission: Malignant Hypertension.\n .\n Primary Care Physician: MD / MD\n .\n CC: Right leg pain.\n .\n HPI: Ms. is a 24 y.o. F with lupus, Chronic Kidney Disease V (not\n currently on HD or PD), and multiple admissions for hypertensive\n urgency/emergency, who presented to the ED for continued R leg pain\n that starts in her R buttocks and refers down her R leg. She describes\n it as feeling like the pain is deep within her bone. The pain was\n this AM, and she felt like she couldn't get out of bed. Denies\n any swelling of her RLE. When getting VS in , pt noted to be very\n hypertensive at 263/176. The patient reportedly has bseline SBPs in\n 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM\n on day of admission. She denies headache, vision changes, double\n vision, chest pain, shortness of breath, abdominal pain, BRBPR,\n dysuria. During MD interview, the patient was nauseous and had small\n amount of emesis of a recent Coolata. Pt states that flushing her PD\n cath causes a large amout of stomach pain. Currently, she has RLE\n pain.\n .\n In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in\n ED ranged from -175 with HR in 96-108. Initially given\n labetalol 10 mg IV x 1 and then started on labetalol gtt for her\n elevated blood pressures and titrated to 3 mg/min. LENI of R leg was\n negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per\n ED, cannot do V/Q scan due to volume overload after talking with\n radiology. Renal c/s initiated. A-line placed.\n .\n Of note, the patient was recently admitted from 08.26-29.08. The\n patient initially presented to the ED after referral from her\n nephrologist's office where she had complaints of right leg pain and\n was found to be hypertensive to 250/145. She was admitted after\n initiation of a labetalol drip and nitropaste with improvement in sbp\n to 180. The patient did receive 2 U of PRBC's during this\n hospitalization for baseline anemia. The patient did have a work-up for\n her right leg pain complaints with plain films of the right hip and MRI\n of the L-spine which did not reveal an explanation for her symptoms and\n did rule out avascular necrosis. The patient received dilaudid for pain\n control and was ambulating without pain prior to discharge. In\n addition, the patient completed a course of ciprofloxacin for a\n positive UA with negative cultures. The patient was unable to tolerate\n peritoneal dialysis for unclear reasons. Peritoneal dialysate culture\n was negative for infection.\n .\n ROS: as stated above in HPI.\n .\n MEDICATIONS (from discharge summary ):\n - Prednisone 5 mg Daily\n - Coumadin 2 mg at bedtime\n - Nifedipine 60 mg Sustained Release Daily\n - Hydralazine 50 mg every 8 hours\n - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday\n - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY\n - Aliskiren 150 mg Twice daily\n - Docusate Sodium 100 mg 2 times a day\n - Labetalol 900 mg three times a day\n - Lactulose 15-30 ml once a day: goal is soft bowel movements per\n day\n .\n ALLERGIES: Penicillins / Percocet\n .\n PAST MEDICAL HISTORY:\n - Systemic lupus erythematosus. Diagnosed (16 years old) when she\n had swollen fingers, arm rash and arthralgias. Previous treatment with\n cytoxan, cellcept; currently on prednisone. Complicated by uveitis\n () and ESRD ().\n - CKD/ESRD. Diagosed . Initiated dialysis . PD catheter\n placement . Pt reluctant to start PD.\n - Malignant hypertension. Baseline BPs 180's - 120's. History of\n hypertensive crisis with seizures. History of two intraparenchymal\n hemorrhages that were thought to be due to the posterior reversible\n leukoencephalopathy syndrome.\n - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN.\n - Thrombotic events. SVC thrombosis (); related to a catheter.\n Negative lupus anticoagulant (, , 9/). Negative\n anticardiolipin antibodies IgG and IgM x4 (-). Negative Beta-2\n glycoprotein antibody (, 8/).\n - HOCM: Last noted on echo .\n - Anemia.\n - History of left eye enucleation for fungal infection.\n - History of vaginal bleeding lasting 2 months s/p DepoProvera\n injection requiring transfusion.\n - History of Coag negative Staph bacteremia and HD line\n infection - and \n .\n PAST SURGICAL HISTORY:\n 1. Placement of multiple catheters including dialysis.\n 2. Tonsillectomy.\n 3. Left eye enucleation in .\n 4. PD catheter placement in .\n .\n SOCIAL HISTORY: Single. Lives with her mother and brother. On\n disability. Denies EtOH, tobacco or drug use.\n .\n FAMILY HISTORY: No history of autoimmune or thrombophilic disorders.\n .\n PHYSICAL EXAM:\n VS: T 98.9 99$% RA\n GEN: NAD, pleaseant female sitting in bed with moon facies\n HEENT: EOMI of R eye, L eye prosthesis, OP - no exudate, no erythema,\n MMM, no LAD\n CHEST: CTAB except at R base with decreased breath sounds; no w/r/r\n CV: tachy, no m/r/g appreciated, + S4\n ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i\n EXT: no c/c/e, + SLR of RLE, able to wiggle toes and raise BLE off bed\n NEURO: II - XII grossly intact\n DERM: no rashes noted\n .\n LABORATORIES:\n Na 138, K 5.9 (hemolyzed), Cl 108, Bicarb 21, BUN/Cr 51/8.4, glucose\n 85, WBC 5.5 (74 N, 17.5 L), Hct 24.7, platelets 101.\n .\n UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50\n WBC\n .\n MICROBIOLOGY:\n Blood culture (): Pending.\n Urine culture (): No growth.\n Peritoneal fluid (): Gram stain no PMN's or microorganisms.\n Culture pending.\n .\n STUDIES:\n EKG : sinus tachy @ 100 bpm, nl axis, borderline PR prolongation,\n long QT interval, no acute ST-TWI. No change from prio on .\n PORTABLE CXR (my read): Cardiomegaly. Some increased haziness of\n RLL/R diaphragm from CXR.\n R LENI (wet read): No DVT.\n .\n TTE (): The left atrium is normal in size. There is severe\n symmetric left ventricular hypertrophy. The left ventricular cavity is\n unusually small. Regional left ventricular wall motion is normal. Left\n ventricular systolic function is hyperdynamic (EF>75%). There is a mild\n resting left ventricular outflow tract obstruction. The gradient\n increased with the Valsalva manuever. The findings are consistent with\n hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular\n septal defect. Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) appear structurally normal with\n good leaflet excursion. No masses or vegetations are seen on the aortic\n valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears\n structurally normal with trivial mitral regurgitation. There is no\n mitral valve prolapse. No mass or vegetation is seen on the mitral\n valve. The estimated pulmonary artery systolic pressure is normal.\n There is a trivial/physiologic pericardial effusion.\n .\n R HIP XR : No acute fracture or dislocation.\n .\n MRI L-SPINE : Diffuse low-signal intensity is identified in the\n bone marrow of the lumbar and lower thoracic spine as described above,\n possibly related with anemic changes, please correlate clinically.\n There is no evidence of spinal canal stenosis or neural foraminal\n narrowing at the different intervertebral disc spaces.\n .\n ASSESSMENT & PLAN: 24 y.o. F with ESRD (not on HD or PD) and lupus,\n admitted for malignant hypertension, currently on labetalol gtt.\n .\n # Malignant hypertension: SBPs currently in 200s with baseline SBP\n 130-180s. No symptoms/signs of hypertensive emergency as pt without\n seizures, no acute worsening of renal function (anuric at baseline)\n Denies HA, blurry vision, chest pain. + nausea/vomiting\n - Continue labetalol drip with down-titration as possible for goal SBP\n in 170-180s\n - NTG transdermal now\n - Transition to home dose oral labetalol when able\n - Re-start home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren when able\n - Monitor BPs closely\n - Neuro checks q 4 hours\n .\n # Right leg pain: Lumbar spine MRI and R hip XR on most recent\n admission were both negative. Likely sciatica.\n - IV Morphine as needed for pain\n - Transition to po pain medications when able\n .\n # UTI: UCx pending. Asymptomatic currently.\n - ciprofloxacin x 3 days\n - f/u Urine culture\n - check EKGs daily while on FQ and borderline prolonged QT\n .\n # ESRD: Pt not on PD although with PD catheter. On last admission, she\n had difficulty tolerating PD secondary to pain.\n - Peritoneal dialysis as tolerated\n - Appreciate renal recommendations\n .\n # Hyperkalemia: K elevated to 5.9 on admission, but moderately\n hemolyzed\n - check electrolytes now\n - EKG on arrival to ICU\n .\n # Anemia: Likely related to chronic disease. Baseline Hct 20, currently\n 24. Not on epo given hypertension. Past transfusion requirement.\n - Trend Hct daily\n - Transfer if Hct < 20\n - active T&S\n .\n # Prior SVC thrombus: Related to catheter in . INR goal 2.5 to\n 3.0. Was elevated to 3.4 on d/c on \n - check coags now to decide whether to continue or hold coumadin.\n .\n # Systemic lupus erythematosus:\n - Continue prednisone daily\n .\n # HOCM: Seen on TTE in .\n - BP management as above.\n - Avoid excessive volume removal.\n .\n # Thrombocytopenia: Baseline platelets approximately 100.\n - trend platelets daily\n .\n # FEN: no IVFs / replete lytes prn / ADAT\n .\n # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen\n .\n # ACCESS: Peripheral IV, A-line\n .\n # CONTACT: (mother) \n .\n # CODE: Full Code\n .\n # DISPO: ICU pending blood pressure control\n .\n .\n .\n .\n , MD, MPH\n \n PGY-2\n"},{"category":"Nursing","chartdate":"2141-09-11 00:00:00.000","description":"Nursing Progress Note","row_id":339074,"text":"24 y.o. woman adm with hypertensive crisis with bp 260s/150s, hx\n htn, esrd, had pd catheter placed 2 months ago but uable to tolerate pd\n treatments d/t severe abd pain with exchange. pt was admitted last week\n with leg pain, was discharged on dilaudid but the leg pain grew worse.\n pt given morphine for the pain in the er. the hypertension was treated\n with 10mg iv labetolol without effect. pt was started on a labetolol\n drip at 1mg/min and titrated up to 3mg/mg with bp 230s/150s. pt also\n s/o shortness of breath. LENIs negative for dvt. cxr normal. urine sent\n in er. hct 24.7, pt with baseline anemia. bun 51, cr 8.4, k 5.9,\n moderately hemolyzed. pt transferred to 4 icu for treatement of\n her hypertensive crisis.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n Sbp in 230s on arrival to icu via aline. Sbp 10 points lower via\n noninvasive cuff. Labetalol drip was infusing at 3mg/hr and titrated up\n to as high as 5mg/hr with 1 inch nitropaste placed on chest wall. Pt\n c/o +n/v 10cc strawberry colored emesis (pt had strawberry drink in\n er). Also c/o right leg pain she\ns been having.\n Action:\n Labetalol drip maintained at 5mg/hr until pt able to take po meds.\n Given iv zofran for n/v with good effect. Given 2mg iv morphine with\n good effect with pain to her baseline 5. pt given po hydralazine\n and po labetalol with lunch.\n Response:\n Sbp lowering to as low as 160s via noninvasive cuff and 180s aline.\n (goal sbp 130-170, dbp <100). Labetalol drip weaned to as low as 1mg/hr\n but sbp still 170s-180s noninvasive cuff and 190s-200s aline. New 1\n inch nitropaste applied to chest wall with old paste wiped off at\n 16:55. developed a headache shortly after new nitropaste applied. Given\n 650mg Tylenol.\n Plan:\n Continue to attempt to wean labetalol drip, continue antihypertensives\n as ordered. Morphine prn right leg pain. Tylenol prn headache. Zofran\n prn nausea.\n"},{"category":"Nursing","chartdate":"2141-09-12 00:00:00.000","description":"Nursing Transfer Note","row_id":339272,"text":"24 y.o. F with ESRD (not on HD or PD) and lupus, admitted for malignant\n hypertension, currently on home regimen.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n SBP 160-170\ns/100\ns- 110\ns with baseline SBP 130-180s, No\n symptoms/signs of hypertensive emergency as pt without seizures, no\n acute worsening of renal function (anuric at baseline) Denies HA,\n blurry vision, chest pain. Denies nausea/vomiting. No peripheral\n edema. Peripheral pulses present.\n Action:\n Re-started home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren. - Monitor BPs closely. Neuro checks q 4 hours\n Response:\n SBP at 150-160\ns/100\ns ( 2 pm hydralazine held due to SBP of 120\n Plan:\n Continue to monitor patient hemodynamic status, hypertensive meds\n ASDIR.\n Neuro: alert oriented X3, follows commands, steady gait. Incompliant\n w/some of the care. RT leg pain - Lumbar spine MRI and R hip XR on most\n recent admission were both negative. Likely sciatica\n morphine IV\n given w/some effect\n Resp: on RA sats at high 90\ns-100%. Bil LS clear, RRR, unlabored\n breathing.\n GI: abd soft non tender, non distended, positive for BS. Regular diet\n (patient been refusing renal diet). Denies N/V. PD site - c/d/i.\n dressing changed today.\n GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted.\n Uses commode to void. Clean yellow urine. Dx of UTI on cipro. Urine\n cultures were sent. F/u results.\n Skin: no skin impairment\n Social: patient is a FULL CODE. Family in to visit.\n K- 5.4 kayexalate 30gr given at 11 am awaiting results.\n HX of SVC thrombus related to catheter in . INR goal 2.5 to 3.0.\n Patient on coumadin 5mg daily.\n SLE\n on daily prednisone.\n"},{"category":"Physician ","chartdate":"2141-09-12 00:00:00.000","description":"Physician Attending Progress Note","row_id":339234,"text":"Chief Complaint: lower extremity pain\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n year old female presented with right lower extremity pain and found to\n be very hypertensive.\n Sent up from the ED on labetolol drip.\n 24 Hour Events:\n ARTERIAL LINE - START 11:15 AM\n EKG - At 12:47 PM\n History obtained from Patient\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Med list reviewed\n Changes to medical and family history:\n Lupus\n ESRD\n Malignant Hypertension\n Thrombocytopenia\n HOCM\n Anemia\n Left eye enucleation\n Coag negative staph\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis\n Flowsheet Data as of 10:04 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: 35.6\nC (96\n HR: 83 (71 - 99) bpm\n BP: 148/103(113) {115/58(74) - 208/153(166)} mmHg\n RR: 15 (13 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,725 mL\n 180 mL\n PO:\n 440 mL\n 180 mL\n TF:\n IVF:\n 1,285 mL\n Blood products:\n Total out:\n 255 mL\n 150 mL\n Urine:\n 250 mL\n 150 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 1,470 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///16/\n Physical Examination\n General Appearance: Well nourished\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric)\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, No(t) Oriented (to): , Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 8.3 g/dL\n 93 K/uL\n 99 mg/dL\n 8.5 mg/dL\n 16 mEq/L\n 5.4 mEq/L\n 52 mg/dL\n 107 mEq/L\n 136 mEq/L\n 24.7 %\n 3.9 K/uL\n [image002.jpg]\n 11:43 AM\n 06:10 AM\n WBC\n 3.9\n Hct\n 24.7\n Plt\n 93\n Cr\n 8.1\n 8.5\n Glucose\n 86\n 99\n Other labs: PT / PTT / INR:18.9/39.2/1.7, Ca++:6.6 mg/dL, Mg++:1.6\n mg/dL, PO4:5.6 mg/dL\n Assessment and Plan\n A:\n 1) Hypertensive Urgency: still with some relatively high BPs (160/100)\n but asymptomatic and off labetolol drip.\n Plan:\n - Continue clonidine, labetolol,\n 2) ESRD: still refusing dialysis. I discussed this with her including\n risk of refusal which include death.\n 3) Right lower extremity pain:\n 4) Hyperkalemia: Kayexalate as refusing dialysis.\n 5) SLE\n 6) Thromobocytopenia: Stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:15 AM\n 20 Gauge - 11:25 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: 35 minutes\n"},{"category":"Nursing","chartdate":"2141-09-12 00:00:00.000","description":"Nursing Progress Note","row_id":339131,"text":"Ms. is a 24 y.o. F with lupus, Chronic Kidney Disease V (not\n currently on HD or PD), and multiple admissions for hypertensive\n urgency/emergency, who presented to the ED for continued R leg pain\n that starts in her R buttocks and refers down her R leg. She describes\n it as feeling like the pain is deep within her bone. The pain was\n this AM, and she felt like she couldn't get out of bed. Denies\n any swelling of her RLE. When getting VS in , pt noted to be very\n hypertensive at 263/176. The patient reportedly has baseline SBPs in\n 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM\n on day of admission. She denies headache, vision changes, double\n vision, chest pain, shortness of breath, abdominal pain, BRBPR,\n dysuria. During MD interview, the patient was nauseous and had small\n amount of emesis of a recent Coolata. Pt states that flushing her PD\n cath causes a large amout of stomach pain. Currently, she has RLE\n pain. Pt admitted to\n 4 for malignant hypertension, was on Labetolol gtt.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n Labetolol gtt off on days. Bp on the lower side at change of shift\n 120-130/74. (nitropaste removed) currently bp 160/98 HR 70\ns SR\n BP higher via A-line (A-line with good dynamic response, good\n tracing) on left arm 20 point difference in BP . In Right\n arm 10 point difference). We are using the A-line to monitor bp\n INR 1.7 ~ pt received 5 mg po Coumadin. No further pain from right\n leg.\n Pt denies HA, blurry vision, chest pain. No further nausea/vomiting.\n Action:\n Bp lower beginning of shift (120/70) Hydralazine, Labetalol\n Aliskiren held.\n Response:\n Bp slowly rising over shift.\n Plan:\n Give antihypertensives if SBP over 160. Coumadine 5 mg po qd prn\n Morphine for leg pain, prn Tylenol for headache. Prn Zofran for\n nausea. Monitor lytes.\n GU: pt voiding in commode. Urine output 200 cc\ns. bun 49, crt\n 8.1 pt with UTI\n on Cipro.\n GI: pt on a regular diet poor appetite. On pantoprazole\n PAIN: no further right leg pain, lumbar spine MRI and R hip xray on\n most recent admission were both negative. Likely sciatica\n prn\n morphine as needed.\n .\n"},{"category":"Physician ","chartdate":"2141-09-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":339197,"text":"Chief Complaint:\n 24 Hour Events:\n Pressures finally dropped to 130/80s and labetelol drip was stopped\n ARTERIAL LINE - START 11:15 AM\n EKG - At 12:47 PM\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 01:21 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 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: 36.9\nC (98.4\n HR: 79 (71 - 99) bpm\n BP: 142/105(113) {115/58(74) - 208/153(166)} mmHg\n RR: 13 (13 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,725 mL\n 180 mL\n PO:\n 440 mL\n 180 mL\n TF:\n IVF:\n 1,285 mL\n Blood products:\n Total out:\n 255 mL\n 150 mL\n Urine:\n 250 mL\n 150 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 1,470 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///16/\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 8.3 g/dL\n 86 mg/dL\n 8.1 mg/dL\n 16 mEq/L\n 5.0 mEq/L\n 49 mg/dL\n 110 mEq/L\n 139 mEq/L\n 24.7 %\n 3.9 K/uL\n [image002.jpg]\n 11:43 AM\n 06:10 AM\n WBC\n 3.9\n Hct\n 24.7\n Cr\n 8.1\n Glucose\n 86\n Other labs: PT / PTT / INR:18.4/42.8/1.7, Ca++:6.2 mg/dL, Mg++:1.6\n mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:15 AM\n 20 Gauge - 11:25 AM\n 18 Gauge - 11:26 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":"2141-09-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":339202,"text":"Chief Complaint:\n 24 Hour Events:\n Pressures finally dropped to 130/80s and labetelol drip was stopped\n ARTERIAL LINE - START 11:15 AM\n EKG - At 12:47 PM\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 01:21 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 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: 36.9\nC (98.4\n HR: 79 (71 - 99) bpm\n BP: 142/105(113) {115/58(74) - 208/153(166)} mmHg\n RR: 13 (13 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,725 mL\n 180 mL\n PO:\n 440 mL\n 180 mL\n TF:\n IVF:\n 1,285 mL\n Blood products:\n Total out:\n 255 mL\n 150 mL\n Urine:\n 250 mL\n 150 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 1,470 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///16/\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 8.3 g/dL\n 86 mg/dL\n 8.1 mg/dL\n 16 mEq/L\n 5.0 mEq/L\n 49 mg/dL\n 110 mEq/L\n 139 mEq/L\n 24.7 %\n 3.9 K/uL\n [image002.jpg]\n 11:43 AM\n 06:10 AM\n WBC\n 3.9\n Hct\n 24.7\n Cr\n 8.1\n Glucose\n 86\n Other labs: PT / PTT / INR:18.4/42.8/1.7, Ca++:6.2 mg/dL, Mg++:1.6\n mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n ASSESSMENT & PLAN: 24 y.o. F with ESRD (not on HD or PD) and lupus,\n admitted for malignant hypertension, currently on labetalol gtt.\n .\n # Malignant hypertension: SBPs currently in 200s with baseline SBP\n 130-180s. No symptoms/signs of hypertensive emergency as pt without\n seizures, no acute worsening of renal function (anuric at baseline)\n Denies HA, blurry vision, chest pain. + nausea/vomiting\n - Continue labetalol drip with down-titration as possible for goal SBP\n in 170-180s\n - NTG transdermal now\n - Transition to home dose oral labetalol when able\n - Re-start home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren when able\n - Monitor BPs closely\n - Neuro checks q 4 hours\n .\n # Right leg pain: Lumbar spine MRI and R hip XR on most recent\n admission were both negative. Likely sciatica.\n - IV Morphine as needed for pain\n - Transition to po pain medications when able\n .\n # UTI: UCx pending. Asymptomatic currently.\n - ciprofloxacin x 3 days\n - f/u Urine culture\n - check EKGs daily while on FQ and borderline prolonged QT\n .\n # ESRD: Pt not on PD although with PD catheter. On last admission, she\n had difficulty tolerating PD secondary to pain.\n - Peritoneal dialysis as tolerated\n - Appreciate renal recommendations\n .\n # Hyperkalemia: K elevated to 5.9 on admission, but moderately\n hemolyzed\n - check electrolytes now\n - EKG on arrival to ICU\n .\n # Anemia: Likely related to chronic disease. Baseline Hct 20, currently\n 24. Not on epo given hypertension. Past transfusion requirement.\n - Trend Hct daily\n - Transfer if Hct < 20\n - active T&S\n .\n # Prior SVC thrombus: Related to catheter in . INR goal 2.5 to\n 3.0. Was elevated to 3.4 on d/c on \n - check coags now to decide whether to continue or hold coumadin.\n .\n # Systemic lupus erythematosus:\n - Continue prednisone daily\n .\n # HOCM: Seen on TTE in .\n - BP management as above.\n - Avoid excessive volume removal.\n .\n # Thrombocytopenia: Baseline platelets approximately 100.\n - trend platelets daily\n .\n # FEN: no IVFs / replete lytes prn / ADAT\n .\n # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen\n .\n # ACCESS: Peripheral IV, A-line\n .\n # CONTACT: (mother) \n .\n # CODE: Full Code\n .\n # DISPO: ICU pending blood pressure control\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:15 AM\n 20 Gauge - 11:25 AM\n 18 Gauge - 11:26 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":"2141-09-11 00:00:00.000","description":"Nursing Progress Note","row_id":339030,"text":"24 y.o. woman adm with hypertensive crisis with bp 260s/150s, hx\n htn, esrd, had pd catheter placed 2 months ago but uable to tolerate pd\n treatments d/t severe abd pain with exchange. pt was admitted last week\n with leg pain, was discharged on dilaudid but the leg pain grew worse.\n pt given morphine for the pain in the er. the hypertension was treated\n with 10mg iv labetolol without effect. pt was started on a labetolol\n drip at 1mg/min and titrated up to 3mg/mg with bp 230s/150s. pt also\n s/o shortness of breath. LENIs negative for dvt. cxr normal. urine sent\n in er. hct 24.7, pt with baseline anemia. bun 51, cr 8.4, k 5.9,\n moderately hemolyzed. pt transferred to 4 icu for treatement of\n her hypertensive crisis.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2141-09-11 00:00:00.000","description":"Nursing Progress Note","row_id":339099,"text":"24 y.o. woman adm with hypertensive crisis with bp 260s/150s, hx\n htn, esrd, had pd catheter placed 2 months ago but uable to tolerate pd\n treatments d/t severe abd pain with exchange. pt was admitted last week\n with leg pain, was discharged on dilaudid but the leg pain grew worse.\n pt given morphine for the pain in the er. the hypertension was treated\n with 10mg iv labetolol without effect. pt was started on a labetolol\n drip at 1mg/min and titrated up to 3mg/mg with bp 230s/150s. pt also\n s/o shortness of breath. LENIs negative for dvt. cxr normal. urine sent\n in er. hct 24.7, pt with baseline anemia. bun 51, cr 8.4, k 5.9,\n moderately hemolyzed. pt transferred to 4 icu for treatment of\n her hypertensive crisis.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n Sbp in 230s on arrival to icu via aline. Sbp 10 points lower via\n noninvasive cuff. Labetalol drip was infusing at 3mg/hr and titrated up\n to as high as 5mg/hr with 1 inch nitropaste placed on chest wall. Pt\n c/o +n/v 10cc strawberry colored emesis (pt had strawberry drink in\n er). Also c/o right leg pain she\ns been having.\n Action:\n Labetalol drip maintained at 5mg/hr until pt able to take po meds.\n Given iv zofran for n/v with good effect. Given 2mg iv morphine with\n good effect with pain to her baseline 5. pt given po hydralazine\n and po labetalol with lunch.\n Response:\n Sbp lowering to as low as 160s via noninvasive cuff and 180s aline.\n (goal sbp 130-170, dbp <100). Labetalol drip weaned to as low as 1mg/hr\n but sbp still 170s-180s noninvasive cuff and 190s-200s aline. New 1\n inch nitropaste applied to chest wall with old paste wiped off at\n 16:55. developed a headache shortly after new nitropaste applied. Given\n 650mg Tylenol with relief. Sbp down to 150s noninvasive cuff. 180s\n aline. Labetolol drip currently at 1mg/hr.\n Plan:\n Continue to attempt to wean labetalol drip, continue antihypertensives\n as ordered. Morphine prn right leg pain. Tylenol prn headache. Zofran\n prn nausea. Monitor lytes. Receiving 3mg calcium gluconate currently\n for calcium relpletion. Repeat k 5.0 from 5.9( 5.9 was moderately\n hemolyzed).\n"},{"category":"Nursing","chartdate":"2141-09-11 00:00:00.000","description":"Nursing Progress Note","row_id":339028,"text":".H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2141-09-12 00:00:00.000","description":"Nursing Transfer Note","row_id":339295,"text":"24 y.o. F with ESRD (not on HD or PD) and lupus, admitted for malignant\n hypertension, currently on home regimen.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n SBP 160-170\ns/100\ns- 110\ns with baseline SBP 130-180s, No\n symptoms/signs of hypertensive emergency as pt without seizures, no\n acute worsening of renal function (anuric at baseline) Denies HA,\n blurry vision, chest pain. Denies nausea/vomiting. No peripheral\n edema. Peripheral pulses present.\n Action:\n Re-started home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren. - Monitor BPs closely. Neuro checks q 4 hours\n Response:\n SBP at 150-160\ns/100\ns ( 2 pm hydralazine held due to SBP of 120\n Plan:\n Continue to monitor patient hemodynamic status, hypertensive meds\n ASDIR.\n Neuro: alert oriented X3, follows commands, steady gait. Incompliant\n w/some of the care. RT leg pain - Lumbar spine MRI and R hip XR on most\n recent admission were both negative. Likely sciatica\n morphine IV\n given w/some effect\n Resp: on RA sats at high 90\ns-100%. Bil LS clear, RRR, unlabored\n breathing.\n GI: abd soft non tender, non distended, positive for BS. Regular diet\n (patient been refusing renal diet). Denies N/V. PD site - c/d/i.\n dressing changed today.\n GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted.\n Uses commode to void. Clean yellow urine. Dx of UTI on cipro. Urine\n cultures were sent. F/u results.\n Skin: no skin impairment\n Social: patient is a FULL CODE. Family in to visit.\n K- 5.4 kayexalate 30gr given at 11 am awaiting results. at 1500 K-5.6\n another 15gr of kayexalate given. PO4 -6.8 started on Sevelamer\n HX of SVC thrombus related to catheter in . INR goal 2.5 to 3.0.\n Patient on coumadin 5mg daily.\n SLE\n on daily prednisone.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERTENSION\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 51.6 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Precautions:\n PMH: Renal Failure\n CV-PMH: Hypertension\n Additional history: SLE diagnosed in (16yrs old) when she had\n swollen fingers, arm rash, and arthralgias. previous treatment with\n cytoxan, cellcept, currently on prednisone. complicated by uveitis\n () and ESRD ().\n CKD/ESRD, diagnosed in , initiated hemodialysis . PD catheter\n placement . pt reluctant to start PD and didn't tolerate PD flush\n well at all with severe abd pain.\n malignant hypertension, baseline sBPs 180s-120s. history of\n hypertensive crisis with seizures. history of 2 intraparenchymal\n hemorrhages that wer thought to be due to the posterior reversible\n leukoencephalopathy syndrome.\n TTP (got plasmapheresis) versus malignant HTN\n thrombotic events. SVC thrombosis () related to a catheter.\n Negative lupus anticoagulant (, , 9/).\n Negative anticardiolipin antiboties IgG and IgM x4 (-). Negtive\n Beta-2 gylcoprotein antibody (, 8/).\n -HOCM: last noted on echo .\n -anemia\n -history of left eye enucleation for fungal infection.\n -history of vaginal bleeding lasting 2 months s/p DepoProvera\n injection requiring transfusion.\n -history of coag negative Staph bacteremia and HD line infection \n and .\n past surgical histories: placement of multiple catheters including\n dialysis, tonsillectomy, left eye enucleation in , PD\n catheter placement in .\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:74\n Temperature:\n 97\n Arterial BP:\n S:157\n D:131\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,070 mL\n 24h total out:\n 450 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 02:38 PM\n Potassium:\n 5.6 mEq/L\n 02:38 PM\n Chloride:\n 110 mEq/L\n 02:38 PM\n CO2:\n 20 mEq/L\n 02:38 PM\n BUN:\n 49 mg/dL\n 02:38 PM\n Creatinine:\n 8.3 mg/dL\n 02:38 PM\n Glucose:\n 121 mg/dL\n 02:38 PM\n Hematocrit:\n 24.7 %\n 06:10 AM\n Valuables / Signature\n Patient valuables: sent w/patient\n Transferred from: MICU/\n Transferred to: 9\n Date & time of Transfer: \n ------ Protected Section ------\n Patient refused kayexalate. (k-5.6) team aware\n ------ Protected Section Addendum Entered By: , RN\n on: 15:53 ------\n"},{"category":"General","chartdate":"2141-09-11 00:00:00.000","description":"Initial H&P","row_id":339083,"text":" ADMISSION NOTE\n .\n Reason for MICU Admission: Malignant Hypertension.\n .\n Primary Care Physician: MD / MD\n .\n CC: Right leg pain.\n .\n HPI: Ms. is a 24 y.o. F with lupus, Chronic Kidney Disease V (not\n currently on HD or PD), and multiple admissions for hypertensive\n urgency/emergency, who presented to the ED for continued R leg pain\n that starts in her R buttocks and refers down her R leg. She describes\n it as feeling like the pain is deep within her bone. The pain was\n this AM, and she felt like she couldn't get out of bed. Denies\n any swelling of her RLE. When getting VS in , pt noted to be very\n hypertensive at 263/176. The patient reportedly has bseline SBPs in\n 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM\n on day of admission. She denies headache, vision changes, double\n vision, chest pain, shortness of breath, abdominal pain, BRBPR,\n dysuria. During MD interview, the patient was nauseous and had small\n amount of emesis of a recent Coolata. Pt states that flushing her PD\n cath causes a large amout of stomach pain. Currently, she has RLE\n pain.\n .\n In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in\n ED ranged from -175 with HR in 96-108. Initially given\n labetalol 10 mg IV x 1 and then started on labetalol gtt for her\n elevated blood pressures and titrated to 3 mg/min. LENI of R leg was\n negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per\n ED, cannot do V/Q scan due to volume overload after talking with\n radiology. Renal c/s initiated. A-line placed.\n .\n Of note, the patient was recently admitted from 08.26-29.08. The\n patient initially presented to the ED after referral from her\n nephrologist's office where she had complaints of right leg pain and\n was found to be hypertensive to 250/145. She was admitted after\n initiation of a labetalol drip and nitropaste with improvement in sbp\n to 180. The patient did receive 2 U of PRBC's during this\n hospitalization for baseline anemia. The patient did have a work-up for\n her right leg pain complaints with plain films of the right hip and MRI\n of the L-spine which did not reveal an explanation for her symptoms and\n did rule out avascular necrosis. The patient received dilaudid for pain\n control and was ambulating without pain prior to discharge. In\n addition, the patient completed a course of ciprofloxacin for a\n positive UA with negative cultures. The patient was unable to tolerate\n peritoneal dialysis for unclear reasons. Peritoneal dialysate culture\n was negative for infection.\n .\n ROS: as stated above in HPI.\n .\n MEDICATIONS (from discharge summary ):\n - Prednisone 5 mg Daily\n - Coumadin 2 mg at bedtime\n - Nifedipine 60 mg Sustained Release Daily\n - Hydralazine 50 mg every 8 hours\n - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday\n - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY\n - Aliskiren 150 mg Twice daily\n - Docusate Sodium 100 mg 2 times a day\n - Labetalol 900 mg three times a day\n - Lactulose 15-30 ml once a day: goal is soft bowel movements per\n day\n .\n ALLERGIES: Penicillins / Percocet\n .\n PAST MEDICAL HISTORY:\n - Systemic lupus erythematosus. Diagnosed (16 years old) when she\n had swollen fingers, arm rash and arthralgias. Previous treatment with\n cytoxan, cellcept; currently on prednisone. Complicated by uveitis\n () and ESRD ().\n - CKD/ESRD. Diagosed . Initiated dialysis . PD catheter\n placement . Pt reluctant to start PD.\n - Malignant hypertension. Baseline BPs 180's - 120's. History of\n hypertensive crisis with seizures. History of two intraparenchymal\n hemorrhages that were thought to be due to the posterior reversible\n leukoencephalopathy syndrome.\n - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN.\n - Thrombotic events. SVC thrombosis (); related to a catheter.\n Negative lupus anticoagulant (, , 9/). Negative\n anticardiolipin antibodies IgG and IgM x4 (-). Negative Beta-2\n glycoprotein antibody (, 8/).\n - HOCM: Last noted on echo .\n - Anemia.\n - History of left eye enucleation for fungal infection.\n - History of vaginal bleeding lasting 2 months s/p DepoProvera\n injection requiring transfusion.\n - History of Coag negative Staph bacteremia and HD line\n infection - and \n .\n PAST SURGICAL HISTORY:\n 1. Placement of multiple catheters including dialysis.\n 2. Tonsillectomy.\n 3. Left eye enucleation in .\n 4. PD catheter placement in .\n .\n SOCIAL HISTORY: Single. Lives with her mother and brother. On\n disability. Denies EtOH, tobacco or drug use.\n .\n FAMILY HISTORY: No history of autoimmune or thrombophilic disorders.\n .\n PHYSICAL EXAM:\n VS: T 98.9 99$% RA\n GEN: NAD, pleaseant female sitting in bed with moon facies\n HEENT: EOMI of R eye, L eye prosthesis, OP - no exudate, no erythema,\n MMM, no LAD\n CHEST: CTAB except at R base with decreased breath sounds; no w/r/r\n CV: tachy, no m/r/g appreciated, + S4\n ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i\n EXT: no c/c/e, + SLR of RLE, able to wiggle toes and raise BLE off bed\n NEURO: II - XII grossly intact\n DERM: no rashes noted\n .\n LABORATORIES:\n Na 138, K 5.9 (hemolyzed), Cl 108, Bicarb 21, BUN/Cr 51/8.4, glucose\n 85, WBC 5.5 (74 N, 17.5 L), Hct 24.7, platelets 101.\n .\n UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50\n WBC\n .\n MICROBIOLOGY:\n Blood culture (): Pending.\n Urine culture (): No growth.\n Peritoneal fluid (): Gram stain no PMN's or microorganisms.\n Culture pending.\n .\n STUDIES:\n EKG : sinus tachy @ 100 bpm, nl axis, borderline PR prolongation,\n long QT interval, no acute ST-TWI. No change from prio on .\n PORTABLE CXR (my read): Cardiomegaly. Some increased haziness of\n RLL/R diaphragm from CXR.\n R LENI (wet read): No DVT.\n .\n TTE (): The left atrium is normal in size. There is severe\n symmetric left ventricular hypertrophy. The left ventricular cavity is\n unusually small. Regional left ventricular wall motion is normal. Left\n ventricular systolic function is hyperdynamic (EF>75%). There is a mild\n resting left ventricular outflow tract obstruction. The gradient\n increased with the Valsalva manuever. The findings are consistent with\n hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular\n septal defect. Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) appear structurally normal with\n good leaflet excursion. No masses or vegetations are seen on the aortic\n valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears\n structurally normal with trivial mitral regurgitation. There is no\n mitral valve prolapse. No mass or vegetation is seen on the mitral\n valve. The estimated pulmonary artery systolic pressure is normal.\n There is a trivial/physiologic pericardial effusion.\n .\n R HIP XR : No acute fracture or dislocation.\n .\n MRI L-SPINE : Diffuse low-signal intensity is identified in the\n bone marrow of the lumbar and lower thoracic spine as described above,\n possibly related with anemic changes, please correlate clinically.\n There is no evidence of spinal canal stenosis or neural foraminal\n narrowing at the different intervertebral disc spaces.\n .\n ASSESSMENT & PLAN: 24 y.o. F with ESRD (not on HD or PD) and lupus,\n admitted for malignant hypertension, currently on labetalol gtt.\n .\n # Malignant hypertension: SBPs currently in 200s with baseline SBP\n 130-180s. No symptoms/signs of hypertensive emergency as pt without\n seizures, no acute worsening of renal function (anuric at baseline)\n Denies HA, blurry vision, chest pain. + nausea/vomiting\n - Continue labetalol drip with down-titration as possible for goal SBP\n in 170-180s\n - NTG transdermal now\n - Transition to home dose oral labetalol when able\n - Re-start home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren when able\n - Monitor BPs closely\n - Neuro checks q 4 hours\n .\n # Right leg pain: Lumbar spine MRI and R hip XR on most recent\n admission were both negative. Likely sciatica.\n - IV Morphine as needed for pain\n - Transition to po pain medications when able\n .\n # UTI: UCx pending. Asymptomatic currently.\n - ciprofloxacin x 3 days\n - f/u Urine culture\n - check EKGs daily while on FQ and borderline prolonged QT\n .\n # ESRD: Pt not on PD although with PD catheter. On last admission, she\n had difficulty tolerating PD secondary to pain.\n - Peritoneal dialysis as tolerated\n - Appreciate renal recommendations\n .\n # Hyperkalemia: K elevated to 5.9 on admission, but moderately\n hemolyzed\n - check electrolytes now\n - EKG on arrival to ICU\n .\n # Anemia: Likely related to chronic disease. Baseline Hct 20, currently\n 24. Not on epo given hypertension. Past transfusion requirement.\n - Trend Hct daily\n - Transfer if Hct < 20\n - active T&S\n .\n # Prior SVC thrombus: Related to catheter in . INR goal 2.5 to\n 3.0. Was elevated to 3.4 on d/c on \n - check coags now to decide whether to continue or hold coumadin.\n .\n # Systemic lupus erythematosus:\n - Continue prednisone daily\n .\n # HOCM: Seen on TTE in .\n - BP management as above.\n - Avoid excessive volume removal.\n .\n # Thrombocytopenia: Baseline platelets approximately 100.\n - trend platelets daily\n .\n # FEN: no IVFs / replete lytes prn / ADAT\n .\n # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen\n .\n # ACCESS: Peripheral IV, A-line\n .\n # CONTACT: (mother) \n .\n # CODE: Full Code\n .\n # DISPO: ICU pending blood pressure control\n .\n .\n .\n .\n , MD, MPH\n \n PGY-2\n ------ Protected Section ------\n I saw this patient with Dr. , the ICU resident, and agree with her\n HPI, PMHx, Fhx, SocHX, ROS, PE and plan as outlined above. \n is a 24 yo bf with SLE, CRF not on dialysis, severe HTN who came\n to the ED today because of right leg pain, but noted to have elevated\n BP (260/130\ns).. She currently appears without distress, and denies\n CP/SOB/vision changes/headaches/MS changes to indicate HTN emergency.\n Lungs: slightly diminished at R base, otherwise clear. CV: mildly\n tachy, RR, +S4. Abd: soft, nontender, +bs. Ext without edema.\n She is in the for hypertensive urgency, which is being treated\n with a labetolol gtt, resumption of home medicines and invasive BP\n monitoring Renal team following. RLE pain treated with morphine and\n consider hip MRI for further evaluation. Further plans as outlined\n above.\n Pt is critically ill.\n Total time spent on patient: 40 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:57 ------\n"},{"category":"Nursing","chartdate":"2141-09-12 00:00:00.000","description":"Nursing Transfer Note","row_id":339286,"text":"24 y.o. F with ESRD (not on HD or PD) and lupus, admitted for malignant\n hypertension, currently on home regimen.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n SBP 160-170\ns/100\ns- 110\ns with baseline SBP 130-180s, No\n symptoms/signs of hypertensive emergency as pt without seizures, no\n acute worsening of renal function (anuric at baseline) Denies HA,\n blurry vision, chest pain. Denies nausea/vomiting. No peripheral\n edema. Peripheral pulses present.\n Action:\n Re-started home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren. - Monitor BPs closely. Neuro checks q 4 hours\n Response:\n SBP at 150-160\ns/100\ns ( 2 pm hydralazine held due to SBP of 120\n Plan:\n Continue to monitor patient hemodynamic status, hypertensive meds\n ASDIR.\n Neuro: alert oriented X3, follows commands, steady gait. Incompliant\n w/some of the care. RT leg pain - Lumbar spine MRI and R hip XR on most\n recent admission were both negative. Likely sciatica\n morphine IV\n given w/some effect\n Resp: on RA sats at high 90\ns-100%. Bil LS clear, RRR, unlabored\n breathing.\n GI: abd soft non tender, non distended, positive for BS. Regular diet\n (patient been refusing renal diet). Denies N/V. PD site - c/d/i.\n dressing changed today.\n GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted.\n Uses commode to void. Clean yellow urine. Dx of UTI on cipro. Urine\n cultures were sent. F/u results.\n Skin: no skin impairment\n Social: patient is a FULL CODE. Family in to visit.\n K- 5.4 kayexalate 30gr given at 11 am awaiting results.\n HX of SVC thrombus related to catheter in . INR goal 2.5 to 3.0.\n Patient on coumadin 5mg daily.\n SLE\n on daily prednisone.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERTENSION\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 51.6 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Precautions:\n PMH: Renal Failure\n CV-PMH: Hypertension\n Additional history: SLE diagnosed in (16yrs old) when she had\n swollen fingers, arm rash, and arthralgias. previous treatment with\n cytoxan, cellcept, currently on prednisone. complicated by uveitis\n () and ESRD ().\n CKD/ESRD, diagnosed in , initiated hemodialysis . PD catheter\n placement . pt reluctant to start PD and didn't tolerate PD flush\n well at all with severe abd pain.\n malignant hypertension, baseline sBPs 180s-120s. history of\n hypertensive crisis with seizures. history of 2 intraparenchymal\n hemorrhages that wer thought to be due to the posterior reversible\n leukoencephalopathy syndrome.\n TTP (got plasmapheresis) versus malignant HTN\n thrombotic events. SVC thrombosis () related to a catheter.\n Negative lupus anticoagulant (, , 9/).\n Negative anticardiolipin antiboties IgG and IgM x4 (-). Negtive\n Beta-2 gylcoprotein antibody (, 8/).\n -HOCM: last noted on echo .\n -anemia\n -history of left eye enucleation for fungal infection.\n -history of vaginal bleeding lasting 2 months s/p DepoProvera\n injection requiring transfusion.\n -history of coag negative Staph bacteremia and HD line infection \n and .\n past surgical histories: placement of multiple catheters including\n dialysis, tonsillectomy, left eye enucleation in , PD\n catheter placement in .\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:74\n Temperature:\n 97\n Arterial BP:\n S:157\n D:131\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,070 mL\n 24h total out:\n 450 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 06:10 AM\n Potassium:\n 5.4 mEq/L\n 06:10 AM\n Chloride:\n 107 mEq/L\n 06:10 AM\n CO2:\n 16 mEq/L\n 06:10 AM\n BUN:\n 52 mg/dL\n 06:10 AM\n Creatinine:\n 8.5 mg/dL\n 06:10 AM\n Glucose:\n 99 mg/dL\n 06:10 AM\n Hematocrit:\n 24.7 %\n 06:10 AM\n Valuables / Signature\n Patient valuables: sent w/patient\n Transferred from: MICU/\n Transferred to: 9\n Date & time of Transfer: \n"},{"category":"Physician ","chartdate":"2141-09-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":339288,"text":"Chief Complaint:\n 24 Hour Events:\n Pressures finally dropped to 130/80s and labetelol drip was stopped\n ARTERIAL LINE - START 11:15 AM\n EKG - At 12:47 PM\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 01:21 PM\n Other medications:\n Nifedipine CR 60 po daily\n Labetalol 900 mg PO TID\n Hydral 50 mg PO q 8\n AlisKiren NF 150 mg PO BID\n Tylenol\n Clonidine patch 0.3 mg q wed\n Prednisone 5 mg PO daily\n Calcium carbonate 500 mg PO QID\n Warfarin 5 mg PO qhs\n Morphine\n Ondansetron\n Docusate, senna, bisacoldy\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 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: 36.9\nC (98.4\n HR: 79 (71 - 99) bpm\n BP: 142/105(113) {115/58(74) - 208/153(166)} mmHg\n RR: 13 (13 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,725 mL\n 180 mL\n PO:\n 440 mL\n 180 mL\n TF:\n IVF:\n 1,285 mL\n Blood products:\n Total out:\n 255 mL\n 150 mL\n Urine:\n 250 mL\n 150 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 1,470 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///16/\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 8.3 g/dL\n 86 mg/dL\n 8.1 mg/dL\n 16 mEq/L\n 5.0 mEq/L\n 49 mg/dL\n 110 mEq/L\n 139 mEq/L\n 24.7 %\n 3.9 K/uL\n [image002.jpg]\n 11:43 AM\n 06:10 AM\n WBC\n 3.9\n Hct\n 24.7\n Cr\n 8.1\n Glucose\n 86\n Other labs: PT / PTT / INR:18.4/42.8/1.7, Ca++:6.2 mg/dL, Mg++:1.6\n mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n ASSESSMENT & PLAN: 24 y.o. F with ESRD (not on HD or PD) and lupus,\n admitted for malignant hypertension, currently on labetalol gtt.\n .\n # Malignant hypertension: SBPs currently in 200s with baseline SBP\n 130-180s. No symptoms/signs of hypertensive emergency as pt without\n seizures, no acute worsening of renal function (anuric at baseline)\n Denies HA, blurry vision, chest pain. + nausea/vomiting\n - patient without any symptoms now, patient is refusing hemodialysis\n -labetalol drip stopped, patient on home BP meds, goal systolic range\n 160-170s\n - Monitor BPs closely, neuro checks q 4 hours\n .\n # Right leg pain: Lumbar spine MRI and R hip XR on most recent\n admission were both negative. Likely sciatica.\n - IV Morphine as needed for pain\n - Transition to po pain medications when able\n - on chronic steroids concern for potential risk of AVN of right hip,\n would consider CT of right hip on transfer out of the unit\n .\n # UTI:\n - UA grossly positive, ucx pending\n - ciprofloxacin x 3 days\n - f/u Urine culture\n - check EKGs daily while on FQ and borderline prolonged QT\n .\n # ESRD: Pt not on PD although with PD catheter. On last admission, she\n had difficulty tolerating PD secondary to pain.\n - Peritoneal dialysis as tolerated\n - Appreciate renal recommendations\n possible PD dialysis, replete\n Calcium\n .\n # Hyperkalemia: K elevated to 5.9 on admission, but moderately\n hemolyzed\n - repetat K 5.4, patient given kayexalate, checking EKGs daily now with\n borderline QT\n - cont to monitor daily electrolytes\n .\n # Anemia: Likely related to chronic disease. Baseline Hct 20, currently\n 24. Not on epo given hypertension. Past transfusion requirement.\n - Trend Hct daily, Transfer if Hct < 20\n - active T&S\n .\n # Prior SVC thrombus: Related to catheter in . INR goal 2.5 to\n 3.0. Was elevated to 3.4 on d/c on \n - this morning INR 1.7, will not bridge at this time with heparin\n - continue coumadin 5 mg PO qhs and re-check INR in AM.\n .\n # Systemic lupus erythematosus:\n - Continue prednisone daily\n .\n # HOCM: Seen on TTE in .\n - BP management as above.\n - Avoid excessive volume removal\n .\n # Thrombocytopenia: Baseline platelets approximately 100.\n - platelets are now 93, now indication for tranfusion at this time\n - consider heme/onc consult as all 3 cell lines down\n .\n # FEN: no IVFs / replete lytes prn / ADAT\n .\n # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen\n .\n # ACCESS: Peripheral IV, A-line\n .\n # CONTACT: (mother) \n .\n # CODE: Full Code\n .\n # DISPO: to floor today as now off of labetalol drip\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:15 AM\n 20 Gauge - 11:25 AM\n 18 Gauge - 11:26 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":"2141-09-12 00:00:00.000","description":"Nursing Transfer Note","row_id":339289,"text":"24 y.o. F with ESRD (not on HD or PD) and lupus, admitted for malignant\n hypertension, currently on home regimen.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n SBP 160-170\ns/100\ns- 110\ns with baseline SBP 130-180s, No\n symptoms/signs of hypertensive emergency as pt without seizures, no\n acute worsening of renal function (anuric at baseline) Denies HA,\n blurry vision, chest pain. Denies nausea/vomiting. No peripheral\n edema. Peripheral pulses present.\n Action:\n Re-started home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren. - Monitor BPs closely. Neuro checks q 4 hours\n Response:\n SBP at 150-160\ns/100\ns ( 2 pm hydralazine held due to SBP of 120\n Plan:\n Continue to monitor patient hemodynamic status, hypertensive meds\n ASDIR.\n Neuro: alert oriented X3, follows commands, steady gait. Incompliant\n w/some of the care. RT leg pain - Lumbar spine MRI and R hip XR on most\n recent admission were both negative. Likely sciatica\n morphine IV\n given w/some effect\n Resp: on RA sats at high 90\ns-100%. Bil LS clear, RRR, unlabored\n breathing.\n GI: abd soft non tender, non distended, positive for BS. Regular diet\n (patient been refusing renal diet). Denies N/V. PD site - c/d/i.\n dressing changed today.\n GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted.\n Uses commode to void. Clean yellow urine. Dx of UTI on cipro. Urine\n cultures were sent. F/u results.\n Skin: no skin impairment\n Social: patient is a FULL CODE. Family in to visit.\n K- 5.4 kayexalate 30gr given at 11 am awaiting results. at 1500 K-5.6\n another 15gr of kayexalate given. PO4 -6.8 started on Sevelamer\n HX of SVC thrombus related to catheter in . INR goal 2.5 to 3.0.\n Patient on coumadin 5mg daily.\n SLE\n on daily prednisone.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERTENSION\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 51.6 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Precautions:\n PMH: Renal Failure\n CV-PMH: Hypertension\n Additional history: SLE diagnosed in (16yrs old) when she had\n swollen fingers, arm rash, and arthralgias. previous treatment with\n cytoxan, cellcept, currently on prednisone. complicated by uveitis\n () and ESRD ().\n CKD/ESRD, diagnosed in , initiated hemodialysis . PD catheter\n placement . pt reluctant to start PD and didn't tolerate PD flush\n well at all with severe abd pain.\n malignant hypertension, baseline sBPs 180s-120s. history of\n hypertensive crisis with seizures. history of 2 intraparenchymal\n hemorrhages that wer thought to be due to the posterior reversible\n leukoencephalopathy syndrome.\n TTP (got plasmapheresis) versus malignant HTN\n thrombotic events. SVC thrombosis () related to a catheter.\n Negative lupus anticoagulant (, , 9/).\n Negative anticardiolipin antiboties IgG and IgM x4 (-). Negtive\n Beta-2 gylcoprotein antibody (, 8/).\n -HOCM: last noted on echo .\n -anemia\n -history of left eye enucleation for fungal infection.\n -history of vaginal bleeding lasting 2 months s/p DepoProvera\n injection requiring transfusion.\n -history of coag negative Staph bacteremia and HD line infection \n and .\n past surgical histories: placement of multiple catheters including\n dialysis, tonsillectomy, left eye enucleation in , PD\n catheter placement in .\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:74\n Temperature:\n 97\n Arterial BP:\n S:157\n D:131\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,070 mL\n 24h total out:\n 450 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 02:38 PM\n Potassium:\n 5.6 mEq/L\n 02:38 PM\n Chloride:\n 110 mEq/L\n 02:38 PM\n CO2:\n 20 mEq/L\n 02:38 PM\n BUN:\n 49 mg/dL\n 02:38 PM\n Creatinine:\n 8.3 mg/dL\n 02:38 PM\n Glucose:\n 121 mg/dL\n 02:38 PM\n Hematocrit:\n 24.7 %\n 06:10 AM\n Valuables / Signature\n Patient valuables: sent w/patient\n Transferred from: MICU/\n Transferred to: 9\n Date & time of Transfer: \n"},{"category":"Radiology","chartdate":"2141-09-11 00:00:00.000","description":"R UNILAT LOWER EXT VEINS RIGHT","row_id":1031432,"text":" 8:54 AM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: dvt?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman with r leg pain, sob\n REASON FOR THIS EXAMINATION:\n dvt?\n ______________________________________________________________________________\n WET READ: JKPe MON 10:03 AM\n no dvt\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath and right leg pain. Evaluate for DVT.\n\n Comparison is made to exam, also noted to be negative.\n\n RIGHT LOWER EXTREMITY ULTRASOUND\n\n -scale and Doppler son of the right common femoral, superficial\n femoral, and popliteal veins demonstrate normal flow, compressibility,\n augmentation, waveforms. Appropriate color flow and compression is noted\n within the calf veins. No intraluminal thrombus is present.\n\n IMPRESSION:\n\n No evidence of right lower extremity DVT.\n\n\n"},{"category":"Radiology","chartdate":"2141-09-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1031418,"text":" 8:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman with shortness of breath\n REASON FOR THIS EXAMINATION:\n infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath.\n\n UPRIGHT PORTABLE CHEST\n\n Comparison is made to multiple chest radiographs dating back to .\n\n Exam is somewhat limited by the portable technique and patient rotation. There\n is increased vascular distention and interstitial markings extending out to\n the periphery in addition to increased patchy opacities within the lower lobes\n bilaterally. Small bilateral layering effusions are identified. Heart size\n is stably enlarged. No pneumothorax.\n\n IMPRESSION:\n\n Findings are most suggestive of moderate fluid overload in this patient with\n known end-stage renal disease/SLE. Patchy opacities at the bases may\n represent regions of alveolar edema although a superimposed pneumonia would be\n difficult to exclude. A repeat radiograph after diuresis/dialysis would be\n helpful.\n\n Small bilateral effusions.\n\n These findings were discussed with Dr. aligned shortly after exam\n acquisition.\n\n"},{"category":"ECG","chartdate":"2141-09-13 00:00:00.000","description":"Report","row_id":170208,"text":"Sinus rhythm with slowing of the rate as compared with prior tracing of .\nThe previously mentioned multiple abnormalities persist without diagnostic\ninterim change. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2141-09-12 00:00:00.000","description":"Report","row_id":170209,"text":"Sinus rhythm. There is variation in precordial lead placement as compared\nwith prior tracing of . The prominent negative terminal deflection\nof the P wave in lead V1 is no longer evident which may relate to lead\nplacement. No diagnostic interim change.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2141-09-11 00:00:00.000","description":"Report","row_id":170210,"text":"Sinus rhythm. Left atrial enlargement. Compared to the previous tracing\nof no diagnostic interim change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2141-09-11 00:00:00.000","description":"Report","row_id":170442,"text":"Sinus tachycardia. The tracing is marred by baseline artifact. There is\nleft atrial enlargement. Compared to the previous tracing of \nthe rate has increased. The axis is more rightward. Otherwise, no diagnostic\ninterim change.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"General\",\n \"chartdate\": \"2141-09-11 00:00:00.000\",\n \"description\": \"Initial H&P\",\n \"row_id\": 339012,\n \"text\": \" ADMISSION NOTE\\n .\\n Reason for MICU Admission: Malignant Hypertension.\\n .\\n Primary Care Physician: MD / MD\\n .\\n CC: Right leg pain.\\n .\\n HPI: Ms. is a 24 y.o. F with lupus, Chronic Kidney Disease V (not\\n currently on HD or PD), and multiple admissions for hypertensive\\n urgency/emergency, who presented to the ED for continued R leg pain\\n that starts in her R buttocks and refers down her R leg. She describes\\n it as feeling like the pain is deep within her bone. The pain was\\n this AM, and she felt like she couldn't get out of bed. Denies\\n any swelling of her RLE. When getting VS in , pt noted to be very\\n hypertensive at 263/176. The patient reportedly has bseline SBPs in\\n 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM\\n on day of admission. She denies headache, vision changes, double\\n vision, chest pain, shortness of breath, abdominal pain, BRBPR,\\n dysuria. During MD interview, the patient was nauseous and had small\\n amount of emesis of a recent Coolata. Pt states that flushing her PD\\n cath causes a large amout of stomach pain. Currently, she has RLE\\n pain.\\n .\\n In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in\\n ED ranged from -175 with HR in 96-108. Initially given\\n labetalol 10 mg IV x 1 and then started on labetalol gtt for her\\n elevated blood pressures and titrated to 3 mg/min. LENI of R leg was\\n negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per\\n ED, cannot do V/Q scan due to volume overload after talking with\\n radiology. Renal c/s initiated. A-line placed.\\n .\\n Of note, the patient was recently admitted from 08.26-29.08. The\\n patient initially presented to the ED after referral from her\\n nephrologist's office where she had complaints of right leg pain and\\n was found to be hypertensive to 250/145. She was admitted after\\n initiation of a labetalol drip and nitropaste with improvement in sbp\\n to 180. The patient did receive 2 U of PRBC's during this\\n hospitalization for baseline anemia. The patient did have a work-up for\\n her right leg pain complaints with plain films of the right hip and MRI\\n of the L-spine which did not reveal an explanation for her symptoms and\\n did rule out avascular necrosis. The patient received dilaudid for pain\\n control and was ambulating without pain prior to discharge. In\\n addition, the patient completed a course of ciprofloxacin for a\\n positive UA with negative cultures. The patient was unable to tolerate\\n peritoneal dialysis for unclear reasons. Peritoneal dialysate culture\\n was negative for infection.\\n .\\n ROS: as stated above in HPI.\\n .\\n MEDICATIONS (from discharge summary ):\\n - Prednisone 5 mg Daily\\n - Coumadin 2 mg at bedtime\\n - Nifedipine 60 mg Sustained Release Daily\\n - Hydralazine 50 mg every 8 hours\\n - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday\\n - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY\\n - Aliskiren 150 mg Twice daily\\n - Docusate Sodium 100 mg 2 times a day\\n - Labetalol 900 mg three times a day\\n - Lactulose 15-30 ml once a day: goal is soft bowel movements per\\n day\\n .\\n ALLERGIES: Penicillins / Percocet\\n .\\n PAST MEDICAL HISTORY:\\n - Systemic lupus erythematosus. Diagnosed (16 years old) when she\\n had swollen fingers, arm rash and arthralgias. Previous treatment with\\n cytoxan, cellcept; currently on prednisone. Complicated by uveitis\\n () and ESRD ().\\n - CKD/ESRD. Diagosed . Initiated dialysis . PD catheter\\n placement . Pt reluctant to start PD.\\n - Malignant hypertension. Baseline BPs 180's - 120's. History of\\n hypertensive crisis with seizures. History of two intraparenchymal\\n hemorrhages that were thought to be due to the posterior reversible\\n leukoencephalopathy syndrome.\\n - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN.\\n - Thrombotic events. SVC thrombosis (); related to a catheter.\\n Negative lupus anticoagulant (, , 9/). Negative\\n anticardiolipin antibodies IgG and IgM x4 (-). Negative Beta-2\\n glycoprotein antibody (, 8/).\\n - HOCM: Last noted on echo .\\n - Anemia.\\n - History of left eye enucleation for fungal infection.\\n - History of vaginal bleeding lasting 2 months s/p DepoProvera\\n injection requiring transfusion.\\n - History of Coag negative Staph bacteremia and HD line\\n infection - and \\n .\\n PAST SURGICAL HISTORY:\\n 1. Placement of multiple catheters including dialysis.\\n 2. Tonsillectomy.\\n 3. Left eye enucleation in .\\n 4. PD catheter placement in .\\n .\\n SOCIAL HISTORY: Single. Lives with her mother and brother. On\\n disability. Denies EtOH, tobacco or drug use.\\n .\\n FAMILY HISTORY: No history of autoimmune or thrombophilic disorders.\\n .\\n PHYSICAL EXAM:\\n VS: T 98.9 99$% RA\\n GEN: NAD, pleaseant female sitting in bed with moon facies\\n HEENT: EOMI of R eye, L eye prosthesis, OP - no exudate, no erythema,\\n MMM, no LAD\\n CHEST: CTAB except at R base with decreased breath sounds; no w/r/r\\n CV: tachy, no m/r/g appreciated, + S4\\n ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i\\n EXT: no c/c/e, + SLR of RLE, able to wiggle toes and raise BLE off bed\\n NEURO: II - XII grossly intact\\n DERM: no rashes noted\\n .\\n LABORATORIES:\\n Na 138, K 5.9 (hemolyzed), Cl 108, Bicarb 21, BUN/Cr 51/8.4, glucose\\n 85, WBC 5.5 (74 N, 17.5 L), Hct 24.7, platelets 101.\\n .\\n UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50\\n WBC\\n .\\n MICROBIOLOGY:\\n Blood culture (): Pending.\\n Urine culture (): No growth.\\n Peritoneal fluid (): Gram stain no PMN's or microorganisms.\\n Culture pending.\\n .\\n STUDIES:\\n EKG : sinus tachy @ 100 bpm, nl axis, borderline PR prolongation,\\n long QT interval, no acute ST-TWI. No change from prio on .\\n PORTABLE CXR (my read): Cardiomegaly. Some increased haziness of\\n RLL/R diaphragm from CXR.\\n R LENI (wet read): No DVT.\\n .\\n TTE (): The left atrium is normal in size. There is severe\\n symmetric left ventricular hypertrophy. The left ventricular cavity is\\n unusually small. Regional left ventricular wall motion is normal. Left\\n ventricular systolic function is hyperdynamic (EF>75%). There is a mild\\n resting left ventricular outflow tract obstruction. The gradient\\n increased with the Valsalva manuever. The findings are consistent with\\n hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular\\n septal defect. Right ventricular chamber size and free wall motion are\\n normal. The aortic valve leaflets (3) appear structurally normal with\\n good leaflet excursion. No masses or vegetations are seen on the aortic\\n valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears\\n structurally normal with trivial mitral regurgitation. There is no\\n mitral valve prolapse. No mass or vegetation is seen on the mitral\\n valve. The estimated pulmonary artery systolic pressure is normal.\\n There is a trivial/physiologic pericardial effusion.\\n .\\n R HIP XR : No acute fracture or dislocation.\\n .\\n MRI L-SPINE : Diffuse low-signal intensity is identified in the\\n bone marrow of the lumbar and lower thoracic spine as described above,\\n possibly related with anemic changes, please correlate clinically.\\n There is no evidence of spinal canal stenosis or neural foraminal\\n narrowing at the different intervertebral disc spaces.\\n .\\n ASSESSMENT & PLAN: 24 y.o. F with ESRD (not on HD or PD) and lupus,\\n admitted for malignant hypertension, currently on labetalol gtt.\\n .\\n # Malignant hypertension: SBPs currently in 200s with baseline SBP\\n 130-180s. No symptoms/signs of hypertensive emergency as pt without\\n seizures, no acute worsening of renal function (anuric at baseline)\\n Denies HA, blurry vision, chest pain. + nausea/vomiting\\n - Continue labetalol drip with down-titration as possible for goal SBP\\n in 170-180s\\n - NTG transdermal now\\n - Transition to home dose oral labetalol when able\\n - Re-start home regimen of nifedipine, hydralazine, clonidine patch,\\n aliskiren when able\\n - Monitor BPs closely\\n - Neuro checks q 4 hours\\n .\\n # Right leg pain: Lumbar spine MRI and R hip XR on most recent\\n admission were both negative. Likely sciatica.\\n - IV Morphine as needed for pain\\n - Transition to po pain medications when able\\n .\\n # UTI: UCx pending. Asymptomatic currently.\\n - ciprofloxacin x 3 days\\n - f/u Urine culture\\n - check EKGs daily while on FQ and borderline prolonged QT\\n .\\n # ESRD: Pt not on PD although with PD catheter. On last admission, she\\n had difficulty tolerating PD secondary to pain.\\n - Peritoneal dialysis as tolerated\\n - Appreciate renal recommendations\\n .\\n # Hyperkalemia: K elevated to 5.9 on admission, but moderately\\n hemolyzed\\n - check electrolytes now\\n - EKG on arrival to ICU\\n .\\n # Anemia: Likely related to chronic disease. Baseline Hct 20, currently\\n 24. Not on epo given hypertension. Past transfusion requirement.\\n - Trend Hct daily\\n - Transfer if Hct < 20\\n - active T&S\\n .\\n # Prior SVC thrombus: Related to catheter in . INR goal 2.5 to\\n 3.0. Was elevated to 3.4 on d/c on \\n - check coags now to decide whether to continue or hold coumadin.\\n .\\n # Systemic lupus erythematosus:\\n - Continue prednisone daily\\n .\\n # HOCM: Seen on TTE in .\\n - BP management as above.\\n - Avoid excessive volume removal.\\n .\\n # Thrombocytopenia: Baseline platelets approximately 100.\\n - trend platelets daily\\n .\\n # FEN: no IVFs / replete lytes prn / ADAT\\n .\\n # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen\\n .\\n # ACCESS: Peripheral IV, A-line\\n .\\n # CONTACT: (mother) \\n .\\n # CODE: Full Code\\n .\\n # DISPO: ICU pending blood pressure control\\n .\\n .\\n .\\n .\\n , MD, MPH\\n \\n PGY-2\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-09-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 339074,\n \"text\": \"24 y.o. woman adm with hypertensive crisis with bp 260s/150s, hx\\n htn, esrd, had pd catheter placed 2 months ago but uable to tolerate pd\\n treatments d/t severe abd pain with exchange. pt was admitted last week\\n with leg pain, was discharged on dilaudid but the leg pain grew worse.\\n pt given morphine for the pain in the er. the hypertension was treated\\n with 10mg iv labetolol without effect. pt was started on a labetolol\\n drip at 1mg/min and titrated up to 3mg/mg with bp 230s/150s. pt also\\n s/o shortness of breath. LENIs negative for dvt. cxr normal. urine sent\\n in er. hct 24.7, pt with baseline anemia. bun 51, cr 8.4, k 5.9,\\n moderately hemolyzed. pt transferred to 4 icu for treatement of\\n her hypertensive crisis.\\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\\n emergency)\\n Assessment:\\n Sbp in 230s on arrival to icu via aline. Sbp 10 points lower via\\n noninvasive cuff. Labetalol drip was infusing at 3mg/hr and titrated up\\n to as high as 5mg/hr with 1 inch nitropaste placed on chest wall. Pt\\n c/o +n/v 10cc strawberry colored emesis (pt had strawberry drink in\\n er). Also c/o right leg pain she\\ns been having.\\n Action:\\n Labetalol drip maintained at 5mg/hr until pt able to take po meds.\\n Given iv zofran for n/v with good effect. Given 2mg iv morphine with\\n good effect with pain to her baseline 5. pt given po hydralazine\\n and po labetalol with lunch.\\n Response:\\n Sbp lowering to as low as 160s via noninvasive cuff and 180s aline.\\n (goal sbp 130-170, dbp <100). Labetalol drip weaned to as low as 1mg/hr\\n but sbp still 170s-180s noninvasive cuff and 190s-200s aline. New 1\\n inch nitropaste applied to chest wall with old paste wiped off at\\n 16:55. developed a headache shortly after new nitropaste applied. Given\\n 650mg Tylenol.\\n Plan:\\n Continue to attempt to wean labetalol drip, continue antihypertensives\\n as ordered. Morphine prn right leg pain. Tylenol prn headache. Zofran\\n prn nausea.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-09-12 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 339272,\n \"text\": \"24 y.o. F with ESRD (not on HD or PD) and lupus, admitted for malignant\\n hypertension, currently on home regimen.\\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\\n emergency)\\n Assessment:\\n SBP 160-170\\ns/100\\ns- 110\\ns with baseline SBP 130-180s, No\\n symptoms/signs of hypertensive emergency as pt without seizures, no\\n acute worsening of renal function (anuric at baseline) Denies HA,\\n blurry vision, chest pain. Denies nausea/vomiting. No peripheral\\n edema. Peripheral pulses present.\\n Action:\\n Re-started home regimen of nifedipine, hydralazine, clonidine patch,\\n aliskiren. - Monitor BPs closely. Neuro checks q 4 hours\\n Response:\\n SBP at 150-160\\ns/100\\ns ( 2 pm hydralazine held due to SBP of 120\\n Plan:\\n Continue to monitor patient hemodynamic status, hypertensive meds\\n ASDIR.\\n Neuro: alert oriented X3, follows commands, steady gait. Incompliant\\n w/some of the care. RT leg pain - Lumbar spine MRI and R hip XR on most\\n recent admission were both negative. Likely sciatica\\n morphine IV\\n given w/some effect\\n Resp: on RA sats at high 90\\ns-100%. Bil LS clear, RRR, unlabored\\n breathing.\\n GI: abd soft non tender, non distended, positive for BS. Regular diet\\n (patient been refusing renal diet). Denies N/V. PD site - c/d/i.\\n dressing changed today.\\n GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted.\\n Uses commode to void. Clean yellow urine. Dx of UTI on cipro. Urine\\n cultures were sent. F/u results.\\n Skin: no skin impairment\\n Social: patient is a FULL CODE. Family in to visit.\\n K- 5.4 kayexalate 30gr given at 11 am awaiting results.\\n HX of SVC thrombus related to catheter in . INR goal 2.5 to 3.0.\\n Patient on coumadin 5mg daily.\\n SLE\\n on daily prednisone.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-09-12 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 339234,\n \"text\": \"Chief Complaint: lower extremity pain\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n year old female presented with right lower extremity pain and found to\\n be very hypertensive.\\n Sent up from the ED on labetolol drip.\\n 24 Hour Events:\\n ARTERIAL LINE - START 11:15 AM\\n EKG - At 12:47 PM\\n History obtained from Patient\\n Allergies:\\n Penicillins\\n Rash;\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n itching;\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Other medications:\\n Med list reviewed\\n Changes to medical and family history:\\n Lupus\\n ESRD\\n Malignant Hypertension\\n Thrombocytopenia\\n HOCM\\n Anemia\\n Left eye enucleation\\n Coag negative staph\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\\n Respiratory: No(t) Cough, No(t) Dyspnea\\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis\\n Flowsheet Data as of 10:04 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: 35.6\\nC (96\\n HR: 83 (71 - 99) bpm\\n BP: 148/103(113) {115/58(74) - 208/153(166)} mmHg\\n RR: 15 (13 - 32) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 60 Inch\\n Total In:\\n 1,725 mL\\n 180 mL\\n PO:\\n 440 mL\\n 180 mL\\n TF:\\n IVF:\\n 1,285 mL\\n Blood products:\\n Total out:\\n 255 mL\\n 150 mL\\n Urine:\\n 250 mL\\n 150 mL\\n NG:\\n 5 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,470 mL\\n 30 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 100%\\n ABG: ///16/\\n Physical Examination\\n General Appearance: Well nourished\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric)\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, No(t) Oriented (to): , Movement: Not assessed, Tone: Not\\n assessed\\n Labs / Radiology\\n 8.3 g/dL\\n 93 K/uL\\n 99 mg/dL\\n 8.5 mg/dL\\n 16 mEq/L\\n 5.4 mEq/L\\n 52 mg/dL\\n 107 mEq/L\\n 136 mEq/L\\n 24.7 %\\n 3.9 K/uL\\n [image002.jpg]\\n 11:43 AM\\n 06:10 AM\\n WBC\\n 3.9\\n Hct\\n 24.7\\n Plt\\n 93\\n Cr\\n 8.1\\n 8.5\\n Glucose\\n 86\\n 99\\n Other labs: PT / PTT / INR:18.9/39.2/1.7, Ca++:6.6 mg/dL, Mg++:1.6\\n mg/dL, PO4:5.6 mg/dL\\n Assessment and Plan\\n A:\\n 1) Hypertensive Urgency: still with some relatively high BPs (160/100)\\n but asymptomatic and off labetolol drip.\\n Plan:\\n - Continue clonidine, labetolol,\\n 2) ESRD: still refusing dialysis. I discussed this with her including\\n risk of refusal which include death.\\n 3) Right lower extremity pain:\\n 4) Hyperkalemia: Kayexalate as refusing dialysis.\\n 5) SLE\\n 6) Thromobocytopenia: Stable\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 11:15 AM\\n 20 Gauge - 11:25 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: 35 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-09-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 339131,\n \"text\": \"Ms. is a 24 y.o. F with lupus, Chronic Kidney Disease V (not\\n currently on HD or PD), and multiple admissions for hypertensive\\n urgency/emergency, who presented to the ED for continued R leg pain\\n that starts in her R buttocks and refers down her R leg. She describes\\n it as feeling like the pain is deep within her bone. The pain was\\n this AM, and she felt like she couldn't get out of bed. Denies\\n any swelling of her RLE. When getting VS in , pt noted to be very\\n hypertensive at 263/176. The patient reportedly has baseline SBPs in\\n 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM\\n on day of admission. She denies headache, vision changes, double\\n vision, chest pain, shortness of breath, abdominal pain, BRBPR,\\n dysuria. During MD interview, the patient was nauseous and had small\\n amount of emesis of a recent Coolata. Pt states that flushing her PD\\n cath causes a large amout of stomach pain. Currently, she has RLE\\n pain. Pt admitted to\\n 4 for malignant hypertension, was on Labetolol gtt.\\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\\n emergency)\\n Assessment:\\n Labetolol gtt off on days. Bp on the lower side at change of shift\\n 120-130/74. (nitropaste removed) currently bp 160/98 HR 70\\ns SR\\n BP higher via A-line (A-line with good dynamic response, good\\n tracing) on left arm 20 point difference in BP . In Right\\n arm 10 point difference). We are using the A-line to monitor bp\\n INR 1.7 ~ pt received 5 mg po Coumadin. No further pain from right\\n leg.\\n Pt denies HA, blurry vision, chest pain. No further nausea/vomiting.\\n Action:\\n Bp lower beginning of shift (120/70) Hydralazine, Labetalol\\n Aliskiren held.\\n Response:\\n Bp slowly rising over shift.\\n Plan:\\n Give antihypertensives if SBP over 160. Coumadine 5 mg po qd prn\\n Morphine for leg pain, prn Tylenol for headache. Prn Zofran for\\n nausea. Monitor lytes.\\n GU: pt voiding in commode. Urine output 200 cc\\ns. bun 49, crt\\n 8.1 pt with UTI\\n on Cipro.\\n GI: pt on a regular diet poor appetite. On pantoprazole\\n PAIN: no further right leg pain, lumbar spine MRI and R hip xray on\\n most recent admission were both negative. Likely sciatica\\n prn\\n morphine as needed.\\n .\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-09-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 339197,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pressures finally dropped to 130/80s and labetelol drip was stopped\\n ARTERIAL LINE - START 11:15 AM\\n EKG - At 12:47 PM\\n Allergies:\\n Penicillins\\n Rash;\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n itching;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 01:21 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:56 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: 36.9\\nC (98.4\\n HR: 79 (71 - 99) bpm\\n BP: 142/105(113) {115/58(74) - 208/153(166)} mmHg\\n RR: 13 (13 - 32) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 60 Inch\\n Total In:\\n 1,725 mL\\n 180 mL\\n PO:\\n 440 mL\\n 180 mL\\n TF:\\n IVF:\\n 1,285 mL\\n Blood products:\\n Total out:\\n 255 mL\\n 150 mL\\n Urine:\\n 250 mL\\n 150 mL\\n NG:\\n 5 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,470 mL\\n 30 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 100%\\n ABG: ///16/\\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 8.3 g/dL\\n 86 mg/dL\\n 8.1 mg/dL\\n 16 mEq/L\\n 5.0 mEq/L\\n 49 mg/dL\\n 110 mEq/L\\n 139 mEq/L\\n 24.7 %\\n 3.9 K/uL\\n [image002.jpg]\\n 11:43 AM\\n 06:10 AM\\n WBC\\n 3.9\\n Hct\\n 24.7\\n Cr\\n 8.1\\n Glucose\\n 86\\n Other labs: PT / PTT / INR:18.4/42.8/1.7, Ca++:6.2 mg/dL, Mg++:1.6\\n mg/dL, PO4:5.8 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 11:15 AM\\n 20 Gauge - 11:25 AM\\n 18 Gauge - 11:26 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-09-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 339202,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pressures finally dropped to 130/80s and labetelol drip was stopped\\n ARTERIAL LINE - START 11:15 AM\\n EKG - At 12:47 PM\\n Allergies:\\n Penicillins\\n Rash;\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n itching;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 01:21 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:56 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: 36.9\\nC (98.4\\n HR: 79 (71 - 99) bpm\\n BP: 142/105(113) {115/58(74) - 208/153(166)} mmHg\\n RR: 13 (13 - 32) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 60 Inch\\n Total In:\\n 1,725 mL\\n 180 mL\\n PO:\\n 440 mL\\n 180 mL\\n TF:\\n IVF:\\n 1,285 mL\\n Blood products:\\n Total out:\\n 255 mL\\n 150 mL\\n Urine:\\n 250 mL\\n 150 mL\\n NG:\\n 5 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,470 mL\\n 30 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 100%\\n ABG: ///16/\\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 8.3 g/dL\\n 86 mg/dL\\n 8.1 mg/dL\\n 16 mEq/L\\n 5.0 mEq/L\\n 49 mg/dL\\n 110 mEq/L\\n 139 mEq/L\\n 24.7 %\\n 3.9 K/uL\\n [image002.jpg]\\n 11:43 AM\\n 06:10 AM\\n WBC\\n 3.9\\n Hct\\n 24.7\\n Cr\\n 8.1\\n Glucose\\n 86\\n Other labs: PT / PTT / INR:18.4/42.8/1.7, Ca++:6.2 mg/dL, Mg++:1.6\\n mg/dL, PO4:5.8 mg/dL\\n Assessment and Plan\\n ASSESSMENT & PLAN: 24 y.o. F with ESRD (not on HD or PD) and lupus,\\n admitted for malignant hypertension, currently on labetalol gtt.\\n .\\n # Malignant hypertension: SBPs currently in 200s with baseline SBP\\n 130-180s. No symptoms/signs of hypertensive emergency as pt without\\n seizures, no acute worsening of renal function (anuric at baseline)\\n Denies HA, blurry vision, chest pain. + nausea/vomiting\\n - Continue labetalol drip with down-titration as possible for goal SBP\\n in 170-180s\\n - NTG transdermal now\\n - Transition to home dose oral labetalol when able\\n - Re-start home regimen of nifedipine, hydralazine, clonidine patch,\\n aliskiren when able\\n - Monitor BPs closely\\n - Neuro checks q 4 hours\\n .\\n # Right leg pain: Lumbar spine MRI and R hip XR on most recent\\n admission were both negative. Likely sciatica.\\n - IV Morphine as needed for pain\\n - Transition to po pain medications when able\\n .\\n # UTI: UCx pending. Asymptomatic currently.\\n - ciprofloxacin x 3 days\\n - f/u Urine culture\\n - check EKGs daily while on FQ and borderline prolonged QT\\n .\\n # ESRD: Pt not on PD although with PD catheter. On last admission, she\\n had difficulty tolerating PD secondary to pain.\\n - Peritoneal dialysis as tolerated\\n - Appreciate renal recommendations\\n .\\n # Hyperkalemia: K elevated to 5.9 on admission, but moderately\\n hemolyzed\\n - check electrolytes now\\n - EKG on arrival to ICU\\n .\\n # Anemia: Likely related to chronic disease. Baseline Hct 20, currently\\n 24. Not on epo given hypertension. Past transfusion requirement.\\n - Trend Hct daily\\n - Transfer if Hct < 20\\n - active T&S\\n .\\n # Prior SVC thrombus: Related to catheter in . INR goal 2.5 to\\n 3.0. Was elevated to 3.4 on d/c on \\n - check coags now to decide whether to continue or hold coumadin.\\n .\\n # Systemic lupus erythematosus:\\n - Continue prednisone daily\\n .\\n # HOCM: Seen on TTE in .\\n - BP management as above.\\n - Avoid excessive volume removal.\\n .\\n # Thrombocytopenia: Baseline platelets approximately 100.\\n - trend platelets daily\\n .\\n # FEN: no IVFs / replete lytes prn / ADAT\\n .\\n # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen\\n .\\n # ACCESS: Peripheral IV, A-line\\n .\\n # CONTACT: (mother) \\n .\\n # CODE: Full Code\\n .\\n # DISPO: ICU pending blood pressure control\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 11:15 AM\\n 20 Gauge - 11:25 AM\\n 18 Gauge - 11:26 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-09-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 339030,\n \"text\": \"24 y.o. woman adm with hypertensive crisis with bp 260s/150s, hx\\n htn, esrd, had pd catheter placed 2 months ago but uable to tolerate pd\\n treatments d/t severe abd pain with exchange. pt was admitted last week\\n with leg pain, was discharged on dilaudid but the leg pain grew worse.\\n pt given morphine for the pain in the er. the hypertension was treated\\n with 10mg iv labetolol without effect. pt was started on a labetolol\\n drip at 1mg/min and titrated up to 3mg/mg with bp 230s/150s. pt also\\n s/o shortness of breath. LENIs negative for dvt. cxr normal. urine sent\\n in er. hct 24.7, pt with baseline anemia. bun 51, cr 8.4, k 5.9,\\n moderately hemolyzed. pt transferred to 4 icu for treatement of\\n her hypertensive crisis.\\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\\n emergency)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-09-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 339099,\n \"text\": \"24 y.o. woman adm with hypertensive crisis with bp 260s/150s, hx\\n htn, esrd, had pd catheter placed 2 months ago but uable to tolerate pd\\n treatments d/t severe abd pain with exchange. pt was admitted last week\\n with leg pain, was discharged on dilaudid but the leg pain grew worse.\\n pt given morphine for the pain in the er. the hypertension was treated\\n with 10mg iv labetolol without effect. pt was started on a labetolol\\n drip at 1mg/min and titrated up to 3mg/mg with bp 230s/150s. pt also\\n s/o shortness of breath. LENIs negative for dvt. cxr normal. urine sent\\n in er. hct 24.7, pt with baseline anemia. bun 51, cr 8.4, k 5.9,\\n moderately hemolyzed. pt transferred to 4 icu for treatment of\\n her hypertensive crisis.\\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\\n emergency)\\n Assessment:\\n Sbp in 230s on arrival to icu via aline. Sbp 10 points lower via\\n noninvasive cuff. Labetalol drip was infusing at 3mg/hr and titrated up\\n to as high as 5mg/hr with 1 inch nitropaste placed on chest wall. Pt\\n c/o +n/v 10cc strawberry colored emesis (pt had strawberry drink in\\n er). Also c/o right leg pain she\\ns been having.\\n Action:\\n Labetalol drip maintained at 5mg/hr until pt able to take po meds.\\n Given iv zofran for n/v with good effect. Given 2mg iv morphine with\\n good effect with pain to her baseline 5. pt given po hydralazine\\n and po labetalol with lunch.\\n Response:\\n Sbp lowering to as low as 160s via noninvasive cuff and 180s aline.\\n (goal sbp 130-170, dbp <100). Labetalol drip weaned to as low as 1mg/hr\\n but sbp still 170s-180s noninvasive cuff and 190s-200s aline. New 1\\n inch nitropaste applied to chest wall with old paste wiped off at\\n 16:55. developed a headache shortly after new nitropaste applied. Given\\n 650mg Tylenol with relief. Sbp down to 150s noninvasive cuff. 180s\\n aline. Labetolol drip currently at 1mg/hr.\\n Plan:\\n Continue to attempt to wean labetalol drip, continue antihypertensives\\n as ordered. Morphine prn right leg pain. Tylenol prn headache. Zofran\\n prn nausea. Monitor lytes. Receiving 3mg calcium gluconate currently\\n for calcium relpletion. Repeat k 5.0 from 5.9( 5.9 was moderately\\n hemolyzed).\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-09-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 339028,\n \"text\": \".H/O hypertension, malignant (hypertensive crisis, hypertensive\\n emergency)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-09-12 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 339295,\n \"text\": \"24 y.o. F with ESRD (not on HD or PD) and lupus, admitted for malignant\\n hypertension, currently on home regimen.\\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\\n emergency)\\n Assessment:\\n SBP 160-170\\ns/100\\ns- 110\\ns with baseline SBP 130-180s, No\\n symptoms/signs of hypertensive emergency as pt without seizures, no\\n acute worsening of renal function (anuric at baseline) Denies HA,\\n blurry vision, chest pain. Denies nausea/vomiting. No peripheral\\n edema. Peripheral pulses present.\\n Action:\\n Re-started home regimen of nifedipine, hydralazine, clonidine patch,\\n aliskiren. - Monitor BPs closely. Neuro checks q 4 hours\\n Response:\\n SBP at 150-160\\ns/100\\ns ( 2 pm hydralazine held due to SBP of 120\\n Plan:\\n Continue to monitor patient hemodynamic status, hypertensive meds\\n ASDIR.\\n Neuro: alert oriented X3, follows commands, steady gait. Incompliant\\n w/some of the care. RT leg pain - Lumbar spine MRI and R hip XR on most\\n recent admission were both negative. Likely sciatica\\n morphine IV\\n given w/some effect\\n Resp: on RA sats at high 90\\ns-100%. Bil LS clear, RRR, unlabored\\n breathing.\\n GI: abd soft non tender, non distended, positive for BS. Regular diet\\n (patient been refusing renal diet). Denies N/V. PD site - c/d/i.\\n dressing changed today.\\n GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted.\\n Uses commode to void. Clean yellow urine. Dx of UTI on cipro. Urine\\n cultures were sent. F/u results.\\n Skin: no skin impairment\\n Social: patient is a FULL CODE. Family in to visit.\\n K- 5.4 kayexalate 30gr given at 11 am awaiting results. at 1500 K-5.6\\n another 15gr of kayexalate given. PO4 -6.8 started on Sevelamer\\n HX of SVC thrombus related to catheter in . INR goal 2.5 to 3.0.\\n Patient on coumadin 5mg daily.\\n SLE\\n on daily prednisone.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n HYPERTENSION\\n Code status:\\n Full code\\n Height:\\n 60 Inch\\n Admission weight:\\n 51.6 kg\\n Daily weight:\\n Allergies/Reactions:\\n Penicillins\\n Rash;\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n itching;\\n Precautions:\\n PMH: Renal Failure\\n CV-PMH: Hypertension\\n Additional history: SLE diagnosed in (16yrs old) when she had\\n swollen fingers, arm rash, and arthralgias. previous treatment with\\n cytoxan, cellcept, currently on prednisone. complicated by uveitis\\n () and ESRD ().\\n CKD/ESRD, diagnosed in , initiated hemodialysis . PD catheter\\n placement . pt reluctant to start PD and didn't tolerate PD flush\\n well at all with severe abd pain.\\n malignant hypertension, baseline sBPs 180s-120s. history of\\n hypertensive crisis with seizures. history of 2 intraparenchymal\\n hemorrhages that wer thought to be due to the posterior reversible\\n leukoencephalopathy syndrome.\\n TTP (got plasmapheresis) versus malignant HTN\\n thrombotic events. SVC thrombosis () related to a catheter.\\n Negative lupus anticoagulant (, , 9/).\\n Negative anticardiolipin antiboties IgG and IgM x4 (-). Negtive\\n Beta-2 gylcoprotein antibody (, 8/).\\n -HOCM: last noted on echo .\\n -anemia\\n -history of left eye enucleation for fungal infection.\\n -history of vaginal bleeding lasting 2 months s/p DepoProvera\\n injection requiring transfusion.\\n -history of coag negative Staph bacteremia and HD line infection \\n and .\\n past surgical histories: placement of multiple catheters including\\n dialysis, tonsillectomy, left eye enucleation in , PD\\n catheter placement in .\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:129\\n D:74\\n Temperature:\\n 97\\n Arterial BP:\\n S:157\\n D:131\\n Respiratory rate:\\n 16 insp/min\\n Heart Rate:\\n 88 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 99% %\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 1,070 mL\\n 24h total out:\\n 450 mL\\n Pertinent Lab Results:\\n Sodium:\\n 141 mEq/L\\n 02:38 PM\\n Potassium:\\n 5.6 mEq/L\\n 02:38 PM\\n Chloride:\\n 110 mEq/L\\n 02:38 PM\\n CO2:\\n 20 mEq/L\\n 02:38 PM\\n BUN:\\n 49 mg/dL\\n 02:38 PM\\n Creatinine:\\n 8.3 mg/dL\\n 02:38 PM\\n Glucose:\\n 121 mg/dL\\n 02:38 PM\\n Hematocrit:\\n 24.7 %\\n 06:10 AM\\n Valuables / Signature\\n Patient valuables: sent w/patient\\n Transferred from: MICU/\\n Transferred to: 9\\n Date & time of Transfer: \\n ------ Protected Section ------\\n Patient refused kayexalate. (k-5.6) team aware\\n ------ Protected Section Addendum Entered By: , RN\\n on: 15:53 ------\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2141-09-11 00:00:00.000\",\n \"description\": \"Initial H&P\",\n \"row_id\": 339083,\n \"text\": \" ADMISSION NOTE\\n .\\n Reason for MICU Admission: Malignant Hypertension.\\n .\\n Primary Care Physician: MD / MD\\n .\\n CC: Right leg pain.\\n .\\n HPI: Ms. is a 24 y.o. F with lupus, Chronic Kidney Disease V (not\\n currently on HD or PD), and multiple admissions for hypertensive\\n urgency/emergency, who presented to the ED for continued R leg pain\\n that starts in her R buttocks and refers down her R leg. She describes\\n it as feeling like the pain is deep within her bone. The pain was\\n this AM, and she felt like she couldn't get out of bed. Denies\\n any swelling of her RLE. When getting VS in , pt noted to be very\\n hypertensive at 263/176. The patient reportedly has bseline SBPs in\\n 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM\\n on day of admission. She denies headache, vision changes, double\\n vision, chest pain, shortness of breath, abdominal pain, BRBPR,\\n dysuria. During MD interview, the patient was nauseous and had small\\n amount of emesis of a recent Coolata. Pt states that flushing her PD\\n cath causes a large amout of stomach pain. Currently, she has RLE\\n pain.\\n .\\n In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in\\n ED ranged from -175 with HR in 96-108. Initially given\\n labetalol 10 mg IV x 1 and then started on labetalol gtt for her\\n elevated blood pressures and titrated to 3 mg/min. LENI of R leg was\\n negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per\\n ED, cannot do V/Q scan due to volume overload after talking with\\n radiology. Renal c/s initiated. A-line placed.\\n .\\n Of note, the patient was recently admitted from 08.26-29.08. The\\n patient initially presented to the ED after referral from her\\n nephrologist's office where she had complaints of right leg pain and\\n was found to be hypertensive to 250/145. She was admitted after\\n initiation of a labetalol drip and nitropaste with improvement in sbp\\n to 180. The patient did receive 2 U of PRBC's during this\\n hospitalization for baseline anemia. The patient did have a work-up for\\n her right leg pain complaints with plain films of the right hip and MRI\\n of the L-spine which did not reveal an explanation for her symptoms and\\n did rule out avascular necrosis. The patient received dilaudid for pain\\n control and was ambulating without pain prior to discharge. In\\n addition, the patient completed a course of ciprofloxacin for a\\n positive UA with negative cultures. The patient was unable to tolerate\\n peritoneal dialysis for unclear reasons. Peritoneal dialysate culture\\n was negative for infection.\\n .\\n ROS: as stated above in HPI.\\n .\\n MEDICATIONS (from discharge summary ):\\n - Prednisone 5 mg Daily\\n - Coumadin 2 mg at bedtime\\n - Nifedipine 60 mg Sustained Release Daily\\n - Hydralazine 50 mg every 8 hours\\n - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday\\n - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY\\n - Aliskiren 150 mg Twice daily\\n - Docusate Sodium 100 mg 2 times a day\\n - Labetalol 900 mg three times a day\\n - Lactulose 15-30 ml once a day: goal is soft bowel movements per\\n day\\n .\\n ALLERGIES: Penicillins / Percocet\\n .\\n PAST MEDICAL HISTORY:\\n - Systemic lupus erythematosus. Diagnosed (16 years old) when she\\n had swollen fingers, arm rash and arthralgias. Previous treatment with\\n cytoxan, cellcept; currently on prednisone. Complicated by uveitis\\n () and ESRD ().\\n - CKD/ESRD. Diagosed . Initiated dialysis . PD catheter\\n placement . Pt reluctant to start PD.\\n - Malignant hypertension. Baseline BPs 180's - 120's. History of\\n hypertensive crisis with seizures. History of two intraparenchymal\\n hemorrhages that were thought to be due to the posterior reversible\\n leukoencephalopathy syndrome.\\n - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN.\\n - Thrombotic events. SVC thrombosis (); related to a catheter.\\n Negative lupus anticoagulant (, , 9/). Negative\\n anticardiolipin antibodies IgG and IgM x4 (-). Negative Beta-2\\n glycoprotein antibody (, 8/).\\n - HOCM: Last noted on echo .\\n - Anemia.\\n - History of left eye enucleation for fungal infection.\\n - History of vaginal bleeding lasting 2 months s/p DepoProvera\\n injection requiring transfusion.\\n - History of Coag negative Staph bacteremia and HD line\\n infection - and \\n .\\n PAST SURGICAL HISTORY:\\n 1. Placement of multiple catheters including dialysis.\\n 2. Tonsillectomy.\\n 3. Left eye enucleation in .\\n 4. PD catheter placement in .\\n .\\n SOCIAL HISTORY: Single. Lives with her mother and brother. On\\n disability. Denies EtOH, tobacco or drug use.\\n .\\n FAMILY HISTORY: No history of autoimmune or thrombophilic disorders.\\n .\\n PHYSICAL EXAM:\\n VS: T 98.9 99$% RA\\n GEN: NAD, pleaseant female sitting in bed with moon facies\\n HEENT: EOMI of R eye, L eye prosthesis, OP - no exudate, no erythema,\\n MMM, no LAD\\n CHEST: CTAB except at R base with decreased breath sounds; no w/r/r\\n CV: tachy, no m/r/g appreciated, + S4\\n ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i\\n EXT: no c/c/e, + SLR of RLE, able to wiggle toes and raise BLE off bed\\n NEURO: II - XII grossly intact\\n DERM: no rashes noted\\n .\\n LABORATORIES:\\n Na 138, K 5.9 (hemolyzed), Cl 108, Bicarb 21, BUN/Cr 51/8.4, glucose\\n 85, WBC 5.5 (74 N, 17.5 L), Hct 24.7, platelets 101.\\n .\\n UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50\\n WBC\\n .\\n MICROBIOLOGY:\\n Blood culture (): Pending.\\n Urine culture (): No growth.\\n Peritoneal fluid (): Gram stain no PMN's or microorganisms.\\n Culture pending.\\n .\\n STUDIES:\\n EKG : sinus tachy @ 100 bpm, nl axis, borderline PR prolongation,\\n long QT interval, no acute ST-TWI. No change from prio on .\\n PORTABLE CXR (my read): Cardiomegaly. Some increased haziness of\\n RLL/R diaphragm from CXR.\\n R LENI (wet read): No DVT.\\n .\\n TTE (): The left atrium is normal in size. There is severe\\n symmetric left ventricular hypertrophy. The left ventricular cavity is\\n unusually small. Regional left ventricular wall motion is normal. Left\\n ventricular systolic function is hyperdynamic (EF>75%). There is a mild\\n resting left ventricular outflow tract obstruction. The gradient\\n increased with the Valsalva manuever. The findings are consistent with\\n hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular\\n septal defect. Right ventricular chamber size and free wall motion are\\n normal. The aortic valve leaflets (3) appear structurally normal with\\n good leaflet excursion. No masses or vegetations are seen on the aortic\\n valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears\\n structurally normal with trivial mitral regurgitation. There is no\\n mitral valve prolapse. No mass or vegetation is seen on the mitral\\n valve. The estimated pulmonary artery systolic pressure is normal.\\n There is a trivial/physiologic pericardial effusion.\\n .\\n R HIP XR : No acute fracture or dislocation.\\n .\\n MRI L-SPINE : Diffuse low-signal intensity is identified in the\\n bone marrow of the lumbar and lower thoracic spine as described above,\\n possibly related with anemic changes, please correlate clinically.\\n There is no evidence of spinal canal stenosis or neural foraminal\\n narrowing at the different intervertebral disc spaces.\\n .\\n ASSESSMENT & PLAN: 24 y.o. F with ESRD (not on HD or PD) and lupus,\\n admitted for malignant hypertension, currently on labetalol gtt.\\n .\\n # Malignant hypertension: SBPs currently in 200s with baseline SBP\\n 130-180s. No symptoms/signs of hypertensive emergency as pt without\\n seizures, no acute worsening of renal function (anuric at baseline)\\n Denies HA, blurry vision, chest pain. + nausea/vomiting\\n - Continue labetalol drip with down-titration as possible for goal SBP\\n in 170-180s\\n - NTG transdermal now\\n - Transition to home dose oral labetalol when able\\n - Re-start home regimen of nifedipine, hydralazine, clonidine patch,\\n aliskiren when able\\n - Monitor BPs closely\\n - Neuro checks q 4 hours\\n .\\n # Right leg pain: Lumbar spine MRI and R hip XR on most recent\\n admission were both negative. Likely sciatica.\\n - IV Morphine as needed for pain\\n - Transition to po pain medications when able\\n .\\n # UTI: UCx pending. Asymptomatic currently.\\n - ciprofloxacin x 3 days\\n - f/u Urine culture\\n - check EKGs daily while on FQ and borderline prolonged QT\\n .\\n # ESRD: Pt not on PD although with PD catheter. On last admission, she\\n had difficulty tolerating PD secondary to pain.\\n - Peritoneal dialysis as tolerated\\n - Appreciate renal recommendations\\n .\\n # Hyperkalemia: K elevated to 5.9 on admission, but moderately\\n hemolyzed\\n - check electrolytes now\\n - EKG on arrival to ICU\\n .\\n # Anemia: Likely related to chronic disease. Baseline Hct 20, currently\\n 24. Not on epo given hypertension. Past transfusion requirement.\\n - Trend Hct daily\\n - Transfer if Hct < 20\\n - active T&S\\n .\\n # Prior SVC thrombus: Related to catheter in . INR goal 2.5 to\\n 3.0. Was elevated to 3.4 on d/c on \\n - check coags now to decide whether to continue or hold coumadin.\\n .\\n # Systemic lupus erythematosus:\\n - Continue prednisone daily\\n .\\n # HOCM: Seen on TTE in .\\n - BP management as above.\\n - Avoid excessive volume removal.\\n .\\n # Thrombocytopenia: Baseline platelets approximately 100.\\n - trend platelets daily\\n .\\n # FEN: no IVFs / replete lytes prn / ADAT\\n .\\n # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen\\n .\\n # ACCESS: Peripheral IV, A-line\\n .\\n # CONTACT: (mother) \\n .\\n # CODE: Full Code\\n .\\n # DISPO: ICU pending blood pressure control\\n .\\n .\\n .\\n .\\n , MD, MPH\\n \\n PGY-2\\n ------ Protected Section ------\\n I saw this patient with Dr. , the ICU resident, and agree with her\\n HPI, PMHx, Fhx, SocHX, ROS, PE and plan as outlined above. \\n is a 24 yo bf with SLE, CRF not on dialysis, severe HTN who came\\n to the ED today because of right leg pain, but noted to have elevated\\n BP (260/130\\ns).. She currently appears without distress, and denies\\n CP/SOB/vision changes/headaches/MS changes to indicate HTN emergency.\\n Lungs: slightly diminished at R base, otherwise clear. CV: mildly\\n tachy, RR, +S4. Abd: soft, nontender, +bs. Ext without edema.\\n She is in the for hypertensive urgency, which is being treated\\n with a labetolol gtt, resumption of home medicines and invasive BP\\n monitoring Renal team following. RLE pain treated with morphine and\\n consider hip MRI for further evaluation. Further plans as outlined\\n above.\\n Pt is critically ill.\\n Total time spent on patient: 40 minutes.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 17:57 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-09-12 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 339286,\n \"text\": \"24 y.o. F with ESRD (not on HD or PD) and lupus, admitted for malignant\\n hypertension, currently on home regimen.\\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\\n emergency)\\n Assessment:\\n SBP 160-170\\ns/100\\ns- 110\\ns with baseline SBP 130-180s, No\\n symptoms/signs of hypertensive emergency as pt without seizures, no\\n acute worsening of renal function (anuric at baseline) Denies HA,\\n blurry vision, chest pain. Denies nausea/vomiting. No peripheral\\n edema. Peripheral pulses present.\\n Action:\\n Re-started home regimen of nifedipine, hydralazine, clonidine patch,\\n aliskiren. - Monitor BPs closely. Neuro checks q 4 hours\\n Response:\\n SBP at 150-160\\ns/100\\ns ( 2 pm hydralazine held due to SBP of 120\\n Plan:\\n Continue to monitor patient hemodynamic status, hypertensive meds\\n ASDIR.\\n Neuro: alert oriented X3, follows commands, steady gait. Incompliant\\n w/some of the care. RT leg pain - Lumbar spine MRI and R hip XR on most\\n recent admission were both negative. Likely sciatica\\n morphine IV\\n given w/some effect\\n Resp: on RA sats at high 90\\ns-100%. Bil LS clear, RRR, unlabored\\n breathing.\\n GI: abd soft non tender, non distended, positive for BS. Regular diet\\n (patient been refusing renal diet). Denies N/V. PD site - c/d/i.\\n dressing changed today.\\n GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted.\\n Uses commode to void. Clean yellow urine. Dx of UTI on cipro. Urine\\n cultures were sent. F/u results.\\n Skin: no skin impairment\\n Social: patient is a FULL CODE. Family in to visit.\\n K- 5.4 kayexalate 30gr given at 11 am awaiting results.\\n HX of SVC thrombus related to catheter in . INR goal 2.5 to 3.0.\\n Patient on coumadin 5mg daily.\\n SLE\\n on daily prednisone.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n HYPERTENSION\\n Code status:\\n Full code\\n Height:\\n 60 Inch\\n Admission weight:\\n 51.6 kg\\n Daily weight:\\n Allergies/Reactions:\\n Penicillins\\n Rash;\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n itching;\\n Precautions:\\n PMH: Renal Failure\\n CV-PMH: Hypertension\\n Additional history: SLE diagnosed in (16yrs old) when she had\\n swollen fingers, arm rash, and arthralgias. previous treatment with\\n cytoxan, cellcept, currently on prednisone. complicated by uveitis\\n () and ESRD ().\\n CKD/ESRD, diagnosed in , initiated hemodialysis . PD catheter\\n placement . pt reluctant to start PD and didn't tolerate PD flush\\n well at all with severe abd pain.\\n malignant hypertension, baseline sBPs 180s-120s. history of\\n hypertensive crisis with seizures. history of 2 intraparenchymal\\n hemorrhages that wer thought to be due to the posterior reversible\\n leukoencephalopathy syndrome.\\n TTP (got plasmapheresis) versus malignant HTN\\n thrombotic events. SVC thrombosis () related to a catheter.\\n Negative lupus anticoagulant (, , 9/).\\n Negative anticardiolipin antiboties IgG and IgM x4 (-). Negtive\\n Beta-2 gylcoprotein antibody (, 8/).\\n -HOCM: last noted on echo .\\n -anemia\\n -history of left eye enucleation for fungal infection.\\n -history of vaginal bleeding lasting 2 months s/p DepoProvera\\n injection requiring transfusion.\\n -history of coag negative Staph bacteremia and HD line infection \\n and .\\n past surgical histories: placement of multiple catheters including\\n dialysis, tonsillectomy, left eye enucleation in , PD\\n catheter placement in .\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:129\\n D:74\\n Temperature:\\n 97\\n Arterial BP:\\n S:157\\n D:131\\n Respiratory rate:\\n 16 insp/min\\n Heart Rate:\\n 88 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 99% %\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 1,070 mL\\n 24h total out:\\n 450 mL\\n Pertinent Lab Results:\\n Sodium:\\n 136 mEq/L\\n 06:10 AM\\n Potassium:\\n 5.4 mEq/L\\n 06:10 AM\\n Chloride:\\n 107 mEq/L\\n 06:10 AM\\n CO2:\\n 16 mEq/L\\n 06:10 AM\\n BUN:\\n 52 mg/dL\\n 06:10 AM\\n Creatinine:\\n 8.5 mg/dL\\n 06:10 AM\\n Glucose:\\n 99 mg/dL\\n 06:10 AM\\n Hematocrit:\\n 24.7 %\\n 06:10 AM\\n Valuables / Signature\\n Patient valuables: sent w/patient\\n Transferred from: MICU/\\n Transferred to: 9\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-09-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 339288,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Pressures finally dropped to 130/80s and labetelol drip was stopped\\n ARTERIAL LINE - START 11:15 AM\\n EKG - At 12:47 PM\\n Allergies:\\n Penicillins\\n Rash;\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n itching;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 01:21 PM\\n Other medications:\\n Nifedipine CR 60 po daily\\n Labetalol 900 mg PO TID\\n Hydral 50 mg PO q 8\\n AlisKiren NF 150 mg PO BID\\n Tylenol\\n Clonidine patch 0.3 mg q wed\\n Prednisone 5 mg PO daily\\n Calcium carbonate 500 mg PO QID\\n Warfarin 5 mg PO qhs\\n Morphine\\n Ondansetron\\n Docusate, senna, bisacoldy\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:56 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: 36.9\\nC (98.4\\n HR: 79 (71 - 99) bpm\\n BP: 142/105(113) {115/58(74) - 208/153(166)} mmHg\\n RR: 13 (13 - 32) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 60 Inch\\n Total In:\\n 1,725 mL\\n 180 mL\\n PO:\\n 440 mL\\n 180 mL\\n TF:\\n IVF:\\n 1,285 mL\\n Blood products:\\n Total out:\\n 255 mL\\n 150 mL\\n Urine:\\n 250 mL\\n 150 mL\\n NG:\\n 5 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,470 mL\\n 30 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 100%\\n ABG: ///16/\\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 8.3 g/dL\\n 86 mg/dL\\n 8.1 mg/dL\\n 16 mEq/L\\n 5.0 mEq/L\\n 49 mg/dL\\n 110 mEq/L\\n 139 mEq/L\\n 24.7 %\\n 3.9 K/uL\\n [image002.jpg]\\n 11:43 AM\\n 06:10 AM\\n WBC\\n 3.9\\n Hct\\n 24.7\\n Cr\\n 8.1\\n Glucose\\n 86\\n Other labs: PT / PTT / INR:18.4/42.8/1.7, Ca++:6.2 mg/dL, Mg++:1.6\\n mg/dL, PO4:5.8 mg/dL\\n Assessment and Plan\\n ASSESSMENT & PLAN: 24 y.o. F with ESRD (not on HD or PD) and lupus,\\n admitted for malignant hypertension, currently on labetalol gtt.\\n .\\n # Malignant hypertension: SBPs currently in 200s with baseline SBP\\n 130-180s. No symptoms/signs of hypertensive emergency as pt without\\n seizures, no acute worsening of renal function (anuric at baseline)\\n Denies HA, blurry vision, chest pain. + nausea/vomiting\\n - patient without any symptoms now, patient is refusing hemodialysis\\n -labetalol drip stopped, patient on home BP meds, goal systolic range\\n 160-170s\\n - Monitor BPs closely, neuro checks q 4 hours\\n .\\n # Right leg pain: Lumbar spine MRI and R hip XR on most recent\\n admission were both negative. Likely sciatica.\\n - IV Morphine as needed for pain\\n - Transition to po pain medications when able\\n - on chronic steroids concern for potential risk of AVN of right hip,\\n would consider CT of right hip on transfer out of the unit\\n .\\n # UTI:\\n - UA grossly positive, ucx pending\\n - ciprofloxacin x 3 days\\n - f/u Urine culture\\n - check EKGs daily while on FQ and borderline prolonged QT\\n .\\n # ESRD: Pt not on PD although with PD catheter. On last admission, she\\n had difficulty tolerating PD secondary to pain.\\n - Peritoneal dialysis as tolerated\\n - Appreciate renal recommendations\\n possible PD dialysis, replete\\n Calcium\\n .\\n # Hyperkalemia: K elevated to 5.9 on admission, but moderately\\n hemolyzed\\n - repetat K 5.4, patient given kayexalate, checking EKGs daily now with\\n borderline QT\\n - cont to monitor daily electrolytes\\n .\\n # Anemia: Likely related to chronic disease. Baseline Hct 20, currently\\n 24. Not on epo given hypertension. Past transfusion requirement.\\n - Trend Hct daily, Transfer if Hct < 20\\n - active T&S\\n .\\n # Prior SVC thrombus: Related to catheter in . INR goal 2.5 to\\n 3.0. Was elevated to 3.4 on d/c on \\n - this morning INR 1.7, will not bridge at this time with heparin\\n - continue coumadin 5 mg PO qhs and re-check INR in AM.\\n .\\n # Systemic lupus erythematosus:\\n - Continue prednisone daily\\n .\\n # HOCM: Seen on TTE in .\\n - BP management as above.\\n - Avoid excessive volume removal\\n .\\n # Thrombocytopenia: Baseline platelets approximately 100.\\n - platelets are now 93, now indication for tranfusion at this time\\n - consider heme/onc consult as all 3 cell lines down\\n .\\n # FEN: no IVFs / replete lytes prn / ADAT\\n .\\n # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen\\n .\\n # ACCESS: Peripheral IV, A-line\\n .\\n # CONTACT: (mother) \\n .\\n # CODE: Full Code\\n .\\n # DISPO: to floor today as now off of labetalol drip\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 11:15 AM\\n 20 Gauge - 11:25 AM\\n 18 Gauge - 11:26 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-09-12 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 339289,\n \"text\": \"24 y.o. F with ESRD (not on HD or PD) and lupus, admitted for malignant\\n hypertension, currently on home regimen.\\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\\n emergency)\\n Assessment:\\n SBP 160-170\\ns/100\\ns- 110\\ns with baseline SBP 130-180s, No\\n symptoms/signs of hypertensive emergency as pt without seizures, no\\n acute worsening of renal function (anuric at baseline) Denies HA,\\n blurry vision, chest pain. Denies nausea/vomiting. No peripheral\\n edema. Peripheral pulses present.\\n Action:\\n Re-started home regimen of nifedipine, hydralazine, clonidine patch,\\n aliskiren. - Monitor BPs closely. Neuro checks q 4 hours\\n Response:\\n SBP at 150-160\\ns/100\\ns ( 2 pm hydralazine held due to SBP of 120\\n Plan:\\n Continue to monitor patient hemodynamic status, hypertensive meds\\n ASDIR.\\n Neuro: alert oriented X3, follows commands, steady gait. Incompliant\\n w/some of the care. RT leg pain - Lumbar spine MRI and R hip XR on most\\n recent admission were both negative. Likely sciatica\\n morphine IV\\n given w/some effect\\n Resp: on RA sats at high 90\\ns-100%. Bil LS clear, RRR, unlabored\\n breathing.\\n GI: abd soft non tender, non distended, positive for BS. Regular diet\\n (patient been refusing renal diet). Denies N/V. PD site - c/d/i.\\n dressing changed today.\\n GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted.\\n Uses commode to void. Clean yellow urine. Dx of UTI on cipro. Urine\\n cultures were sent. F/u results.\\n Skin: no skin impairment\\n Social: patient is a FULL CODE. Family in to visit.\\n K- 5.4 kayexalate 30gr given at 11 am awaiting results. at 1500 K-5.6\\n another 15gr of kayexalate given. PO4 -6.8 started on Sevelamer\\n HX of SVC thrombus related to catheter in . INR goal 2.5 to 3.0.\\n Patient on coumadin 5mg daily.\\n SLE\\n on daily prednisone.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n HYPERTENSION\\n Code status:\\n Full code\\n Height:\\n 60 Inch\\n Admission weight:\\n 51.6 kg\\n Daily weight:\\n Allergies/Reactions:\\n Penicillins\\n Rash;\\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\\n itching;\\n Precautions:\\n PMH: Renal Failure\\n CV-PMH: Hypertension\\n Additional history: SLE diagnosed in (16yrs old) when she had\\n swollen fingers, arm rash, and arthralgias. previous treatment with\\n cytoxan, cellcept, currently on prednisone. complicated by uveitis\\n () and ESRD ().\\n CKD/ESRD, diagnosed in , initiated hemodialysis . PD catheter\\n placement . pt reluctant to start PD and didn't tolerate PD flush\\n well at all with severe abd pain.\\n malignant hypertension, baseline sBPs 180s-120s. history of\\n hypertensive crisis with seizures. history of 2 intraparenchymal\\n hemorrhages that wer thought to be due to the posterior reversible\\n leukoencephalopathy syndrome.\\n TTP (got plasmapheresis) versus malignant HTN\\n thrombotic events. SVC thrombosis () related to a catheter.\\n Negative lupus anticoagulant (, , 9/).\\n Negative anticardiolipin antiboties IgG and IgM x4 (-). Negtive\\n Beta-2 gylcoprotein antibody (, 8/).\\n -HOCM: last noted on echo .\\n -anemia\\n -history of left eye enucleation for fungal infection.\\n -history of vaginal bleeding lasting 2 months s/p DepoProvera\\n injection requiring transfusion.\\n -history of coag negative Staph bacteremia and HD line infection \\n and .\\n past surgical histories: placement of multiple catheters including\\n dialysis, tonsillectomy, left eye enucleation in , PD\\n catheter placement in .\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:129\\n D:74\\n Temperature:\\n 97\\n Arterial BP:\\n S:157\\n D:131\\n Respiratory rate:\\n 16 insp/min\\n Heart Rate:\\n 88 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 99% %\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 1,070 mL\\n 24h total out:\\n 450 mL\\n Pertinent Lab Results:\\n Sodium:\\n 141 mEq/L\\n 02:38 PM\\n Potassium:\\n 5.6 mEq/L\\n 02:38 PM\\n Chloride:\\n 110 mEq/L\\n 02:38 PM\\n CO2:\\n 20 mEq/L\\n 02:38 PM\\n BUN:\\n 49 mg/dL\\n 02:38 PM\\n Creatinine:\\n 8.3 mg/dL\\n 02:38 PM\\n Glucose:\\n 121 mg/dL\\n 02:38 PM\\n Hematocrit:\\n 24.7 %\\n 06:10 AM\\n Valuables / Signature\\n Patient valuables: sent w/patient\\n Transferred from: MICU/\\n Transferred to: 9\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2141-09-11 00:00:00.000\",\n \"description\": \"R UNILAT LOWER EXT VEINS RIGHT\",\n \"row_id\": 1031432,\n \"text\": \" 8:54 AM\\n UNILAT LOWER EXT VEINS RIGHT Clip # \\n Reason: dvt?\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 24 year old woman with r leg pain, sob\\n REASON FOR THIS EXAMINATION:\\n dvt?\\n ______________________________________________________________________________\\n WET READ: JKPe MON 10:03 AM\\n no dvt\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Shortness of breath and right leg pain. Evaluate for DVT.\\n\\n Comparison is made to exam, also noted to be negative.\\n\\n RIGHT LOWER EXTREMITY ULTRASOUND\\n\\n -scale and Doppler son of the right common femoral, superficial\\n femoral, and popliteal veins demonstrate normal flow, compressibility,\\n augmentation, waveforms. Appropriate color flow and compression is noted\\n within the calf veins. No intraluminal thrombus is present.\\n\\n IMPRESSION:\\n\\n No evidence of right lower extremity DVT.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2141-09-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1031418,\n \"text\": \" 8:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: infiltrate?\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 24 year old woman with shortness of breath\\n REASON FOR THIS EXAMINATION:\\n infiltrate?\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Shortness of breath.\\n\\n UPRIGHT PORTABLE CHEST\\n\\n Comparison is made to multiple chest radiographs dating back to .\\n\\n Exam is somewhat limited by the portable technique and patient rotation. There\\n is increased vascular distention and interstitial markings extending out to\\n the periphery in addition to increased patchy opacities within the lower lobes\\n bilaterally. Small bilateral layering effusions are identified. Heart size\\n is stably enlarged. No pneumothorax.\\n\\n IMPRESSION:\\n\\n Findings are most suggestive of moderate fluid overload in this patient with\\n known end-stage renal disease/SLE. Patchy opacities at the bases may\\n represent regions of alveolar edema although a superimposed pneumonia would be\\n difficult to exclude. A repeat radiograph after diuresis/dialysis would be\\n helpful.\\n\\n Small bilateral effusions.\\n\\n These findings were discussed with Dr. aligned shortly after exam\\n acquisition.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2141-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 170208,\n \"text\": \"Sinus rhythm with slowing of the rate as compared with prior tracing of .\\nThe previously mentioned multiple abnormalities persist without diagnostic\\ninterim change. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2141-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 170209,\n \"text\": \"Sinus rhythm. There is variation in precordial lead placement as compared\\nwith prior tracing of . The prominent negative terminal deflection\\nof the P wave in lead V1 is no longer evident which may relate to lead\\nplacement. No diagnostic interim change.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2141-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 170210,\n \"text\": \"Sinus rhythm. Left atrial enlargement. Compared to the previous tracing\\nof no diagnostic interim change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2141-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 170442,\n \"text\": \"Sinus tachycardia. The tracing is marred by baseline artifact. There is\\nleft atrial enlargement. Compared to the previous tracing of \\nthe rate has increased. The axis is more rightward. Otherwise, no diagnostic\\ninterim change.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":23597,"cells":{"subject_id":{"kind":"number","value":32203,"string":"32,203"},"hadm_id":{"kind":"number","value":170201,"string":"170,201"},"target_text":{"kind":"string","value":"34 y/o M with AIDS, Kaposi's sarcoma, and Castleman's disease who was admitted for hypercalcemia. . # Hypercalcemia - Etiology unknown. Extensive work-up undertaken during last admission, many of the results still pending. Causes of hypercalcemia with a low PTH include malignancy, Vitamin D excess, increased bone turnover, thiazide diuretic use and Milk Alkali syndrome. Primary adrenal insufficiency can also cause a hypercalcemia decreased vascular volume and calcium clearance. Given pt's h/o malignancy, hypercalcemia of malignancy cannot be excluded. Some solid tumor malignancies can produce a PTH related peptide. Treated with IV fluids with appropriate response. PTH related peptide still pending. Vitamin D studies still pending. . # Non gap Metabolic Acidosis: Likely a renal tubular acidosis secondary to Fanconi-like syndrome due to tenofavir use. Losing glucose, phosphate, sodium, potassium in urine. FePhos 73% at last admission. D/c'd tenofavir on this admission. Given potassium and bicarb via PICC line. Discharged with potassium and sodium bicarbonate supplements and renal follow up. . # Anemia - 34.3 at time of initial admission , now 25.7. Likely this is patient's baseline as he had been hemoconcentrated in setting of nausea, vomiting and minimal PO intake. . # Hyponatremia: Recently started on steroids for adrenal insufficiency. Steroids continued in house. . # Renal failure: improved from last admission with creatinine 1.8. Still with renal failure and known proteinuria diagnosed on last admission. Unclear etiology of intrinsic renal failure. be secondary to antiretrovirals. need renal biopsy. Follow up arranged with renal as an outpatient. . # AIDS: Discontineud tenofavir and started on abacavir/lamivudine combo pill. Hope to see improvement in renal function in months. Follow up with Dr. . . # Contact - Girlfriend, . # Code Status - Full Code"},"extractive_notes_summ":{"kind":"string","value":"Rule out pneumothorax. Brought to EW. IMPRESSION: Tip of PICC line in mid SVC. admitted to OSH with electrolyte imbalance . CHEST, PORTABLE UPRIGHT, ONE VIEW: Tip of left PICC line overlies the mid SVC. No VEA noted.BS clear. Sinus rhythm. Early R wave appearance with early repolarization variant.Possible right ventricular hypertrophy though pattern may represent a normalvariant. Found to have several electrolyes deficient with low bicarb. COMPARISON: . Given bicarb, IVF with improvement in MS. Tox screen negative. Sats 99-100 RAA/p; VSS. Follow electrolytes, temp. IV THERAPY REPLACED INFILTRATED PIV AND PT BE ASSESSED FOR MIDLINE . Hilar and mediastinal contours are normal. if he understood when asked month, yr, place.Temp 99.6PO.Voiding lge amts, lt yellow urineSBP 112, Hr 112-116. Assess line placement. ? Discharged one day PTA for anemia, weakness, FTT. Was able to tell me his name. Electrolytes repleted. CONT TO C/O THIRST.CREAT 1.8 TO START ON D5W @ 100HR WHEN K PHOS FINISHED. Trans to ICU for further managment.MS: Follows commands, MAE. Pt was noted to be driving irratically. Compared to prior tracing of no significant intervaldiagnostic change is seen. 12:16 PM CHEST PORT. ABLE TO FOLLOW SIMPLE COMMANDS AND RECOGNIZE MED NAMES.RESP: LCTA RR UNLABORED MAINT SATS 98-100%C/V: ST NO ECTOPY, BP STABLE 1TEENS-120S.F/E/N:DIFFACULTY REPLETING PHOS W/ IV K PHOS.LAST EVE K+ 3.5 PRIOR TO RECIEVING 60K PO STANDING DOSE.IONIZED CA 1.62 VOIDING 400-500CC URINE , URINE LYTES SENT. Will need French interpreter. Heart size is normal. Lungs are clear. NPN 1900 -0700NEURO: AWAKE AND ALERT, DIFFACULT TO ASSESS ORIENTATION LIMTED ENG VOCABULARY. No pleural or osseous abnormality identified. TEAM AWARE.PLAN: REPLETE PHOS, DRAW LYTES AND AM LABS AFTER REPLETION.MONITOR HEMODYNAMICS, EMOTIONAL SUPPORT FOR PT AND FAMILY 4 ICU ADMISSION/NPN 1700-190034 YO with HX HIV/visceral kaposi sarcoma, castleman's, recurrent hyponatremia, pancytopenia, FTT. No evidence of pneumothorax. No evidence of pneumothorax. Has cane but did not Primarily French speaking. Able to walk few steps from stretcher to bed. He was pulled over by police & found to be confused."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2181-11-06 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":989398,"text":" 12:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement, r/o PTX\n Admitting Diagnosis: MENTAL STATUS CHANGES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with s/p PICC placement\n REASON FOR THIS EXAMINATION:\n line placement, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 34-year-old male status post PICC placement. Assess line placement.\n Rule out pneumothorax.\n\n COMPARISON: .\n\n CHEST, PORTABLE UPRIGHT, ONE VIEW: Tip of left PICC line overlies the mid\n SVC. No evidence of pneumothorax. Heart size is normal. Hilar and\n mediastinal contours are normal. Lungs are clear. No pleural or osseous\n abnormality identified.\n\n IMPRESSION: Tip of PICC line in mid SVC. No evidence of pneumothorax.\n\n"},{"category":"Nursing/other","chartdate":"2181-11-05 00:00:00.000","description":"Report","row_id":1670610,"text":" 4 ICU ADMISSION/NPN 1700-1900\n34 YO with HX HIV/visceral kaposi sarcoma, castleman's, recurrent hyponatremia, pancytopenia, FTT. admitted to OSH with electrolyte imbalance . Pt was noted to be driving irratically. He was pulled over by police & found to be confused. Brought to EW. Tox screen negative. Found to have several electrolyes deficient with low bicarb. Electrolytes repleted. Given bicarb, IVF with improvement in MS. Discharged one day PTA for anemia, weakness, FTT. Trans to ICU for further managment.\nMS: Follows commands, MAE. Able to walk few steps from stretcher to bed. Has cane but did not Primarily French speaking. Was able to tell me his name. ? if he understood when asked month, yr, place.\nTemp 99.6PO.\nVoiding lge amts, lt yellow urine\nSBP 112, Hr 112-116. No VEA noted.\nBS clear. Sats 99-100 RA\nA/p; VSS. Follow electrolytes, temp. Will need French interpreter.\n"},{"category":"Nursing/other","chartdate":"2181-11-06 00:00:00.000","description":"Report","row_id":1670611,"text":"NPN 1900 -0700\n\nNEURO: AWAKE AND ALERT, DIFFACULT TO ASSESS ORIENTATION LIMTED ENG VOCABULARY. ABLE TO FOLLOW SIMPLE COMMANDS AND RECOGNIZE MED NAMES.\n\nRESP: LCTA RR UNLABORED MAINT SATS 98-100%\n\nC/V: ST NO ECTOPY, BP STABLE 1TEENS-120S.\n\nF/E/N:DIFFACULTY REPLETING PHOS W/ IV K PHOS.LAST EVE K+ 3.5 PRIOR TO RECIEVING 60K PO STANDING DOSE.IONIZED CA 1.62 VOIDING 400-500CC URINE , URINE LYTES SENT. CONT TO C/O THIRST.CREAT 1.8 TO START ON D5W @ 100HR WHEN K PHOS FINISHED. IV THERAPY REPLACED INFILTRATED PIV AND PT BE ASSESSED FOR MIDLINE . TEAM AWARE.\n\nPLAN: REPLETE PHOS, DRAW LYTES AND AM LABS AFTER REPLETION.MONITOR HEMODYNAMICS, EMOTIONAL SUPPORT FOR PT AND FAMILY\n\n\n\n\n\n\n"},{"category":"ECG","chartdate":"2181-11-09 00:00:00.000","description":"Report","row_id":219910,"text":"Sinus rhythm. Early R wave appearance with early repolarization variant.\nPossible right ventricular hypertrophy though pattern may represent a normal\nvariant. Compared to prior tracing of no significant interval\ndiagnostic change is seen.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2181-11-06 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 989398,\n \"text\": \" 12:16 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: line placement, r/o PTX\\n Admitting Diagnosis: MENTAL STATUS CHANGES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 34 year old man with s/p PICC placement\\n REASON FOR THIS EXAMINATION:\\n line placement, r/o PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 34-year-old male status post PICC placement. Assess line placement.\\n Rule out pneumothorax.\\n\\n COMPARISON: .\\n\\n CHEST, PORTABLE UPRIGHT, ONE VIEW: Tip of left PICC line overlies the mid\\n SVC. No evidence of pneumothorax. Heart size is normal. Hilar and\\n mediastinal contours are normal. Lungs are clear. No pleural or osseous\\n abnormality identified.\\n\\n IMPRESSION: Tip of PICC line in mid SVC. No evidence of pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2181-11-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1670610,\n \"text\": \" 4 ICU ADMISSION/NPN 1700-1900\\n34 YO with HX HIV/visceral kaposi sarcoma, castleman's, recurrent hyponatremia, pancytopenia, FTT. admitted to OSH with electrolyte imbalance . Pt was noted to be driving irratically. He was pulled over by police & found to be confused. Brought to EW. Tox screen negative. Found to have several electrolyes deficient with low bicarb. Electrolytes repleted. Given bicarb, IVF with improvement in MS. Discharged one day PTA for anemia, weakness, FTT. Trans to ICU for further managment.\\nMS: Follows commands, MAE. Able to walk few steps from stretcher to bed. Has cane but did not Primarily French speaking. Was able to tell me his name. ? if he understood when asked month, yr, place.\\nTemp 99.6PO.\\nVoiding lge amts, lt yellow urine\\nSBP 112, Hr 112-116. No VEA noted.\\nBS clear. Sats 99-100 RA\\nA/p; VSS. Follow electrolytes, temp. Will need French interpreter.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2181-11-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1670611,\n \"text\": \"NPN 1900 -0700\\n\\nNEURO: AWAKE AND ALERT, DIFFACULT TO ASSESS ORIENTATION LIMTED ENG VOCABULARY. ABLE TO FOLLOW SIMPLE COMMANDS AND RECOGNIZE MED NAMES.\\n\\nRESP: LCTA RR UNLABORED MAINT SATS 98-100%\\n\\nC/V: ST NO ECTOPY, BP STABLE 1TEENS-120S.\\n\\nF/E/N:DIFFACULTY REPLETING PHOS W/ IV K PHOS.LAST EVE K+ 3.5 PRIOR TO RECIEVING 60K PO STANDING DOSE.IONIZED CA 1.62 VOIDING 400-500CC URINE , URINE LYTES SENT. CONT TO C/O THIRST.CREAT 1.8 TO START ON D5W @ 100HR WHEN K PHOS FINISHED. IV THERAPY REPLACED INFILTRATED PIV AND PT BE ASSESSED FOR MIDLINE . TEAM AWARE.\\n\\nPLAN: REPLETE PHOS, DRAW LYTES AND AM LABS AFTER REPLETION.MONITOR HEMODYNAMICS, EMOTIONAL SUPPORT FOR PT AND FAMILY\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2181-11-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 219910,\n \"text\": \"Sinus rhythm. Early R wave appearance with early repolarization variant.\\nPossible right ventricular hypertrophy though pattern may represent a normal\\nvariant. Compared to prior tracing of no significant interval\\ndiagnostic change is seen.\\n\\n\"\n }\n]"}}},{"rowIdx":23598,"cells":{"subject_id":{"kind":"number","value":81660,"string":"81,660"},"hadm_id":{"kind":"number","value":198618,"string":"198,618"},"target_text":{"kind":"string","value":"50yo woman with HIV and h/o rectal CA s/p chemoXRT currently in remission, with multiple complications including radiation fibrosis and radiation enteritis admitted for abdominal pain and ischemic bowel. Given vitamin K and FFP when she presented and admitted to the ICU. Surgery was not an option due to the radiation enteritis and fibrosis. She then developed fever and infiltrates c/w hospital-acquired pneumonia, treated with vanco/cefepime, and ARF and encephalopathy. . # Encephalopathy: Likely medication induced (pregabalin, hyoscyamine, and zolpidem stopped, methadone dose decreased, and lorazepam changed to PRN). CT and MRI head negative. Neuro consulted. EEG showed generalized encephalopathy. B12, folate, TSH normal, lactate normal, guaic negative. Encephalopathy resolved. Restarted pregabalin at lower dose . . # Ischemic/infarcted bowel/abdominal pain: Treated conservatively as no surgical options, completed 7 day course of cipro/metronidazole . Normal lactate, guaic now normal. . # Pain control: Remains stable. Due to changes in mental status, methadone decreased to 10/15/10/15 and stopped pregabalin and hyoscyamine (Levsin). Palliative Care consulted. Given her continued frequent reliance on PRN hydromorphone q2-4HR, methadone was increased from 10/15/10/15 to 15mg q6HR while the PRN hydromorphone dose was decreased (from a range 4-8 to with an aim for 3mg with each PRN dose, down from her usual 4mg). Her outpatient liquid supply of hydromorphone at 1mg/mL was not practical given her enormous usage. Concentrated hydromorphone 20mg/mL was given and then she was transitioned from IV to PO. Restarted pregabalin at lower dose 50mg TID for renal dosing and to avoid recurrent delirium. She has had good pain control with Oral Dilaudid 20 mg Q2H:PRN increasing to 30mg Q2H:prn during the night from 2200 to 0600 then back to a 20 mg Q2H:PRN at 0800. Palliative care has been involved to assist in managment. . # Hospital-acquired pneumonia: Completed 7 day course of cefepime . Vancomycin stopped . Repeat CXR showed improvement and symptoms resolved. . # Nausea and diarrhea: Chronic diarrhea due to short gut syndrome. However output increased to 5L/d last week with non-AG hyperchloremic metabolic acidosis. C diff negative and . Stool output decreasing, but still nauseous. Norovirus negative. Anti-emetics PRN. . # Thrush: Improved with nystatin. . # Sacral decubitus ulcer and coccygeal osteomyelitis: No surgical management, continued wound care, recent CT showed minimal improvement. Will continue daily dressing and packing with visiting nurses at home. . # Vaginal Bleeding: Has a history of radiation vaginitis documented on EUA on . Seen by Gyn consult without plans for intervention or further diagnostics. Will treat expectantly. Suspect this is due to radiation vaginitis and her anticoagulation with both lovenox and coumadin while bridging coumadin reinitiation. . # Nephrostomy tubes: Exchanged tubes . Then developed acute renal failure. CT showed no obstruction and urine output increased with IVFs. Serosanguinous fluid likely related to stone in setting of anticoagulation; no need for intervention. . # Acute renal failure: No obstruction on CT. Lytes consistent with prerenal cause. Muddy brown casts seen consistent with ATN from recent hypotension. Creatinine improved initially on IVFs, but now stabilizing at 1.5-1.7; IV fluids stopped. Ucx growing yeast, likely colonization. Nephrology consulted. . # Metabolic acidosis: Non-anion-gap. Repeat lactate normal. Likely due to high stool output and dilutional +/- RTA. Stool output slowing. Nephrology consulted. Acidosis improving after starting sodium bicarbonate 650mg PO BID , stopped . . # Anemia/blood loss: Normocytic, likely due to chronic disease as well as acute hematuria. Transfused 2U RBCs ( and ). No evidence of hemolysis. Continued anticoagulation. . # Leukocytosis: Due to pneumonia and ischemic colitis. Resolved. . # Rectal CA: No evidence of recurrence by CT or CEA . Palliative care and Social Work consulted. DNR/DNI, but continue maximal medical therapy. . # HIV: CD4 count 263. Continued HAART therapy. No PCP prophylaxis for now due to appropiate CD4. . # Chronic DVTs: Restarted enoxaparin and warfarin which were held due to hematuria. Increased warfarin dose from 4 to 5mg daily, but changed back to 4mg once near therapeutic at INR 1.8. The plan for patient's coumadin management was confirmed with her primary physician by phone on . . # Difficulty swallowing: Bedside swallow eval normal. . # FEN: Regular diet (per patient's wishes). Repleted hypomagnesemia and hypokalemia. . # DVT PPx: On warfarin 4mg QPM (last dose in hospital on with 5 mg). . # Precautions: Fall, contact ( in urine). . # Lines: Port. . # CODE: DNR/DNI. . Transitional Issues: 1. Coumadin titration: will have INR checked on Mon and Thurs by and results sent to Dr. . Have confirmed these plans by phone with Dr. on . 2. Sacral decubitus ulcer and coccygeal osteomyelitis: No surgical management. Will continue daily dressing and packing with visiting nurses at home. 3. Assessment of volume status and electrolyte abnormalities: has required Mg supplementation ~ twice weekly as inpatient. She will have electrolytes and CBC drawn STAT on Mon and Thurs and results sent to Dr. . She will take po Mg supplements and has IV Mg supplements available with home IV through Home therapies. If needed she can also receive IVF at home. These plans have been confirmed by phone with Dr. on . 4. Pain management: Have been using Dilaudid oral elixir 20mg/ml. of palliative care is available to Dr. to assist with pain control by email or page."},"extractive_notes_summ":{"kind":"string","value":"Partial obstruction of the left nephrostomy tube and patent right nephrostomy tube. Bilateral existing tube nephrostograms. The old catheter was removed. The old catheter was removed and a new 12F Nephrostomy tube was placed over the wire with the pigtail formed within the left renal pelvis, and contrast confirmed location. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. PHYSICIAN: . A 0.035 inch wire was then placed through cut catheter and coiled in the pelvis. A 0.018 inch Glidewire was placed easily through the catheter. Low precordial QRS voltage. Low precordial lead voltage. Initially, the right tube was addressed. A new 12F nephrostomy tube was placed over the wire with the pigtail formed within the left renal pelvis, and contrast confirmed location. 10:04 AM URIN CATH CHECK Clip # Reason: Assess poorly draining Left PCNT Admitting Diagnosis: ABDOMINAL PAIN Contrast: OMNIPAQUE Amt: 30 ********************************* CPT Codes ******************************** * CHG NEPHROTOMY/PYLOSTOMY TUBE -50 BILATERAL * * CHANGE PERC TUBE OR CATH W/CON CHANGE PERC TUBE OR CATH W/CON * * -59 DISTINCT PROCEDURAL SERVICE * **************************************************************************** MEDICAL CONDITION: 50 y/o woman with chronic bilateral nephrostomy tubes secondary to radiation fibrosis/ureteral obstruction. Anesthesiology service induced anesthesia, and the patient was placed prone on our angiographic table and both tubes were prepped and draped in sterile manner. Injection of small amount contrast demonstrated appropriate positioning of the pigtail in the renal pelvis and patent tube. Contrast injection showed (Over) 10:04 AM URIN CATH CHECK Clip # Reason: Assess poorly draining Left PCNT Admitting Diagnosis: ABDOMINAL PAIN Contrast: OMNIPAQUE Amt: 30 FINAL REPORT (Cont) appropriate location of the pigtail in the renal pelvis with contrast draining through sideholes. The patient was brought down to the IR suite, and a preprocedure timeout was performed. Non-specific repolarizationabnormality. PROCEDURE: 1. The catheter was secured to the skin with a silk suture and a Flexi-Trak. The catheter was secured to the skin with a silk suture and a Flexi-Trak. MEDICATIONS: The procedure was performed under general anesthesia, as the patient in the past has a low pain threshold and is unable to tolerate these procedures with moderate sedation. A 0.035 inch wire could not be advanced past last sidehole of the catheter, therefore a Glidewire was used. Had bilat PCNT last week, now with decreased drainage from left PCNT. Compared to theprevious tracing of no diagnostic change. Attention was then turned to the left tube. Patient also reports reduced output from the left kidney. IMPRESSION: 1. Wandering baseline obscures interpretation. (fellow), and Dr (attending radiologist). Additionally, the patient received IV antibiotics. Compared to the previous tracing of no majorchange. Successful exchange of both for new 12 French nephrostomy tubes. No change compared toprevious tracing. CONTRAST: 15 mL Optiray. Successful exchange of 12 French nephrostomy tubes bilaterally. PROCEDURE: Prior to initiation of the procedure, written informed consent was obtained. Please assess REASON FOR THIS EXAMINATION: Assess poorly draining Left PCNT FINAL REPORT INDICATION: 50-year-old woman with chronic bilateral nephrostomy tubes secondary to radiation fibrosis and bilateral ureteral obstruction presenting for routine exchange. 2."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2144-02-16 00:00:00.000","description":"Report","row_id":208620,"text":"Sinus tachycardia. Low precordial QRS voltage. No change compared to\nprevious tracing.\n\n"},{"category":"ECG","chartdate":"2144-02-14 00:00:00.000","description":"Report","row_id":208853,"text":"Sinus tachycardia. Low precordial lead voltage. Non-specific repolarization\nabnormality. Wandering baseline obscures interpretation. Compared to the\nprevious tracing of no diagnostic change.\n\n"},{"category":"ECG","chartdate":"2144-02-03 00:00:00.000","description":"Report","row_id":208854,"text":"Sinus tachycardia. Compared to the previous tracing of no major\nchange.\n\n"},{"category":"Radiology","chartdate":"2144-02-10 00:00:00.000","description":"BILATERAL","row_id":1229746,"text":" 10:04 AM\n URIN CATH CHECK Clip # \n Reason: Assess poorly draining Left PCNT\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OMNIPAQUE Amt: 30\n ********************************* CPT Codes ********************************\n * CHG NEPHROTOMY/PYLOSTOMY TUBE -50 BILATERAL *\n * CHANGE PERC TUBE OR CATH W/CON CHANGE PERC TUBE OR CATH W/CON *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 y/o woman with chronic bilateral nephrostomy tubes secondary to radiation\n fibrosis/ureteral obstruction. Had bilat PCNT last week, now with decreased\n drainage from left PCNT. Please assess\n REASON FOR THIS EXAMINATION:\n Assess poorly draining Left PCNT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old woman with chronic bilateral nephrostomy tubes\n secondary to radiation fibrosis and bilateral ureteral obstruction presenting\n for routine exchange. Patient also reports reduced output from the left\n kidney.\n\n PHYSICIAN: . (fellow), and Dr (attending\n radiologist).\n\n PROCEDURE:\n 1. Bilateral existing tube nephrostograms.\n 2. Successful exchange of 12 French nephrostomy tubes bilaterally.\n\n MEDICATIONS: The procedure was performed under general anesthesia, as the\n patient in the past has a low pain threshold and is unable to tolerate these\n procedures with moderate sedation. Additionally, the patient received IV\n 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 right tube was addressed. Injection of small amount contrast\n demonstrated appropriate positioning of the pigtail in the renal pelvis and\n patent tube. A 0.035 inch wire was then placed through cut catheter\n and coiled in the pelvis. The old catheter was removed. A new 12F nephrostomy\n tube was placed over the wire with the pigtail formed within the left renal\n pelvis, and contrast confirmed location. The catheter was secured to the skin\n with a silk suture and a Flexi-Trak.\n\n Attention was then turned to the left tube. Contrast injection showed\n (Over)\n\n 10:04 AM\n URIN CATH CHECK Clip # \n Reason: Assess poorly draining Left PCNT\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OMNIPAQUE Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appropriate location of the pigtail in the renal pelvis with contrast draining\n through sideholes. A 0.035 inch wire could not be advanced past last\n sidehole of the catheter, therefore a Glidewire was used. A 0.018 inch\n Glidewire was placed easily through the catheter. The old catheter was removed\n and a new 12F Nephrostomy tube was placed over the wire with the pigtail\n formed within the left renal pelvis, and contrast confirmed location. The\n catheter was secured to the skin with a silk suture and a Flexi-Trak.\n\n IMPRESSION:\n 1. Partial obstruction of the left nephrostomy tube and patent right\n nephrostomy tube.\n 2. Successful exchange of both for new 12 French nephrostomy tubes.\n\n\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-02-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 208620,\n \"text\": \"Sinus tachycardia. Low precordial QRS voltage. No change compared to\\nprevious tracing.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-02-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 208853,\n \"text\": \"Sinus tachycardia. Low precordial lead voltage. Non-specific repolarization\\nabnormality. Wandering baseline obscures interpretation. Compared to the\\nprevious tracing of no diagnostic change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-02-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 208854,\n \"text\": \"Sinus tachycardia. Compared to the previous tracing of no major\\nchange.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-02-10 00:00:00.000\",\n \"description\": \"BILATERAL\",\n \"row_id\": 1229746,\n \"text\": \" 10:04 AM\\n URIN CATH CHECK Clip # \\n Reason: Assess poorly draining Left PCNT\\n Admitting Diagnosis: ABDOMINAL PAIN\\n Contrast: OMNIPAQUE Amt: 30\\n ********************************* CPT Codes ********************************\\n * CHG NEPHROTOMY/PYLOSTOMY TUBE -50 BILATERAL *\\n * CHANGE PERC TUBE OR CATH W/CON CHANGE PERC TUBE OR CATH W/CON *\\n * -59 DISTINCT PROCEDURAL SERVICE *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 y/o woman with chronic bilateral nephrostomy tubes secondary to radiation\\n fibrosis/ureteral obstruction. Had bilat PCNT last week, now with decreased\\n drainage from left PCNT. Please assess\\n REASON FOR THIS EXAMINATION:\\n Assess poorly draining Left PCNT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 50-year-old woman with chronic bilateral nephrostomy tubes\\n secondary to radiation fibrosis and bilateral ureteral obstruction presenting\\n for routine exchange. Patient also reports reduced output from the left\\n kidney.\\n\\n PHYSICIAN: . (fellow), and Dr (attending\\n radiologist).\\n\\n PROCEDURE:\\n 1. Bilateral existing tube nephrostograms.\\n 2. Successful exchange of 12 French nephrostomy tubes bilaterally.\\n\\n MEDICATIONS: The procedure was performed under general anesthesia, as the\\n patient in the past has a low pain threshold and is unable to tolerate these\\n procedures with moderate sedation. Additionally, the patient received IV\\n 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 right tube was addressed. Injection of small amount contrast\\n demonstrated appropriate positioning of the pigtail in the renal pelvis and\\n patent tube. A 0.035 inch wire was then placed through cut catheter\\n and coiled in the pelvis. The old catheter was removed. A new 12F nephrostomy\\n tube was placed over the wire with the pigtail formed within the left renal\\n pelvis, and contrast confirmed location. The catheter was secured to the skin\\n with a silk suture and a Flexi-Trak.\\n\\n Attention was then turned to the left tube. Contrast injection showed\\n (Over)\\n\\n 10:04 AM\\n URIN CATH CHECK Clip # \\n Reason: Assess poorly draining Left PCNT\\n Admitting Diagnosis: ABDOMINAL PAIN\\n Contrast: OMNIPAQUE Amt: 30\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n appropriate location of the pigtail in the renal pelvis with contrast draining\\n through sideholes. A 0.035 inch wire could not be advanced past last\\n sidehole of the catheter, therefore a Glidewire was used. A 0.018 inch\\n Glidewire was placed easily through the catheter. The old catheter was removed\\n and a new 12F Nephrostomy tube was placed over the wire with the pigtail\\n formed within the left renal pelvis, and contrast confirmed location. The\\n catheter was secured to the skin with a silk suture and a Flexi-Trak.\\n\\n IMPRESSION:\\n 1. Partial obstruction of the left nephrostomy tube and patent right\\n nephrostomy tube.\\n 2. Successful exchange of both for new 12 French nephrostomy tubes.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":23599,"cells":{"subject_id":{"kind":"number","value":66473,"string":"66,473"},"hadm_id":{"kind":"number","value":131974,"string":"131,974"},"target_text":{"kind":"string","value":"80 yo F with cardiac history significant for AS s/p biprosthetic AVR in 12/99, MR, Afib who initially presented for RHC +/- exercise and possible LHC to evaluate her MR in the setting of progressive SOB. During catheterization, she developed hemoptysis of 150 cc after the Swan Ganz Catheter was inflated and was subsequently found to have partially thrombosed pseudoaneurysm in RML pulmonary artery. An incidental finding of (presumed) migrated epicardial pacing wire in the main pulmonary artery was also noted."},"extractive_notes_summ":{"kind":"string","value":"The right internal jugular catheter ends in the mid SVC. A selective right pulmonary arteriogram was obtained. CT CHEST WITH INTRAVENOUS CONTRAST: A 1-cm round structure originating from the first branch of the right middle lobe medial segment pulmonary artery is consistent with a partially thrombosed pseudoaneurysm. PA and lateral upright chest radiographs were reviewed in comparison to , . The pulmonary artery catheter fragment is re-demonstrated in unchanged location projecting over the main pulmonary artery. Retained catheter fragment in the main pulmonary artery. The remainder of aorta is of normal caliber with atherosclerotic calcifications. 1 cm rounded density off the RML medial segment pulmonary artery c/w thrombosed aneurysm; surrounding density may represent prior hemorrhage, but currently no active extrav. LEFT HEART CATHETERIZATION Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) evidence of right heart strain. CTA of the chest obtained on showed evidence of a partially thrombosed pseudoaneurysm in a right middle lobe segmental branch of the pulmonary artery. Contrast refluxing into the IVC suggests right heart dysfunction. LEFT HEART CATHETERIZATION Contrast: OPTIRAY Amt: 276 FINAL REPORT (Cont) The sheath, catheter and wire were removed and pressure was held until hemostasis was achieved. LEFT HEART CATHETERIZATION Contrast: OPTIRAY Amt: 276 ********************************* CPT Codes ******************************** * SEL CATH PLACMT LT/RT PUL ARTE SEL CATH SEGMENTAL/SUBSEG PUL * * UNILAT PUL SEL ANGIOGRAPHY RIG EA ADD'L VESSEL AFTER BASIC A- * * MOD SEDATION, FIRST 30 MIN. Consider prior anterior wall myocardial infarction. The patient is status post AVR. FINAL REPORT INDICATION: Hemoptysis after PA perforation during right heart catheterization. 2. linear streak in main PA likely reflects motion artifact from a calcified pulmonary valve leaflet. LEFT HEART CATHETERIZATION Contrast: OPTIRAY Amt: 100 FINAL ADDENDUM ADDENDUM: Upon review of multiple prior outside studies from -, which were not available at the time of original dictation, it appears that the linear metallic density in the main pulmonary artery is a detached epicardial wire fragment, which has been in the approximately same location since . 10:58 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? Mild enlargement of the main and central pulmonary arteries suggests pulmonary hypertension. Mild enlargement of the main and central pulmonary arteries suggests pulmonary hypertension. IMPRESSION: Inability to precisely demonstrate the 1-cm pseudoaneurysm seen to arise from the right pulmonary artery within the right lung-middle lobe. Possible right neck hematoma. A linear metallic density extending from the main pulmonary outflow tract into the main pulmonary artery to the origin of the left pulmonary artery appears to be a retained catheter fragment. Patient is after median sternotomy. The aortic valve is replaced. Contrast refluxes into the IVC and hepatic veins. A hypodensity in the left kidney is noted. IV contrast refluxing into hepatic veins. Using an Omniflush catheter and a Glidewire, access was gained into the main and right pulmonary arteries. Aortic knob calcifications are noted. 11:32 AM PULMONARY Clip # Reason: catheter tip retrieval, pseudoaneurysm coiling Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? Partially thrombosed pseudoaneurysm in right middle lobe medial segment pulmonary artery with localized surrounding hemorrhage, but no active extravasation. (Over) 11:32 AM PULMONARY Clip # Reason: catheter tip retrieval, pseudoaneurysm coiling Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? A benign coarse left breast calcification is noted. Patient was referred for pulmonary arteriogram and potential embolization of the pseudoaneurysm. 5:35 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: evidence of additional bleeding from perforation of PA on 6/ Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? 5:35 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: evidence of additional bleeding from perforation of PA on 6/ Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? The heart is moderately enlarged without (Over) 5:35 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: evidence of additional bleeding from perforation of PA on 6/ Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ?"},"n_notes":{"kind":"number","value":7,"string":"7"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2104-06-24 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1195979,"text":" 10:32 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for lung opacity\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with recent heart cath, and subsequent hemoptysis\n REASON FOR THIS EXAMINATION:\n evaluate for lung opacity\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hemoptysis after heart catheterization, evaluate for lung\n opacity.\n\n COMPARISON: , , .\n\n FINDINGS: The lungs are clear without focal consolidation. The previously\n described nodule is not visualized on the current study. The heart is\n enlarged, particularly the left atrium. Chronic widening of the mediastinum is\n unchanged since . However, the widening now extends to the right apex\n which is unchanged from , but new from . This may represent a\n possible apical lung lesion in addition to the mediastinal widening. A >3cm\n wide, rounded density at the right neck was not clearly seen yesterday and is\n definitely new from and may represent hematoma from a line placement.\n There is no pneumothorax or pleural effusion.\n\n IMPRESSION:\n 1. Nodule no longer visualized.\n 2. Chronic mediastinal widening with new right apical extension. If the\n patient has referable findings such as chest pain or Horner syndrome, CT is\n indicated to evaluate for right apical lung lesion. If CT is going to be\n performed for hemoptysis, this finding will be evaluated at that time.\n 3. Possible right neck hematoma. Correlate clinically.\n\n Findings discussed with Dr. by phone at 11:20 a.m., .\n\n"},{"category":"Radiology","chartdate":"2104-07-02 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1197245,"text":" 7:04 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for infection\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with low grade temp and cough\n REASON FOR THIS EXAMINATION:\n evaluate for infection\n ______________________________________________________________________________\n WET READ: MLHh WED 7:41 PM\n Stable mod cardiomegaly, vasc congestion, and chronic mediastinal widening.\n No focal consolidation. R neck swelling.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Low-grade temperature and cough.\n\n PA and lateral upright chest radiographs were reviewed in comparison to , .\n\n Patient is after median sternotomy. The aortic valve is replaced.\n Cardiomegaly and mediastinal contours are unchanged. The pulmonary artery\n catheter fragment is re-demonstrated in unchanged location projecting over the\n main pulmonary artery.\n\n There is new focal opacity in the right lower lung that might reflect\n developing infectious process. No appreciable pleural effusion is noted.\n\n\n"},{"category":"Radiology","chartdate":"2104-07-01 00:00:00.000","description":"SEL CATH PLACMT LT/RT PUL ARTERY","row_id":1196974,"text":" 11:32 AM\n PULMONARY Clip # \n Reason: catheter tip retrieval, pseudoaneurysm coiling\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n Contrast: OPTIRAY Amt: 276\n ********************************* CPT Codes ********************************\n * SEL CATH PLACMT LT/RT PUL ARTE SEL CATH SEGMENTAL/SUBSEG PUL *\n * UNILAT PUL SEL ANGIOGRAPHY RIG EA ADD'L VESSEL AFTER BASIC A- *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with pulmonary artery pseudoaneurysm s/p wedging of swan ganz\n catheter, retained catheter tip in pulm outflow tract\n REASON FOR THIS EXAMINATION:\n catheter tip retrieval, pseudoaneurysm coiling\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old lady with a recent history of hemoptysis. CTA of the\n chest obtained on showed evidence of a partially thrombosed\n pseudoaneurysm in a right middle lobe segmental branch of the pulmonary\n artery. Patient was referred for pulmonary arteriogram and potential\n embolization of the pseudoaneurysm.\n\n Moderate sedation was providied by administering divided doses of Fentanyl\n and Versed throughout the total intra-service time of 3 hours and 20 minutes\n during which the patient's hemodynamic parameters were continuously monitored.\n\n TECHNIQUE: Written informed consent was obtained from the patient. The\n patient was prepped and draped in a standard sterile fashion, on the\n angiography table. A preprocedure huddle and timeout were performed per \n policy. After local anesthesia with 10 mL of lidocaine 1%, access was gained\n into the right common femoral vein using a micropuncture kit, under ultrasound\n guidance. Over wire the access was upsized to a 5 French sheath.\n Using an Omniflush catheter and a Glidewire, access was gained into the main\n and right pulmonary arteries. The catheter was then exchanged for a pigtail\n flush catheter. A selective right pulmonary arteriogram was obtained.\n\n In order to maintain stability, the pigtail catheter was removed over a super-\n stiff Glidewire and the sheath was exchanged for a 90 cm long 6 French sheath\n which was positioned in the main trunk of the right pulmonary artery. With the\n aid of a regular Glidewire and a 90-cm catheter, selective\n catheterization of different branches supplying the middle lobe of the right\n lung was performed. Selective arteriograms of each one of those branches were\n obtained. Due to our inability to precisely visualize the pseudoaneurysm, a\n three-dimensional rotation angiography scan as well as a cone beam CT scan\n were obtained while injecting contrast into the main right pulmonary artery.\n\n (Over)\n\n 11:32 AM\n PULMONARY Clip # \n Reason: catheter tip retrieval, pseudoaneurysm coiling\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n Contrast: OPTIRAY Amt: 276\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The sheath, catheter and wire were removed and pressure was held until\n hemostasis was achieved.\n\n FINDINGS: The right pulmonary arteriogram, as well as selective arteriograms\n of the segmental arteries supplying the middle lobe of the right lung did not\n show evidence of the small pseudoaneurysm seen on CT.\n\n Three-dimensional rotation angiography as well as cone beam CT reconstructions\n also failed to precisely demonstrate filling of the pseudoaneurysm.\n\n COMPLICATIONS: No immediate complications.\n\n IMPRESSION: Inability to precisely demonstrate the 1-cm pseudoaneurysm seen\n to arise from the right pulmonary artery within the right lung-middle lobe. A\n followup CT pulmonary arteriogram will be obtained to assess for persistence\n or thrombosed status of the pseudoaneurysm.\n\n"},{"category":"Radiology","chartdate":"2104-06-26 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1196423,"text":" 5:35 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evidence of additional bleeding from perforation of PA on 6/\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Upon review of multiple prior outside studies from -, which\n were not available at the time of original dictation, it appears that the\n linear metallic density in the main pulmonary artery is a detached epicardial\n wire fragment, which has been in the approximately same location since . A\n second detached epicardial lead is identified adjacent to the left epicardium.\n\n\n Dr. notified Drs. , , and from the\n cardiology service by E-mail at 8:08pm .\n\n\n 5:35 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evidence of additional bleeding from perforation of PA on 6/\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with MR, cardiomyopathy, AF with reoccurance of hemoptysis\n after PA perforation during right heart cath\n REASON FOR THIS EXAMINATION:\n evidence of additional bleeding from perforation of PA on during right\n heart cath\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:11 PM\n 1. no PE or acute aortic syndrome.\n 2. linear streak in main PA likely reflects motion artifact from a calcified\n pulmonary valve leaflet.\n 3. 1 cm rounded density off the RML medial segment pulmonary artery c/w\n thrombosed aneurysm; surrounding density may represent prior hemorrhage, but\n currently no active extrav.\n 4. tracheobronchial tree patent.\n 5. no pleural or pericardial effusion.\n 6. no mediastinal hematoma.\n 7. IV contrast refluxing into hepatic veins.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hemoptysis after PA perforation during right heart\n catheterization.\n\n COMPARISON: No prior CTs available. CXR , , .\n\n TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed\n before and after administration of 100 mL Optiray intravenous contrast.\n Images are presented for display in the axial plane at 5-mm, 2.5-mm, and\n 0.625-mm collimation. A series of multiplanar reformation images are\n submitted for review.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: A 1-cm round structure originating from\n the first branch of the right middle lobe medial segment pulmonary artery is\n consistent with a partially thrombosed pseudoaneurysm. Surrounding\n ground-glass opacity is localized surrounding hemorrhage, but there is no\n active extravasation. A linear metallic density extending from the main\n pulmonary outflow tract into the main pulmonary artery to the origin of the\n left pulmonary artery appears to be a retained catheter fragment. The lungs\n are clear without consolidation, nodule, or mass.\n\n The ascending aorta is mildly dilated to 4.3 cm. The remainder of aorta is of\n normal caliber with atherosclerotic calcifications. There is no intramural\n hematoma or evidence of dissection. Mild enlargement of the main and central\n pulmonary arteries suggests pulmonary hypertension. Pulmonary arterial\n vasculature is well visualized to the subsegmental level without filling\n defect to suggest pulmonary embolism. The heart is moderately enlarged without\n (Over)\n\n 5:35 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evidence of additional bleeding from perforation of PA on 6/\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n evidence of right heart strain. No pathologically enlarged axillary,\n mediastinal, or hilar lymph nodes are present. There is no pleural or\n pericardial effusion. The thyroid is unremarkable without nodules. Fat\n stranding just superior to the right thoracic outlet, without discrete fluid\n collection, is seen. A benign coarse left breast calcification is noted.\n Contrast refluxes into the IVC and hepatic veins.\n\n The study is not tailored for subdiaphragmatic evaluation. A hypodensity in\n the left kidney is noted.\n\n No bone finding suspicious for malignancy or infection is seen. A sclerotic\n focus in left posterior ninth rib is a bone island. Median sternotomy wires\n are intact.\n\n IMPRESSION:\n 1. Partially thrombosed pseudoaneurysm in right middle lobe medial segment\n pulmonary artery with localized surrounding hemorrhage, but no active\n extravasation.\n 2. Retained catheter fragment in the main pulmonary artery.\n 3. Contrast refluxing into the IVC suggests right heart dysfunction.\n 4. Mild enlargement of the main and central pulmonary arteries suggests\n pulmonary hypertension.\n 5. Left renal hypodensity can be further evaluated with renal ultrasound if\n clinically indicated.\n\n Dr. discussed the findings with the pulmonary consult fellow by phone\n at 8 p.m., .\n\n Dr. discussed the finding of retained catheter fragment with Dr.\n by phone at 11 a.m., .\n\n"},{"category":"Radiology","chartdate":"2104-06-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1195833,"text":" 10:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman coughing up blood sp procedure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hemoptysis after cardiac cath\n\n COMPARISON: and .\n\n FINDINGS: Low lung volumes result in bronchovascular crowding. The right\n internal jugular catheter ends in the mid SVC. No focal consolidation is\n present. A nodular density projects over the heart. The patient is status post\n AVR. Mild cardiac enlargement is stable. Hilar contours are normal. Aortic\n knob calcifications are noted. No effusion or pneumothorax.\n\n IMPRESSION:\n 1. No acute cardiopulmonary process.\n 2. Nodular density projects over the heart. Recommend PA and lateral views\n when possible.\n\n Discussed with Dr. by phone 1:44pm .\n\n"},{"category":"Radiology","chartdate":"2104-07-04 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1197569,"text":" 1:14 PM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with fever.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old female with fever. Evaluate for interval change.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL VIEWS: Lung volumes are low. There is increased right\n infrahilar opacity and possibly new left retrocardiac opacity compatible with\n developing infection. Small bilateral pleural effusions are increased. Heart\n size is severely enlarged as before. Sternal wires are intact. Prosthetic\n aortic valve is unchanged. Atherosclerotic calcification of aortic arch is\n present and prominence of the mediastinal contour related to increased\n ascending aorta diameter is better characterized on CT.\n\n"},{"category":"ECG","chartdate":"2104-06-23 00:00:00.000","description":"Report","row_id":115339,"text":"Probable sinus rhythm with atrial premature beats but low amplitude atrial wave\nforms make assessment difficult. Left bundle-branch block with left axis\ndeviation. Consider prior anterior wall myocardial infarction. Since the\nprevious tracing of the rate is faster and right precordial lead T wave\ninversion is now absent.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2104-06-24 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1195979,\n \"text\": \" 10:32 AM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate for lung opacity\\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with recent heart cath, and subsequent hemoptysis\\n REASON FOR THIS EXAMINATION:\\n evaluate for lung opacity\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Hemoptysis after heart catheterization, evaluate for lung\\n opacity.\\n\\n COMPARISON: , , .\\n\\n FINDINGS: The lungs are clear without focal consolidation. The previously\\n described nodule is not visualized on the current study. The heart is\\n enlarged, particularly the left atrium. Chronic widening of the mediastinum is\\n unchanged since . However, the widening now extends to the right apex\\n which is unchanged from , but new from . This may represent a\\n possible apical lung lesion in addition to the mediastinal widening. A >3cm\\n wide, rounded density at the right neck was not clearly seen yesterday and is\\n definitely new from and may represent hematoma from a line placement.\\n There is no pneumothorax or pleural effusion.\\n\\n IMPRESSION:\\n 1. Nodule no longer visualized.\\n 2. Chronic mediastinal widening with new right apical extension. If the\\n patient has referable findings such as chest pain or Horner syndrome, CT is\\n indicated to evaluate for right apical lung lesion. If CT is going to be\\n performed for hemoptysis, this finding will be evaluated at that time.\\n 3. Possible right neck hematoma. Correlate clinically.\\n\\n Findings discussed with Dr. by phone at 11:20 a.m., .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2104-07-02 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1197245,\n \"text\": \" 7:04 PM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate for infection\\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with low grade temp and cough\\n REASON FOR THIS EXAMINATION:\\n evaluate for infection\\n ______________________________________________________________________________\\n WET READ: MLHh WED 7:41 PM\\n Stable mod cardiomegaly, vasc congestion, and chronic mediastinal widening.\\n No focal consolidation. R neck swelling.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Low-grade temperature and cough.\\n\\n PA and lateral upright chest radiographs were reviewed in comparison to , .\\n\\n Patient is after median sternotomy. The aortic valve is replaced.\\n Cardiomegaly and mediastinal contours are unchanged. The pulmonary artery\\n catheter fragment is re-demonstrated in unchanged location projecting over the\\n main pulmonary artery.\\n\\n There is new focal opacity in the right lower lung that might reflect\\n developing infectious process. No appreciable pleural effusion is noted.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2104-07-01 00:00:00.000\",\n \"description\": \"SEL CATH PLACMT LT/RT PUL ARTERY\",\n \"row_id\": 1196974,\n \"text\": \" 11:32 AM\\n PULMONARY Clip # \\n Reason: catheter tip retrieval, pseudoaneurysm coiling\\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\\n Contrast: OPTIRAY Amt: 276\\n ********************************* CPT Codes ********************************\\n * SEL CATH PLACMT LT/RT PUL ARTE SEL CATH SEGMENTAL/SUBSEG PUL *\\n * UNILAT PUL SEL ANGIOGRAPHY RIG EA ADD'L VESSEL AFTER BASIC A- *\\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with pulmonary artery pseudoaneurysm s/p wedging of swan ganz\\n catheter, retained catheter tip in pulm outflow tract\\n REASON FOR THIS EXAMINATION:\\n catheter tip retrieval, pseudoaneurysm coiling\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 80-year-old lady with a recent history of hemoptysis. CTA of the\\n chest obtained on showed evidence of a partially thrombosed\\n pseudoaneurysm in a right middle lobe segmental branch of the pulmonary\\n artery. Patient was referred for pulmonary arteriogram and potential\\n embolization of the pseudoaneurysm.\\n\\n Moderate sedation was providied by administering divided doses of Fentanyl\\n and Versed throughout the total intra-service time of 3 hours and 20 minutes\\n during which the patient's hemodynamic parameters were continuously monitored.\\n\\n TECHNIQUE: Written informed consent was obtained from the patient. The\\n patient was prepped and draped in a standard sterile fashion, on the\\n angiography table. A preprocedure huddle and timeout were performed per \\n policy. After local anesthesia with 10 mL of lidocaine 1%, access was gained\\n into the right common femoral vein using a micropuncture kit, under ultrasound\\n guidance. Over wire the access was upsized to a 5 French sheath.\\n Using an Omniflush catheter and a Glidewire, access was gained into the main\\n and right pulmonary arteries. The catheter was then exchanged for a pigtail\\n flush catheter. A selective right pulmonary arteriogram was obtained.\\n\\n In order to maintain stability, the pigtail catheter was removed over a super-\\n stiff Glidewire and the sheath was exchanged for a 90 cm long 6 French sheath\\n which was positioned in the main trunk of the right pulmonary artery. With the\\n aid of a regular Glidewire and a 90-cm catheter, selective\\n catheterization of different branches supplying the middle lobe of the right\\n lung was performed. Selective arteriograms of each one of those branches were\\n obtained. Due to our inability to precisely visualize the pseudoaneurysm, a\\n three-dimensional rotation angiography scan as well as a cone beam CT scan\\n were obtained while injecting contrast into the main right pulmonary artery.\\n\\n (Over)\\n\\n 11:32 AM\\n PULMONARY Clip # \\n Reason: catheter tip retrieval, pseudoaneurysm coiling\\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\\n Contrast: OPTIRAY Amt: 276\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n The sheath, catheter and wire were removed and pressure was held until\\n hemostasis was achieved.\\n\\n FINDINGS: The right pulmonary arteriogram, as well as selective arteriograms\\n of the segmental arteries supplying the middle lobe of the right lung did not\\n show evidence of the small pseudoaneurysm seen on CT.\\n\\n Three-dimensional rotation angiography as well as cone beam CT reconstructions\\n also failed to precisely demonstrate filling of the pseudoaneurysm.\\n\\n COMPLICATIONS: No immediate complications.\\n\\n IMPRESSION: Inability to precisely demonstrate the 1-cm pseudoaneurysm seen\\n to arise from the right pulmonary artery within the right lung-middle lobe. A\\n followup CT pulmonary arteriogram will be obtained to assess for persistence\\n or thrombosed status of the pseudoaneurysm.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2104-06-26 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1196423,\n \"text\": \" 5:35 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: evidence of additional bleeding from perforation of PA on 6/\\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n FINAL ADDENDUM\\n ADDENDUM: Upon review of multiple prior outside studies from -, which\\n were not available at the time of original dictation, it appears that the\\n linear metallic density in the main pulmonary artery is a detached epicardial\\n wire fragment, which has been in the approximately same location since . A\\n second detached epicardial lead is identified adjacent to the left epicardium.\\n\\n\\n Dr. notified Drs. , , and from the\\n cardiology service by E-mail at 8:08pm .\\n\\n\\n 5:35 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: evidence of additional bleeding from perforation of PA on 6/\\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with MR, cardiomyopathy, AF with reoccurance of hemoptysis\\n after PA perforation during right heart cath\\n REASON FOR THIS EXAMINATION:\\n evidence of additional bleeding from perforation of PA on during right\\n heart cath\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 8:11 PM\\n 1. no PE or acute aortic syndrome.\\n 2. linear streak in main PA likely reflects motion artifact from a calcified\\n pulmonary valve leaflet.\\n 3. 1 cm rounded density off the RML medial segment pulmonary artery c/w\\n thrombosed aneurysm; surrounding density may represent prior hemorrhage, but\\n currently no active extrav.\\n 4. tracheobronchial tree patent.\\n 5. no pleural or pericardial effusion.\\n 6. no mediastinal hematoma.\\n 7. IV contrast refluxing into hepatic veins.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Hemoptysis after PA perforation during right heart\\n catheterization.\\n\\n COMPARISON: No prior CTs available. CXR , , .\\n\\n TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed\\n before and after administration of 100 mL Optiray intravenous contrast.\\n Images are presented for display in the axial plane at 5-mm, 2.5-mm, and\\n 0.625-mm collimation. A series of multiplanar reformation images are\\n submitted for review.\\n\\n CT CHEST WITH INTRAVENOUS CONTRAST: A 1-cm round structure originating from\\n the first branch of the right middle lobe medial segment pulmonary artery is\\n consistent with a partially thrombosed pseudoaneurysm. Surrounding\\n ground-glass opacity is localized surrounding hemorrhage, but there is no\\n active extravasation. A linear metallic density extending from the main\\n pulmonary outflow tract into the main pulmonary artery to the origin of the\\n left pulmonary artery appears to be a retained catheter fragment. The lungs\\n are clear without consolidation, nodule, or mass.\\n\\n The ascending aorta is mildly dilated to 4.3 cm. The remainder of aorta is of\\n normal caliber with atherosclerotic calcifications. There is no intramural\\n hematoma or evidence of dissection. Mild enlargement of the main and central\\n pulmonary arteries suggests pulmonary hypertension. Pulmonary arterial\\n vasculature is well visualized to the subsegmental level without filling\\n defect to suggest pulmonary embolism. The heart is moderately enlarged without\\n (Over)\\n\\n 5:35 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: evidence of additional bleeding from perforation of PA on 6/\\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n evidence of right heart strain. No pathologically enlarged axillary,\\n mediastinal, or hilar lymph nodes are present. There is no pleural or\\n pericardial effusion. The thyroid is unremarkable without nodules. Fat\\n stranding just superior to the right thoracic outlet, without discrete fluid\\n collection, is seen. A benign coarse left breast calcification is noted.\\n Contrast refluxes into the IVC and hepatic veins.\\n\\n The study is not tailored for subdiaphragmatic evaluation. A hypodensity in\\n the left kidney is noted.\\n\\n No bone finding suspicious for malignancy or infection is seen. A sclerotic\\n focus in left posterior ninth rib is a bone island. Median sternotomy wires\\n are intact.\\n\\n IMPRESSION:\\n 1. Partially thrombosed pseudoaneurysm in right middle lobe medial segment\\n pulmonary artery with localized surrounding hemorrhage, but no active\\n extravasation.\\n 2. Retained catheter fragment in the main pulmonary artery.\\n 3. Contrast refluxing into the IVC suggests right heart dysfunction.\\n 4. Mild enlargement of the main and central pulmonary arteries suggests\\n pulmonary hypertension.\\n 5. Left renal hypodensity can be further evaluated with renal ultrasound if\\n clinically indicated.\\n\\n Dr. discussed the findings with the pulmonary consult fellow by phone\\n at 8 p.m., .\\n\\n Dr. discussed the finding of retained catheter fragment with Dr.\\n by phone at 11 a.m., .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2104-06-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1195833,\n \"text\": \" 10:58 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman coughing up blood sp procedure\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Hemoptysis after cardiac cath\\n\\n COMPARISON: and .\\n\\n FINDINGS: Low lung volumes result in bronchovascular crowding. The right\\n internal jugular catheter ends in the mid SVC. No focal consolidation is\\n present. A nodular density projects over the heart. The patient is status post\\n AVR. Mild cardiac enlargement is stable. Hilar contours are normal. Aortic\\n knob calcifications are noted. No effusion or pneumothorax.\\n\\n IMPRESSION:\\n 1. No acute cardiopulmonary process.\\n 2. Nodular density projects over the heart. Recommend PA and lateral views\\n when possible.\\n\\n Discussed with Dr. by phone 1:44pm .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2104-07-04 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1197569,\n \"text\": \" 1:14 PM\\n CHEST (PA & LAT) Clip # \\n Reason: interval change\\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 80 year old woman with fever.\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 80-year-old female with fever. Evaluate for interval change.\\n\\n COMPARISON: .\\n\\n CHEST, PA AND LATERAL VIEWS: Lung volumes are low. There is increased right\\n infrahilar opacity and possibly new left retrocardiac opacity compatible with\\n developing infection. Small bilateral pleural effusions are increased. Heart\\n size is severely enlarged as before. Sternal wires are intact. Prosthetic\\n aortic valve is unchanged. Atherosclerotic calcification of aortic arch is\\n present and prominence of the mediastinal contour related to increased\\n ascending aorta diameter is better characterized on CT.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2104-06-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 115339,\n \"text\": \"Probable sinus rhythm with atrial premature beats but low amplitude atrial wave\\nforms make assessment difficult. Left bundle-branch block with left axis\\ndeviation. Consider prior anterior wall myocardial infarction. Since the\\nprevious tracing of the rate is faster and right precordial lead T wave\\ninversion is now absent.\\n\\n\"\n }\n]"}}}],"truncated":false,"partial":false},"paginationData":{"pageIndex":235,"numItemsPerPage":100,"numTotalItems":24993,"offset":23500,"length":100}},"jwt":"eyJhbGciOiJFZERTQSJ9.eyJyZWFkIjp0cnVlLCJwZXJtaXNzaW9ucyI6eyJyZXBvLmNvbnRlbnQucmVhZCI6dHJ1ZX0sImlhdCI6MTczMTkxMjIxMSwic3ViIjoiL2RhdGFzZXRzL2RtYWNyZXMvbWltaWNpaWktaG9zcGl0YWxjb3Vyc2UtbWV0YSIsImV4cCI6MTczMTkxNTgxMSwiaXNzIjoiaHR0cHM6Ly9odWdnaW5nZmFjZS5jbyJ9.DyvYKQlPIzn6Nwgtv6j0A5TI4gUwJQRvliVV1Ht7FlTxYMbdzXeCPL6SZqwGfqYVEFgjbM034XwPgh-szH3sDg","displayUrls":true},"discussionsStats":{"closed":0,"open":1,"total":1},"fullWidth":true,"hasGatedAccess":true,"hasFullAccess":true,"isEmbedded":false}">
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|---|---|---|---|---|---|
21,529 | 115,035 | Given severity of mitral and aortic valve disease, pt expressing CHF sxs, progressive over past 6 months plan was for valve replacement with MVR and AVR once medically stable. Pt had cath at OSH prior to surgery which showed normal coronaries. Pt was diuresed intially in the CCU with swan guidance. However, prior to surgery pt found to have a UTI which was treated with 7 days of Levaquin. Pt cleared the UTI but her HCT slowly began to drop and she was found to be GUIAC positive. Pt was on a heparin gtt at this point in anticipation of surgery. Gi service was consulted and felt that pt should have a colonoscopy and EGD prior to the surgery to assess risk. Colonoscopy revealed hemorroids and the EGD revealed large gastric varicies. There was concern to severe liver damage given the secondary findings. Therefore the patient underwent a liver biopsy on to, again, asses for risk of surgery. The biopsy showed grade III fibrosis while would put her at 30-50% mortality risk for this surgery. This made the patient no longer a condidate for this surgery. Lipitor was also discontinued for hepatic dysfunction. The patient was fluid resuscitated during the GI bleed and subsequently became markedly fluid overloaded and anasarcic. She was started on smal doses of IV lasix and transfered to the medicine service. At this point her Na was gradually dropping with a nadir of 120 due to CHF and volume overload. In addition, the pt was going into worsening reanl fialure with her creatinine of 3 from a baseline of 1.3. The CHF service was consulted and recommended starting Niseritide as pt did not seem to be responding to this. The patient was aslo started on Amiodarone for her afib and a low dose BB for better rate control to improve cardiac output. The patient had gained 10kg as well. The pt continued to gain wgt on the Niseritide with no improvement in her sodium. The renal service was consulted for assitance with diuresis, hyponatremia and worsening renal failure. They recommended an aggressive regimen of Lasix 160 IV qd abd Diuril 250 IV QD. The patient received this regimen for approximately one week with very good response. She lost 15kg of fluid and was diuresing 2L per day. The Diuril was discontinued and the pt was placed on an IV Lasix taper with the goal of finding an oral regimen that she could be discharged on. Her creatinine came back down to baseline after the diuresis as well. The patient was converted to Lasix 80mg PO BID with good response. Plan would be to address afterload reduction with ACE-I or Imdur and hydralazine after consultation with Dr. on . Pt has DM2 and was maintained on a sliding scale during this admission but added back oupt glyburide on 2 days prior to discharge with good response and FS<180 but will likely need a second since we cannot use metformin any longer with her chronic renal failure. While the patient was on the Heparin gtt awaiting surgery she developed thrombocytopenia. A heparin antibody was checked and was positive. The patient was switch to argatroban for anticoagulation and the pt was diagnosed with HIT. Hematology was consulted for assistance with furture anticoagulation. The patient remained on the argatrogan for 10 days and was started on coumadin therapy towards the end of her admission for continued anticoagulation given her afib and risk of thrombosis after HIT. Thrombocytopenia resolved as coumadin was restarted and INR increased to INR 2.0 on admission. Plan is to maintain INR 2.0-3.0 on doses of coumadin 7.5-10mg per Heme/Onc and she will follow-up with Dr. on in clinic. During this admission the patient was noted to be somewhat depressed at times. She did note that her husband had recently passed away and she was having difficulty dealing with the extent of her admission. Psychiatry was consulted and the patient was started on Remeron. She had confusion with this and was given Haldol for agitation. She seemed to have symptoms of akethesia with this so Haldol was avoided for the remainder of the admission. Pt was then started on Seroquel at night. Within 3 days she developed a Leukopenia which resolved after stopping this medication. After this, the patient decided that she did not want to try any other medications and would deal with her depression through talk therapy when able. The patient did have further episodes of frustration and at one point reversed her code status to DNR/DNI and wanted to return home as CMO. However, after further discussion with psychiatry and the palliative care service the patient stated that she was just very uncomfortable and if efforts such as removing foley and getting better food were met she was very pleased and requesting full medical treatment. A family meeting was held with the patients son and brother and goals of care discussed. The patient is a FULL CODE. | Lytes checked, repleated w/1x dose MD . Lopressor held d/t marginal HR & BP, pauses. Tylenol PO to be admin per order after cultures obtained. Na up to 132, cr 1.5. lytes stableID: tmax 100.9 overnight; continues on vanco and zosyn. MEDICATED X1 WITH MSO4 2MG IV.COPING--NEPHEW IN TO VISIT. Scheduled PO lopressor held d/t SBP <100. Mag 1.6, CCU MD made aware-2gm mag sulf IVB x1 admin per order. RISS in addition to PO meds.GU/renal: Pt voiding in commode; respoded to lasix dose. Low grade temp to afebrile this shift.Endo: Tx blood sugars per Pt's SS.Social: Son into visit, updated by RN. CSRU NSG ADDENDUM:PTT 93.2, heparin drip left at current rate of 100U/hr per sliding scale. nursing note (7a-7p): pre-op for as, increase wbc & febrileneuro: a&ox3, MAE's, OOB to commode x2 & chair x2resp: on 4l/nc w/sats >96%, tachypnic rr 20-33, c/o being SOB @ times, crackles on bilat. OR will be deleyed until resolution of infection is achieved.Review of Systems:Resp - SV on 2l FiO2 via NC, SpO2 >96%, RR 15-25bpm. HCT down to 27.2%, HB down to 9.3, WCC down to 9.7, Lactate 1.5. Cardiac indexes 1.99 & 1.78, CO 4.45 by FICK. ativan at hs, 4am dose held.CV: AF, rate 70-100's; standing lopressor dose given. On schedules IVP lasix.Gi/Gu: +BS x4. Pt tolerating reg diet. OOB to commode x1-sm BM. 1+ pedal edema. HR 85-100bpm, SBP 85-105, MAP 60-75, Tmax 99.4. BS AT 12 130; TAKING MOD AMOUNTS FLUIDS. Becomes anxious X 1, calms down after transferred to chair at her request.CV: Controlled a-fib, rate 50's - 70's, sporadic pauses reported to Dr. (CCU service). ?Tx to F2 for pre-op care. Pre-op bilat LE ultrasound done to r/o DVT.Resp: Remains on NC 4L. Voiding qs, urine cloudy.ID: Cont on IV vanco/zosyn. LUNGS WITH RHONCHI THROUGHOUT.CARDIAC--REMAINS IN A-FIB WITHOUT OBSERVED VEA. BUN elevated, creatinine WNL, K 3.7 (needs order for repletion), Mg 2.0, Ionised Ca 1.21.Neuro - Alert, oriented x 3, GCS 15 (e4v5m6), MAE, Pupils 3mm/3mm reactive. Mild (1+) aortic regurgitation is seen. Moderate PAsystolic hypertension.PERICARDIUM: Small pericardial effusion. Abnormal septal motion/positionconsistent with RV pressure/volume overload.AORTA: Normal aortic root diameter. There is mild symmetric leftventricular hypertrophy. Overall left ventricular systolic function is mildlydepressed. There is a moderate sized left pleural effusion with associated atelectasis/consolidation. Moderate left pleural effusion. Pulmonary vasculature is indistinct consistent with mild failure. Left pleuraleffusion.Conclusions:The left atrium is moderately dilated. Normal ascending aorta diameter.AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. There is moderate pulmonary arterysystolic hypertension. Moderate tosevere [3+] tricuspid regurgitation is seen. IMPRESSION: Cardiomegaly and mild CHF with left pleural effusion with atelectasis/consolidation. afebrile.resp: lungs clear on right, left upper lobe with mild crackles, diminished right base. Mild (1+) AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. ]RIGHT VENTRICLE: Normal RV systolic function. Generalized non-specific repolarization changes.Compared to the previous tracing of T waves are less inverted inlead aVL and ventricular ectopy is absent. There is a moderate sized left pleural effusion. The moderate cardiomegaly and calcified aortic contours are unchanged. Baseline artifactAtrial fibrillationNonspecific intraventricular conduction delayModest low amplitude T waves with probable QT interval prolonged although isdifficult to measure - are nonspecific but clinical correlation is suggestedfor drug/metabolic/electrolyte effectSince previous tracing of , ventricular rate slower and ventricularectopy absent Bilateral venous lower Doppler ultrasound. Valvular heart disease.Height: (in) 65Weight (lb): 220BSA (m2): 2.06 m2BP (mm Hg): 117/66HR (bpm): 98Status: InpatientDate/Time: at 11:46Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.LEFT VENTRICLE: Mild symmetric LVH. There is a small pericardial effusion. Mildly depressed LVEF. Mild CHF Atrial fibrillationConsider left ventricular hypertrophyModest nonspecific ST-T wave changesSince previous tracing of , further lateral T wave changes present Atrial fibrillation with rapid ventricular responseST-T changes are nonspecificPoor R wave progressionBaseline artifactSince previous tracing, QRS changes in lead V4 - ? There is moderate to severe aorticstenosis. Occasional ventricular prematurebeats. There is moderate thickening of the mitral valvechordae. There is abnormal septal motion/positionconsistent with right ventricular pressure/volume overload. The aorta is normal in caliber throughout but again contains atherosclerotic calcifications. FINDINGS: There has been interval removal of a right-sided Swan-Ganz catheter. Mild atherosclerotic calcification is seen within the visualized aorta. CT OF THE ABDOMEN WITHOUT CONTRAST: There is a left pleural effusion, without right pleural effusion. Low-density left adrenal lesion consistent with an adrenal adenoma. CT ANGIOGRAM OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: Contrast is noted to flow retrograde down the inferior vena cava into the hepatic veins. Moderate-to-severe cardiac enlargement is unchanged. CT OF THE PELVIS WITH CONTRAST: The rectum, sigmoid colon, distal ureters, and bladder are normal in appearance. CT OF THE PELVIS WITHOUT CONTRAST: The rectum and sigmoid colon are within normal limits. RIGHT UPPER EXTREMITY ULTRASOUND. Unchanged bilateral pleural effusion. CT ANGIOGRAM OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There are large bilateral pleural effusions, left greater than right, with bilateral lower lobe atelectasis, left greater than right. A right groin hematoma identified on the prior scan of is essentially unchanged. Bilateral, moderate on the left and small on the right, pleural effusion is seen, stable. The left adrenal gland contains a rounded low-density focus most consistent with an adrenal adenoma. These are presumably changes after right femoral vessel catheterization. Continued left lower lobe atelectasis with moderate left pleural effusion. FINDINGS: Grayscale, color, and Doppler son of the right internal jugular, subclavian, axillary, brachial, cephalic, and basilic veins were performed. FINAL REPORT REASON FOR EXAMINATION: Known aortic stenosis and anasarca. Previous left axillary lymph node dissection clips are seen. IMPRESSION: Right PICC line probably terminates in mid superior vena cava, but dedicated PA and lateral chest radiographs would be helpful to confirm precise location. Moderate-sized left pleural effusion with associated atelectasis. There is aortic and iliac artery arthrosclerotic calcifications. Moderate-to-severe enlargement of the heart is seen, stable. IMPRESSION: Persistent moderate left pleural effusion and adjacent atelectasis. There remains a moderate-sized left pleural effusion with adjacent atelectasis in the left lower lobe. | 42 | [
{
"category": "Nursing/other",
"chartdate": "2132-03-13 00:00:00.000",
"description": "Report",
"row_id": 1544983,
"text": "CSRU NSG:\n\nNEURO: A&OX3, no neural deficit noted. Denies pain all shift. Becomes anxious X 1, calms down after transferred to chair at her request.\n\nCV: Controlled a-fib, rate 50's - 70's, sporadic pauses reported to Dr. (CCU service). Atropine at bedside for safety. Lopressor held d/t marginal HR & BP, pauses. Atenolol was d/c'd per CCU service earlier in day, and lopressor was ordered as replacement d/t shorter half-life, making it easier to titrate. Cardiac indexes 1.99 & 1.78, CO 4.45 by FICK. Wedding rings are stuck on L ring finger which is pink, warm and has brisk cap refill. L arm elevated to decrease swelling for ring removal.\n\nPULM: SpO2 98-100% on O2 3L via NC.\n\nGU: Urine clr, yellow, diureses well from 20mg lasix given per 1 time order by Dr. .\n\nGI: Abdomen soft, NT, +BSX4Q. +belching, +flatus, no stool.\n\nINTEG: Skin intact. OOB -> chair X 1.\n\nASSESS: Stable. Awaiting surgery. Wedding rings stuck.\n\nPLAN: Surgery Friday. Attempt to remove wedding rings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-13 00:00:00.000",
"description": "Report",
"row_id": 1544984,
"text": "CSRU NSG ADDENDUM:\n\nPTT 93.2, heparin drip left at current rate of 100U/hr per sliding scale. Next PTT due 0900 hrs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-13 00:00:00.000",
"description": "Report",
"row_id": 1544985,
"text": "CSRU NURSING PROGRESS NOTE 0700-1500\nRESP: WEARING O2 AT 3L NC . SAO2 93-96%. DOING WELL AT ONSET OF SHIFT AND THEN BECAME SOB WITH DECREASE IN O2 SAT AND C/O HEAVINESS AND INABLILITY TO CATCH HER BREATH. OF NOTE, PT WAS VERY EMOTIONAL THIS AM TALKING ABOUT THE RECENT DEATH OF HER HUSBAND OF 50 AND OF HER DAUGHTER DYING OF LIVER CA. IT WAS SHORTLY AFTER THIS THAT PT . PT GIVEN 20 MG LASIX WITH FAIR DIURESIS, 2MG IV MSO4 AND .5 MG PO ATIVAN. EKG DONE WHICH SHOWED NO SIGNIFICANT CHANGE FROM PRIOR EKG'S. PT HAS REMAINED SOB FOR THE DURATION OF THIS SHIFT. O2 CHANGED TO 60 % FACE TENT AS PT IS C/O DRY NOSE. RR 24-32. LUNGS WITH RHONCHI THROUGHOUT.\n\nCARDIAC--REMAINS IN A-FIB WITHOUT OBSERVED VEA. RATE IS 80-110. PA PRESSURES INCREASED WITH INCIDENT OF SOB AND PT STARTED ON IV NTG PRESENTLY AT .5 MCG/KG/MIN. CO BY FICK WAS UNCHANGED DURING THIS TIME OF SOB. 5.4/2.4. TEAM UP TO ASSESS AND ARE AWARE. PT ALSO ON HEPARIN GTT. PTT FOR 1300 PENDING\n\nGI--APPETITE POOR BUT IS TOLERATING LIQUIDS. NO STOOL. +BS.\n\nGU--GIVEN LASIX WITH FAIR RESPONSE VIA FOLEY CATH. URINE IS CL. YELLOW.\n\nENDO--PT IS ON ORAL AGENTS. BS PENDING.\n\nSKIN--INTACT. PT IS OBESE AND HAS ALOT OF LOOSE THIN SKIN.\n\nID--FEBRILE TO 100.8. BLD AND URINE CX SENT YESTERDAY.PT IS NOT ON ABX.\n\nPAIN--NO DIRECT C/O PAIN. JUST \"HEAVINESS\". MEDICATED X1 WITH MSO4 2MG IV.\n\nCOPING--NEPHEW IN TO VISIT. THEY WILL BE IN TOUCH NEXT WEEK. PT IS EMOTIONAL AND CRYING TODAY ABOUT UPCOMING SURGERY AND THE RECENT DEATH OF HER HUSBAND.\n\nNEURO--ALERT AND ORIENTED.MAE SPONT AND TO COMMAND. PT HAS NOT WANTED TO GET OOB BECAUSE SHE FEELS SO WEAK.\n\nA--PT NOT BE READY FOR SURGERY TOMORROW DUE TO FEVER AND EMOTIONAL STATE. REMIANS IN A-FIB WITH NEW CHEST HEAVINESS AND SOB.\n\nP--CHECK LAB RESULTS. ENCOURAGE PULM TOILET. OFFER SUPPORT TO PT. ? IF SURGERY WILL BE POSTPONED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-12 00:00:00.000",
"description": "Report",
"row_id": 1544980,
"text": "NPN 0700-1500;\nTRANSFERRED TO CARDIOLOGY SERVICE\nTEE DONE RESULTS PENDING.\nROS\nO;\" THE WAITING MAKES YOU MORE CHICKEN.\"\n\nNEURO;AOOX3 MAE TO COMMAND STEADY ON FEET.VERY PLEASANT AND FUNNY LADY, WHO IS TELLS MANY GOOD STORIES. ANXIOUS ABOUT PENDING SURGERY ON FRIDAY.BUT EASILY REASSURED,\n\nRESP; LUNGS CLEAR DIMINISHED AT BASES/ ?CRACLES AT BASES. SOB WITH EXERTION SATS 97-99% ON RA RR 29-32\nDENIES PAIN BUT STATED THAT WHEN MOVED BOWELS HAD MILD TWINGE BUT NOTHING SINCE.\n\nCVS; TMAX 38 CORE. BP 109-118/75 HIGH FILLING PRESS TEAM AWARE. 45-60/22-27 AFIB 70-90 NO ECTOPY NOTED. CVP 11-17CO 4 .2CI 1.8-2.2 THERMODILUTION FICK 5.5/2.8. ON NO DRIPS. CONTINUES ONHEPARIN PPT PENDING.\n\nGU PASSING MOD AMOUNTS CLEAR YELLOW URINE VIA FOLEY.\n\nGI; NPO OVERNIGHT AWAITING DIET.GIVEN GLYBURIDE NO METAFORMIN. BS AT 12 130; TAKING MOD AMOUNTS FLUIDS. BELLY SOFT POS BS STRTED ON BOWEL MEDS PASSED MOD AMOUNT GUIAC NEG FORMED STOOL.\n\nOOB TO CHAIR AND BACK TO BED WITH 1 PERSON ASSIST. BUT VERY SOB AND TAKES AFEW MINIUTES TO RETUNRN TO NML.\n\nSOC; SON AND GIRLFRIEND INTO VISIT AND UPDATED WITH PTS CURRENT CONDITION AND ARE AWARE OF POSS TRANS FER TO CCU WHEN A BED BECOMES AVAILABLE.\n\nA/P CONTINUE TO MONITOR PTS HEMODYNAMICS ? DIURESE CONTINUE TO OFFER\nEMOTIONAL SUPPORT TO BOTH PT AND FAMILY . PT \" DAUGHTER DIED OF CANCER IN AND HUSBAND DIED IN FROM HEART DISEASE AND PT IS AT TIMES.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-12 00:00:00.000",
"description": "Report",
"row_id": 1544981,
"text": "Nursing 1500-1900\n\nSee previous nursing note & carevue for full assessment.\n\nObtained L carotid US for pre-op work up. Panaramic dental xray not done d/t symptomatic during stand-up trial (SOB, RR 30s, SBP dipped to 87, pt stated legs felt weak). CI by fick 1.8-team aware, no tx at this time. Increased temp to 101.5, CCU MD made aware plan for blood & urine cultures. CXR done. Tylenol PO to be admin per order after cultures obtained. Mag 1.6, CCU MD made aware-2gm mag sulf IVB x1 admin per order. OOB to commode x1-sm BM. Social work visited w/ pt, will follow throughout hospital stay.\n\nPlan: Obtain cultures. Continue hemodynamic monitoring. Provide support. ?tx to CCU when bed available. Provide support & pre-op education as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-12 00:00:00.000",
"description": "Report",
"row_id": 1544982,
"text": "ADD Nursing 1500-1900: PTT 33.1, heparin gtt increased to 900units/hr per PA . Next PTT due to be drawn @ 2200.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-11 00:00:00.000",
"description": "Report",
"row_id": 1544978,
"text": "csru update\nreceived from 2, pt awake, alert, oriented, mae's. PA line inserted by np , ci>2. sao2 >95% on 4l/nc, scattered crackles bibasally. pressure areas intact, no phone inquiries from family memeber\n\nplan: hemodynamic monitoring\n for further work ups in am\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-12 00:00:00.000",
"description": "Report",
"row_id": 1544979,
"text": "cv:hr 68-81 afib no ectopy. sbp 116-103/ bp in left arm lower thatn right R = 110/70. L = 114/56.\n\nresp: o2 at 2 l nc sats 96-98%. breath sounds diminished at bases. pt sob with any activity. sob when lying flat.tolerates side lying but sob with turns.\n\ngi: bowel sounds present. abd soft. no bm. pt did not eat any supper but is taking liquids. she had a snack of crackers and milk at hs.\n\ngu: foley draining yellow urine clear.\n\nsocial: son in visiting last pm. she is weepy at times. She lost her husband in and lost her only daughter about 2 year ago. She has this one son and he is her spokes person.she c/o anxiety and tolerated ativan .25mg po twice and she said that it did help her.\n\nptt =32.5 on 500 units heparin. increased to 700 units at 0730. bun 25 ,creat = 1.2\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-14 00:00:00.000",
"description": "Report",
"row_id": 1544991,
"text": "nursing note (7a-7p): pre-op for as, increase wbc & febrile\n\nneuro: a&ox3, MAE's, OOB to commode x2 & chair x2\n\nresp: on 4l/nc w/sats >96%, tachypnic rr 20-33, c/o being SOB @ times, crackles on bilat. bases, upper lobes diminished\n\ncv: hr 70-80's a-fib most of day, late afternoon hr increased to 90-100's treated w/lopressor 12.5mg, pa cath & rij cordis removed d/t + cultures, tips sent to lab results pending, peripheral IV access placed r. hand #20 , l. hand # 20 . On heparin 850 units/hr for a-fib, + bilat. edema\n\ngi/gu: decreased UO lasix given mid-afternoon w/minimal effect, foley removed d/t + urine cultures for ecoli, bun & cr increasing, BM x 1, +BS, good appetite may need help w/eating d/t sob & weakness\n\nendo: csru sliding scale\n\ngoal: monitor WBC, monitor renal status, check on pending lab results, con't nursing goal for surgery\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-15 00:00:00.000",
"description": "Report",
"row_id": 1544992,
"text": "CSRU Progress note.\nROS:\nNeuro: Pt alert and oriented X3, MAE. able to stand and pivot to commode, chair and bed. ativan at hs, 4am dose held.\n\nCV: AF, rate 70-100's; standing lopressor dose given. BP stable, SBP 90-120's. Heparin gtt increased to 900U/hr, repeate PTT due at 10am. Extremities warm, pale, palpable pulses. Palpable hematoma to R groin, per pt it is from her cath. no drainage noted. PIV X2, both patent.\n\nResp: Lungs with crackles in bilat bases. Pt remains on 4LNP, pt asking for face tent for added humidification at times. Pt extremely SOB after getting OOB.\n\nGI: Abd obese, good BS. Pt tolerating reg diet. RISS in addition to PO meds.\n\nGU/renal: Pt voiding in commode; respoded to lasix dose. Na up to 132, cr 1.5. lytes stable\n\nID: tmax 100.9 overnight; continues on vanco and zosyn. WBC up to 12.3.\n\nSocial: son in to visit; pt verbalizes stress re: surgery, anxious to have surgery done.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-15 00:00:00.000",
"description": "Report",
"row_id": 1544993,
"text": "Nursing 0700-1500:\nNeuro: A&Ox3. PERRLA. MAEx4. No deficit. scheduled PO ativan held. No anxiety noted this shift. No c/o pain this shift.\n\nCV: Afib 70-90s. Rare-occas PVCs. Lytes checked, repleated w/1x dose MD . SBP 90-low 100s. Scheduled PO lopressor held d/t SBP <100. 1+ pedal edema. Palpable pulses. Heparin gtt at 900 units/hr. PTT this am therapeutic. Next PTT due @ 1600. Pre-op bilat LE ultrasound done to r/o DVT.\n\nResp: Remains on NC 4L. Sats >96%. Becomes SOB w/any activity. Recovers within minutes once at rest. Lung sounds clear w/crackles in LLL. Taught IS, uses between 500-750 w/encouragement. On schedules IVP lasix.\n\nGi/Gu: +BS x4. No BM. +Flatus. Tol reg diet. Voiding qs, urine cloudy.\n\nID: Cont on IV vanco/zosyn. Low grade temp to afebrile this shift.\n\nEndo: Tx blood sugars per Pt's SS.\n\nSocial: Son into visit, updated by RN. Pt followed by social work.\n\nPlan: Awaiting ID to determine length on IV antibiotic tx before cleared for surgery per team. Cont diet & act as tol. Cont pre-op education & providing support as needed. ?Tx to F2 for pre-op care.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-16 00:00:00.000",
"description": "Report",
"row_id": 1544994,
"text": "CSRU Shift Report - 1900-0730\n74 Year Old Female Allergy - Talwin FULL CODE Universal Precautions\n\nAdmission - Severe AS/Moderate MR\n\nPMH - Arryhthmias/CHF/Hypertension\n Diabetes\n TAH\n Mastectomy\n\nPatient admitted to CSRU with severe AS and moderate MR, worked up for AVR/MVR, found to have urinary infection (ecoli), and DVT. OR will be deleyed until resolution of infection is achieved.\n\nReview of Systems:\n\nResp - SV on 2l FiO2 via NC, SpO2 >96%, RR 15-25bpm. Breath sounds clear throughout, good use of IS, good cough, coughing and clearing. Becomes SOB with exertion, recovers after a few minutes rest. Needs sputum sample.\n\nCVS - AFIB with frequent PVCs. HR 85-100bpm, SBP 85-105, MAP 60-75, Tmax 99.4. Peripherally cool, with weak pedal pulses and slight edema. Heparin infusion increased to 1100units/hr 2400 PTT 42 (0600 PTT Pending). HCT down to 27.2%, HB down to 9.3, WCC down to 9.7, Lactate 1.5. Vanco Trough level taken prior to dose. Continues on pipercillin. Metoprolol held as SBP <100.\n\nRenal - UO approximately 100ml/hr, 24hour balance -ve 500ml. 20mg Furosemide . BUN elevated, creatinine WNL, K 3.7 (needs order for repletion), Mg 2.0, Ionised Ca 1.21.\n\nNeuro - Alert, oriented x 3, GCS 15 (e4v5m6), MAE, Pupils 3mm/3mm reactive. Patient is appropriate, anxious at times. Voicing concern over up coming surgery, and how her son is coping. No complaints of pain.\n\nGI - Full cardiac diet as tolerated. Abdomen soft/nontender/+ve bowel sounds. Blood glucose controlled with Q6 ISS.\n\nSkin - Pressure areas intact, up to commode Q2-3. Tolerating side-lying for short periods, able to turn self in bed.\n\nAccess - 2x peripheral IV cannula, patent, dressings intact.\n\nFamily - No contact for family overnight.\n\nPLAN - ?transfer to the floor - Transfer note written\n Wean FiO2 as tolerated\n Encourage use of IS\n Sputum sample\n Q6 PTT (next due 1200)\n Encourage diet\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-13 00:00:00.000",
"description": "Report",
"row_id": 1544986,
"text": "CSRU NURSING PROGRESS NOTE 0700-1500\n*****ADDENDUM TO NOTE: PT'S WEDDING RING WERE REMOVED AND PADDENDUM TO NOTE:\n\nPT SPIKED TEMP TO 103.6 BLOOD AND 102.6 ALACED IN SECURITY ENVELOPE. THEY WERE LOCKED IN HOSPITAL SAFXILLA. GIVEN 650MG PO TYLENOL, PAN CX, CHEM 12 , CBC WITH DIE. PINK RECEIPT IS IN FRONT OF PT'S CHART.*****FF , AND PTT (ON 1000U HEPARIN) SENT AT 1445. RESULTS PENDING.\n\nC- IS OFF FOR TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-13 00:00:00.000",
"description": "Report",
"row_id": 1544987,
"text": "CSRU NURSING PROGRESS NOTE 0700-1500\n*****ADDENDUM TO NOTE: PT'S WEDDING RING WERE REMOVED AND PADDENDUM TO NOTE:\n\nPT SPIKED TEMP TO 103.6 BLOOD AND 102.6 ALACED IN SECURITY ENVELOPE. THEY WERE LOCKED IN HOSPITAL SAFXILLA. GIVEN 650MG PO TYLENOL, PAN CX, CHEM 12 , CBC WITH DIE. PINK RECEIPT IS IN FRONT OF PT'S CHART.*****FF , AND PTT (ON 1000U HEPARIN) SENT AT 1445. RESULTS PENDING.\n\nC- IS OFF FOR TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-13 00:00:00.000",
"description": "Report",
"row_id": 1544988,
"text": "Adendum: Ntg gtt off for bp 59-85/40's with return to baseline bp 90's/40's. Hemodynamics unchanged see flow sheet. Temp down to 100.7, gram + cocci in pairs and chains from blood culture reported by micro. Antibiotics initiated as ordered. Pt reports \"feeling better\" and is able to rest in long naps, call light in reach.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-13 00:00:00.000",
"description": "Report",
"row_id": 1544989,
"text": "NEURO ALERT ORIENTED NO NEURO DEFECITS NOTED\n\nC/V AFIB NO ECT B/P DROP TO 70S SYSTOLIC 250CC NS INFUSING PER DR WITH SOME IMPROVEMENT B/P TO 80S SYSTOLIC PALP PULSES CVP 12\n\nRESP OFM WITH SATS 97-100% LUNGS DIMINISHED L SIDE NONPRODUCTIVE COUGH SOB WITH EXERTION MD AWARE\n\nGU/GI ABD SOFT BOWEL SOUNDS HEARD ATTEMPT TO MOVE BOWELS FLATUS ONLY DECREASING U/O TO PO FLUIDS WELL\n\nMISC CCU TEAM NOTIFIED REGARDING PRELIM POSITIVE BLOOD CULTURE LINE TO REMAIN IN\n\n\nPLAN CONTINUE TO MONITOR FOR SEPSIS MAINTAIN HEMODYNAMICS\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-03-14 00:00:00.000",
"description": "Report",
"row_id": 1544990,
"text": "11p-7a:\nneuro: sleepy initially, alert and oriented x3. denies pain.\n\ncv: remains in afib 90's, rare pvc's noted. sbp dropped to 79-80's, map remains 55-60. pt presently sleeping at this time, able to answer questions appropriately. md notified x 2, she did not want pressors started, ok with map 55-60 regardless of sbp. lopressor held and dose decreased to 12.5 mg po tid. ativan held. sbp improved to sbp in the 90's by 0400. ci > 2.0, see carevue for hemodynamics. easily palpable pedal pulses bilaterally. afebrile.\n\nresp: lungs clear on right, left upper lobe with mild crackles, diminished right base. o2sat> 99% on 10 liter open face tent.\n\ngi/gu: abd soft, nd. bs positive. foley to gravity, good huo.\n\nendo: fs qid, cover per riss.\n\nplan: monitor cardiac status, monitor for fevers, continue with antibiotics.\n"
},
{
"category": "Echo",
"chartdate": "2132-03-12 00:00:00.000",
"description": "Report",
"row_id": 64520,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Valvular heart disease.\nHeight: (in) 65\nWeight (lb): 220\nBSA (m2): 2.06 m2\nBP (mm Hg): 117/66\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 11:46\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mildly depressed LVEF. [Intrinsic LV\nsystolic function likely depressed given the severity of valvular\nregurgitation.]\n\nRIGHT VENTRICLE: Normal RV systolic function. Abnormal septal motion/position\nconsistent with RV pressure/volume overload.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate thickening\nof mitral valve chordae. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Moderate to severe [3+] TR. Eccentric TR jet. Moderate PA\nsystolic hypertension.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Left pleural\neffusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy. Overall left ventricular systolic function is mildly\ndepressed. [Intrinsic left ventricular systolic function is likely more\ndepressed given the severity of valvular regurgitation.] Right ventricular\nsystolic function is normal. There is abnormal septal motion/position\nconsistent with right ventricular pressure/volume overload. The aortic valve\nleaflets are severely thickened/deformed. There is moderate to severe aortic\nstenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets\nare moderately thickened. There is moderate thickening of the mitral valve\nchordae. Moderate to severe (3+) mitral regurgitation is seen. Moderate to\nsevere [3+] tricuspid regurgitation is seen. The tricuspid regurgitation jet\nis eccentric and may be underestimated. There is moderate pulmonary artery\nsystolic hypertension. There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2132-03-13 00:00:00.000",
"description": "Report",
"row_id": 132003,
"text": "Atrial fibrillation\nPoor R wave progression\nConsider possible anterior infarct - age undetermined\nInferior T wave changes are nonspecific\nRepolarization changes may be partly due to rhythm\nSince previous tracing, poor R wave progression new\n\n"
},
{
"category": "ECG",
"chartdate": "2132-03-11 00:00:00.000",
"description": "Report",
"row_id": 132004,
"text": "Atrial fibrillation\nLong QTc interval\nNonspecific T wave flattening in limb leads\nNo previous tracing available for comparison\n\n"
},
{
"category": "ECG",
"chartdate": "2132-04-07 00:00:00.000",
"description": "Report",
"row_id": 131834,
"text": "Baseline artifact\nAtrial fibrillation\nNonspecific intraventricular conduction delay\nModest low amplitude T waves with probable QT interval prolonged although is\ndifficult to measure - are nonspecific but clinical correlation is suggested\nfor drug/metabolic/electrolyte effect\nSince previous tracing of , ventricular rate slower and ventricular\nectopy absent\n\n"
},
{
"category": "ECG",
"chartdate": "2132-03-29 00:00:00.000",
"description": "Report",
"row_id": 131835,
"text": "Atrial fibrillation with a rapid ventricular response, rate approximately 110.\nSemi-regularization of ventricular response. Occasional ventricular premature\nbeats. Semi-vertical axis. Generalized non-specific repolarization changes.\nCompared to the previous tracing of T waves are less inverted in\nlead aVL and ventricular ectopy is absent.\n\n"
},
{
"category": "ECG",
"chartdate": "2132-03-22 00:00:00.000",
"description": "Report",
"row_id": 131836,
"text": "Atrial fibrillation\nConsider left ventricular hypertrophy\nModest nonspecific ST-T wave changes\nSince previous tracing of , further lateral T wave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2132-03-20 00:00:00.000",
"description": "Report",
"row_id": 131837,
"text": "Atrial fibrillation with rapid ventricular response\nST-T changes are nonspecific\nPoor R wave progression\nBaseline artifact\nSince previous tracing, QRS changes in lead V4 - ? lead placement; rate faster;\nbaseline artifact noted\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-16 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 906256,
"text": " 6:45 PM\n RENAL U.S. Clip # \n Reason: r/o abscess\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with CAD, HTN, AS, MR, TR with UTI\n\n REASON FOR THIS EXAMINATION:\n r/o abscess\n ______________________________________________________________________________\n WET READ: MJGe SUN 7:49 PM\n normal renal and bladder.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease, hypertension, urinary tract infection\n with possible abscess.\n\n RENAL ULTRASOUND: The right kidney measures 12.4 cm. The left kidney\n measures 10.5 cm. Both kidneys are normal in appearance. There is no\n evidence for hydronephrosis or stones. There are no perirenal fluid\n collections. The visualized bladder is normal.\n\n IMPRESSION: Normal ultrasound of the kidneys and bladder.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-15 00:00:00.000",
"description": "VEN DUP EXTEXT BIL (MAP/DVT)",
"row_id": 906108,
"text": " 9:27 AM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: 74 OLD WOMEN WITH SWELLING LOWER LIMBS H/O CAD,HTN,AS, R/O DVT BILATERALLY\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with CAD, HTN, AS, MR\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n WET READ: AHPb SAT 11:36 AM\n neg\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old woman with CAD, AS, MR, bilateral leg swelling, rule\n out DVT.\n\n COMPARISON: None.\n\n Bilateral venous lower Doppler ultrasound.\n\n FINDINGS: Grayscale and color Doppler son of bilateral lower\n extremities including the common femoral, superficial femoral, and popliteal\n veins were performed. Normal flow, augmentation, compressibility, and\n waveforms were demonstrated. Intraluminal thrombus was not identified.\n\n IMPRESSION: No evidence for DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905779,
"text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for ? change in CHF from previous CXR\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with AS/MR, sxs of CHF, awaiting surgery\n\n REASON FOR THIS EXAMINATION:\n Eval for ? change in CHF from previous CXR\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Symptoms of CHF, awaiting surgery. Aortic stenosis and mitral\n regurgitation.\n\n COMPARISON: .\n\n FINDINGS: Internal jugular central venous line containing Swan-Ganz catheter\n is unchanged, with tip overlying the right pulmonary artery. The moderate\n cardiomegaly and calcified aortic contours are unchanged. Pulmonary\n vasculature is indistinct consistent with mild failure. There is a moderate\n sized left pleural effusion with associated atelectasis/consolidation.\n Surgical clips are again noted in the left axilla.\n\n IMPRESSION: Cardiomegaly and mild CHF with left pleural effusion with\n atelectasis/consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 905522,
"text": " 6:45 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p PA cath insertion-check placement\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p PA cath insertion-check placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old female with PA catheter insertion. Check placement.\n\n No comparison studies.\n\n CHEST FILM: The tip of the right internal jugular placed pulmonary artery\n catheter is seen overlying the mid right pulmonary artery. There is no\n evidence of pneumothorax. There is a moderate sized left pleural effusion. Air\n bronchograms are also noted along the left middle lung fields consistent with\n consolidation, likely secondary to mild CHF. The right lung field is clear.\n The upper mediastinal contour is slightly indistinct and may be secondary to\n adjacent opacification, likely due to CHF.\n\n IMPRESSION:\n 1. Moderate left pleural effusion.\n 2. Mild CHF\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 908013,
"text": " 9:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r arm picc pulled out 7 cm please check placement call beepe\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with AS/MR, sxs of CHF, worsening SOB\n\n REASON FOR THIS EXAMINATION:\n r arm picc pulled out 7 cm please check placement call beeper with wet\n read asap thanks\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: PICC line withdrawn.\n\n A right PICC line is visualized to the level of the mid-superior vena cava and\n appears more proximal than on the prior study, due to relatively\n technique and suboptimal positioning of the patient, it is\n difficult to confirm the precise tip location on this radiograph. Cardiac\n silhouette remains enlarged and there is persistent congestive heart failure\n with interstitial edema. Moderate left and small right pleural effusions are\n without change.\n\n IMPRESSION: Right PICC line probably terminates in mid superior vena cava,\n but dedicated PA and lateral chest radiographs would be helpful to confirm\n precise location. Findings communicated to the IV nurse caring for the\n patient on the date of the study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-25 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 907417,
"text": " 10:32 AM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n 200CC NON IONIC CONTRAST SUPPLY\n Reason: assess splenomegaly, etiology of gastric varicies\n Admitting Diagnosis: MITRAL REGURGITATION\n Field of view: 48 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with recent EGD with findings of gastric varicies\n REASON FOR THIS EXAMINATION:\n assess splenomegaly, etiology of gastric varicies\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent finding of gastric varices on upper endoscopy. Please\n assess for splenomegaly and etiology of gastric varices.\n\n TECHNIQUE: Multidetector CT images were obtained first through the abdomen\n without intravenous contrast, followed by contrast-enhanced scans through the\n abdomen and pelvis in the arterial, venous, and delayed phases. Coronal and\n sagittal reformatted images were obtained.\n\n CT ANGIOGRAM OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There are\n large bilateral pleural effusions, left greater than right, with bilateral\n lower lobe atelectasis, left greater than right. There is a moderate-sized\n pericardial effusion. Calcifications are seen within the aortic valve.\n Otherwise, the heart and great vessels are unremarkable. Mild atherosclerotic\n calcification is seen within the visualized aorta.\n\n CT ANGIOGRAM OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: Contrast\n is noted to flow retrograde down the inferior vena cava into the hepatic\n veins. No focal liver lesions are identified. The gallbladder, pancreas, and\n right adrenal gland are normal in appearance. The left adrenal gland contains\n a rounded low-density focus most consistent with an adrenal adenoma. The\n kidneys enhance symmetrically and excrete contrast normally. There is no\n evidence of hydronephrosis or hydroureter. The spleen is not enlarged. The\n non-contrast opacified stomach and intra-abdominal loops of small and large\n bowel are normal in appearance and caliber. There is no pathologically\n enlarged mesenteric or retroperitoneal lymphadenopathy. There is a small\n amount of ascites around the liver and spleen and within the paracolic gutters\n bilaterally. There is no free air. Clips are seen within the midline\n abdominal wall subcutaneous tissues, suggestive of prior surgery.\n\n The aorta is normal in caliber throughout but again contains atherosclerotic\n calcifications. Again multiple varices are seen within the splenic hilum\n which extend to the proximal greater curvature of the stomach and form several\n gastric varices. A splenorenal shunt is identified. There is no evidence for\n splenomegaly or splenic vein thrombosis. No esophageal varices are\n identified.\n\n CT OF THE PELVIS WITH CONTRAST: The rectum, sigmoid colon, distal ureters,\n and bladder are normal in appearance. The uterus and adnexa are not well seen\n and may have been removed. There is a small amount of free fluid within the\n (Over)\n\n 10:32 AM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n 200CC NON IONIC CONTRAST SUPPLY\n Reason: assess splenomegaly, etiology of gastric varicies\n Admitting Diagnosis: MITRAL REGURGITATION\n Field of view: 48 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pelvis. A right groin hematoma identified on the prior scan of is\n essentially unchanged. The maximal measurement of this hematoma is\n approximately 4.6 x 2.9 cm. There is no pathologically enlarged inguinal or\n pelvic lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n Degenerative changes are seen within the thoracolumbar spine.\n\n CT REFORMATS: Coronal, sagittal, volume rendering, and MIP reconstruction\n images were essential in delineating the anatomy and pathology of this case,\n particularly the identification of the splenic varices and splenorenal shunt.\n Value grade 5.\n\n IMPRESSION:\n 1. Multiple splenic hilar varices extending to the proximal greater curvature\n of the stomach becoming gastric varices with splenorenal shunt. No evidence\n for splenic vein thrombosis or splenomegaly. No evidence for esophageal\n varices. The combination of these findings, along with a large inferior vena\n cava with contrast reflux into the hepatic veins, bilateral pleural effusions,\n and pericardial effusions suggest right heart failure and volume overload.\n 2. Low-density left adrenal lesion consistent with an adrenal adenoma.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-31 00:00:00.000",
"description": "BX-NEEDLE LIVER BY RADIOLOGIST",
"row_id": 908049,
"text": " 2:18 PM\n BX-NEEDLE LIVER BY RADIOLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: large gastric varices - GI asked to eval extent of liver dis\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with AS/MR/TR\n REASON FOR THIS EXAMINATION:\n large gastric varices - GI asked to eval extent of liver disease vs. right\n heart failure\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND-GUIDED LIVER BIOPSY\n\n CLINICAL HISTORY: Gastric varices. Evaluate liver disease versus right heart\n failure.\n\n FINDINGS: The risks and benefits of the procedure were explained to the\n patient. Although the patient is currently taking 81 mg of aspirin daily, the\n clinical service stated that the benefit of the procedure outweighs the\n increased risk of bleeding. Evaluation of the gallbladder demonstrates sludge\n in the dependent location in the gallbladder and a trace amount of\n pericholecystic fluid. There is no son sign. Written\n informed consent was obtained. The skin over the liver was prepped and draped\n in the usual sterile fashion. A preprocedure timeout was called to confirm\n the patient's identity and type of procedure be performed. A suitable\n location for biopsy was identified using ultrasound guidance. A 16-gauge core\n biopsy needle was inserted into the liver and a single specimen was obtained\n and sent for analysis. The patient tolerated the procedure satisfactorily.\n There were no complications. The attending physician, . , was present\n throughout the entire procedure. Lidocaine 1% and fentanyl and Versed were\n used as anesthesia.\n\n IMPRESSION: Successful core biopsy of the liver.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-05 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 908546,
"text": " 1:28 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: Please eval for extent of hematoma and compression of PICC.\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with recent PICC line placement, now with hematoma.\n REASON FOR THIS EXAMINATION:\n Please eval for extent of hematoma and compression of PICC.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Please evaluate for hematoma.\n\n RIGHT UPPER EXTREMITY ULTRASOUND.\n\n FINDINGS: Grayscale, color, and Doppler son of the right internal\n jugular, subclavian, axillary, brachial, cephalic, and basilic veins were\n performed. There is normal compressibility, waveforms, and augmentation of\n the internal jugular, subclavian, axillary, brachial, basilic veins, and\n cephalic veins. A PICC is noted.\n\n IMPRESSION:\n No evidence of intraluminal thrombus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 907534,
"text": " 8:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? CHF\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with AS/MR, sxs of CHF, worsening SOB\n REASON FOR THIS EXAMINATION:\n ? CHF\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 9:16 A.M. ON .\n\n INDICATION: Worsening shortness of breath. Evaluate for CHF.\n\n FINDINGS: Compared with , the changes of mild CHF seen at that time\n have essentially cleared. The left effusion may have increased slightly. The\n left upper lung field and the right lung appear clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 906823,
"text": " 1:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for hemothorax\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with AS/MR, sxs of CHF, awaiting surgery with\n hypotension, decreased HCT\n REASON FOR THIS EXAMINATION:\n assess for hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 74-year-old female with decreased hematocrit. Assess for\n hemothorax.\n\n COMPARISONS: .\n\n FINDINGS: There has been interval removal of a right-sided Swan-Ganz\n catheter. Moderate-to-severe cardiac enlargement is unchanged. There is a\n moderate pleural effusion with left lower lobe atelectasis. Right lung is\n clear. No pneumothorax is identified. The mediastinal contour is unchanged.\n\n IMPRESSION: No evidence of pneumothorax. Continued left lower lobe\n atelectasis with moderate left pleural effusion. No evidence of pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905928,
"text": " 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate line placement, pneumonia and CHF\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with AS/MR, sxs of CHF, awaiting surgery, fever spike\n today\n REASON FOR THIS EXAMINATION:\n Evaluate line placement, pneumonia and CHF\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:50 A.M. .\n\n HISTORY: AS, MR. Symptoms of CHF. Evaluate line placement.\n\n IMPRESSION: AP chest compared to and 23:\n\n Tip of the Swan-Ganz line projects over the proximal right pulmonary artery.\n Moderate-to-severe cardiac enlargement, left lower lobe atelectasis are\n unchanged and the small left pleural effusion has increased since .\n Right lung is clear. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-12 00:00:00.000",
"description": "P CAROTID LMTD/ DPP PORT",
"row_id": 905674,
"text": " 2:20 PM\n CAROTID LMTD/ DPP PORT Clip # \n Reason: r/o stenosis, NEEDS TO BE PORTABLE\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with As, MR\n REASON FOR THIS EXAMINATION:\n r/o stenosis, NEEDS TO BE PORTABLE\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID SERIES COMPLETE\n\n REASON: Aortic stenosis.\n\n FINDINGS: Duplex evaluation was performed of the left carotid artery. Due to\n the central line in the right neck that side was not evaluated. Minimal\n plaque was identified.\n\n The peak systolic velocities are 68, 68, 55 in the ICA, CCA, ECA respectively.\n The ICA to CCA ratio is 1. This is consistent with less than 40% stenosis.\n There is antegrade flow in the left vertebral artery.\n\n IMPRESSION: Minimal plaque with a left less than 40% carotid stenosis. The\n right carotid was not evaluated due to the central line.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905711,
"text": " 6:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for new pna, w/ fever spike\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with AS/MR, sxs of CHF, awaiting surgery, fever spike\n today\n REASON FOR THIS EXAMINATION:\n Eval for new pna, w/ fever spike\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old with fever spike. Evaluate for pneumonia.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST RADIOGRAPH: A Swan-Ganz catheter is seen in the right\n pulmonary artery. Heart size and mediastinal contours are stable. There is a\n moderate-sized left pleural effusion. A retrocardiac opacity may represent\n atelectasis. There has been slight interval improvement in the mild CHF.\n Clips are noted in the left axilla.\n\n IMPRESSION:\n\n 1. Moderate-sized left pleural effusion with associated atelectasis.\n\n 2. Slight interval improvement in mild CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-01 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 908121,
"text": " 9:17 AM\n CHEST (PA & LAT) Clip # \n Reason: Eval for progression of CHF.\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old with severe AS and anasarca.\n\n REASON FOR THIS EXAMINATION:\n Eval for progression of CHF.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Known aortic stenosis and anasarca. Evaluation for\n progression of congestive heart failure.\n\n PA and lateral upright chest radiograph was compared to the previous films\n from and .\n\n The right PICC line is inserted with its tip projecting over the mid portion\n of superior vena cava. Moderate-to-severe enlargement of the heart is seen,\n stable. The aorta is calcified and tortuous with no evidence of focal\n dilatation.\n\n Bilateral, moderate on the left and small on the right, pleural effusion is\n seen, stable. Adjacent left lung atelectasis is present. No evidence of\n congestive heart failure is demonstrated.\n\n Previous left axillary lymph node dissection clips are seen. Asymmetry of\n breast tissue is demonstrated suggesting previous lumpectomy and partial\n mastectomy on the left.\n\n IMPRESSION:\n 1. Stable cardiomegaly.\n 2. Unchanged bilateral pleural effusion.\n 3. No evidence of congestive heart failure - improvement in comparison to the\n previous film from .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-24 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 907330,
"text": " 4:44 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: MITRAL REGURGITATION\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with AS\n REASON FOR THIS EXAMINATION:\n assess for pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST, \n\n COMPARISON: .\n\n INDICATION: Aortic stenosis and mitral regurgitation.\n\n The cardiac silhouette is markedly enlarged but stable. There remains a\n moderate-sized left pleural effusion with adjacent atelectasis in the left\n lower lobe. A small right pleural effusion is also noted and is not seen on\n the previous study. Note is made of prior left mastectomy and axillary lymph\n node dissection as well as asymmetrical apical thickening on the left,\n possibly related to prior radiation therapy.\n\n IMPRESSION: Persistent moderate left pleural effusion and adjacent\n atelectasis. New small right pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-29 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 907862,
"text": " 12:05 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check picc placement right arm-please page IV RN at wi\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with AS/MR, sxs of CHF, worsening SOB\n\n REASON FOR THIS EXAMINATION:\n check picc placement right arm-please page IV RN at with \n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 74-year-old woman with shortness of breath, aortic stenosis, and\n congestive heart failure, for PICC line placement assessment.\n\n CHEST, AP PORTABLE: Comparison is made to . The tip of the new\n PICC line is not well visualized, but appears to terminate in the distal\n superior vena cava or near the cavoatrial junction. An overlying EKG lead\n partly obscures area, limiting exact precise evaluation. The heart is\n similarly enlarged with a left-sided pleural effusion. There is no\n pneumothorax.\n\n IMPRESSION: Satisfactory positioning of right-sided PICC line. Left effusion\n and cardiomegaly.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-03-20 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 906854,
"text": " 5:07 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for retroperitoneal bleed\n Admitting Diagnosis: MITRAL REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with decreasing HCT, orthostasis, dizziness\n REASON FOR THIS EXAMINATION:\n assess for retroperitoneal bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess for retroperitoneal bleed.\n\n TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic\n symphysis were acquired without intravenous or oral contrast material and\n displayed with 5-mm slice thickness.\n\n COMPARISONS: There are no prior studies available for comparison purposes on\n PACS.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: There is a left pleural effusion, without\n right pleural effusion. The etiology of this is unclear. The right lung base\n is clear. The liver, gallbladder, spleen and pancreas are unremarkable. The\n kidneys are somewhat atrophic. The adrenals appear unremarkable. Large and\n small bowel loops appear within normal limits. No retroperitoneal hemorrhage\n is seen. No ascites is seen. There is no mesenteric or retroperitoneal\n lymphadenopathy. There is aortic and iliac artery arthrosclerotic\n calcifications.\n\n CT OF THE PELVIS WITHOUT CONTRAST: The rectum and sigmoid colon are within\n normal limits. The uterus appears atrophic. The bladder is normal. There\n are several small foci of density that are consistent with blood in the right\n groin area surrounded by fat stranding. These are presumably changes after\n right femoral vessel catheterization. No pelvic lymphadenopathy or free fluid\n is seen.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are seen.\n\n IMPRESSION:\n 1. Left pleural effusion, without right pleural effusion. Etiology of this\n is unclear and a chest x-ray is recommended for further evaluation.\n 2. Right groin hematoma. No drainable fluid collection is seen.\n 3. No evidence for retroperitoneal hemorrhage.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-03 00:00:00.000",
"description": "PERIPHERAL W/O PORT",
"row_id": 908373,
"text": " 12:54 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please replace PICC line. Pt needs access for argatroban con\n Admitting Diagnosis: MITRAL REGURGITATION\n ********************************* CPT Codes ********************************\n * PERIPHERAL W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with PICC placed by IR, now not functioning. Has been assess\n by IV nurse.\n REASON FOR THIS EXAMINATION:\n Please replace PICC line. Pt needs access for argatroban constant infusion.\n Please place double lumen. Pt has hx of HIT, please avoid heparin products.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old female with heparin-induced thrombocytopenia and\n access needed for continuous argatroban infusion. catheter placed by\n IV team on floor could not be advanced past the right forearm.\n\n RADIOLOGIST: Doctors and . The attending radiologist, Dr. \n , was present throughout the procedure.\n\n TECHNIQUE/FINDINGS: The patient was brought to the angiography suite, and\n placed supine on the angiography table. An initial fluoroscopic image\n demonstrated a pre-placed catheter with the tip adjacent to the mid\n humerus. The catheter was cut, and a 5-French sheath was inserted\n over the existing , before the was removed. A 4.5-French\n double lumen catheter and bladder system was then advanced through\n the sheath, and using fluoroscopic guidance, guided into the mid SVC. The\n sheath was removed. Both lumens were aspirated and flushed, and the line was\n secured to the skin via a statlock device. Sterile dressing was applied.\n There were no procedural, or immediate post-procedural complications.\n\n MEDICATIONS: 1% lidocaine for local anesthesia.\n\n IMPRESSION: Successful repositioning of right arm catheter with tip\n in the mid SVC. The line is ready for use.\n\n"
}
] |
32,593 | 143,480 | No antibx cov provided for the pts presumed R sided CAP.MS: Pt cont to c/o pleuritic chest pain rated today, exacerbated by breathing. Hypoxia after bronch REASON FOR THIS EXAMINATION: ? Pt was receiving 0.5mg IVP Dilaudid Q 3 hrs c fair/transient relief of pain per pt. AP UPRIGHT PORTABLE CHEST: In comparison with films of , the patient has taken a very poor inspiration, which most likely accounts for the prominence of the transverse diameter of the heart. Pt with c/o pain but currently not recieving pain meds. Compared totracing #2 sinus rhythm has replaced atrial fibrillation.TRACING #3 Team considering placing an Addiction consult to further manage pts analgesic needs.CV: Hemodynamically stable and afebrile. Sats 90-95 on 2 LNC (sats decrease when asleep)Cardiac: Hemodynamically stable. If there is no known risk factor for pulmonary malignancy, this may be followed up in one year with chest CT. (Over) 1:00 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: eval for PE Admitting Diagnosis: CHEST PAIN;RULE OUT TUBERCULOSIS FINAL REPORT (Cont) s/p brochoscopy positive for hyperemic mucosa but no nodules seen however CAT scan showed nodules LUL.Neuro: oriented x 3, ambulates with steady gait, moves with supervision. No edema pulses easily palpableGI: + BS in 4 quadrents abdomen soft. PIV @ R hand wnlGI: tolerating po's, bowel sounds present positive BM x 1GU: voiding clear urine adequate amount. Sinus tachycardia with occasional atrial premature beats. PNA Admitting Diagnosis: CHEST PAIN;RULE OUT TUBERCULOSIS MEDICAL CONDITION: 46 year old man admit=hemoptysis, rare AFB on concentrated smear, now tachy/pleuritic chest pain, had stopped levofloxacin avoiding levo-related suppression of AFB. His CT demonstrated a patchy infiltrate and a 3 mm nodule in the LUL. He is s/p bronchoscopy that was negative for lesions but positive for for hyperemic mucosa. on airborne precaution, awaiting for 3rd AFB sputum result.CV: hemodynamically stable ( see careview for details ) SR-ST 86-110's easily palpable pedal pulses. 1:00 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: eval for PE Admitting Diagnosis: CHEST PAIN;RULE OUT TUBERCULOSIS MEDICAL CONDITION: 46 year old man with chest pain, hemoptysis, prior CTA unable to rule out PE REASON FOR THIS EXAMINATION: eval for PE No contraindications for IV contrast FINAL REPORT INDICATION: Chest pain, hemoptysis, prior CTA unable to rule out PE. He was given both IM/IV narcan with some response. BILATERAL GRAYSCALE AND DOPPLER ULTRASOUND OF THE LOWER EXTREMITIES: Normal flow, compressibility, and augmentations are seen in bilateral common femoral, superficial femoral, and popliteal veins. There is minimal septal thickening and ground-glass opacity at the right costophrenic sulcus. Frequent atrial premature beats. Mild interval improvement in right lung patchy consolidation and ground- glass opacity, possibly reflecting improving infectious or inflammatory process; aspiration and pulmonary hemorrhage are also considered. Since the examination of one day prior, the patchy consolidation involving the right upper, middle, and lower lobes shows some interval improvement. Not currently on antibioticsSkin: Intact no current issuesSocial: Pt talked to Mother and fiance, full codePlan:1. No BM since admission to the ICU on regular dietRenal: Voiding clear yellow urine via commode.ID: temp 99.8 on admission, on airborne respiratory precautions. Pt c/o feeling depressed this AM, broached c team whether the pt could benefit from an SSRI/psych eval. At noon the pt was found to be somulent with a RR 8-10, ABG at that time was 7.29/62/110. Nursing Progress Note.RESP: Pts third AFB for TB was negative and therefore resp isolation was d/c'ed. Compared to tracing #1 atrial fibrillation is new.TRACING #2 received 0.5 mg of Diluadid x 3 for R pleuritic pain with good effect, dc'd at 0230 after patient complained of itchiness. Routine ICU monitoring and care4. PNA, FINAL REPORT PORTABLE CHEST, AT 1314 HOURS INDICATION: Hemoptysis. 6:55 PM BILAT LOWER EXT VEINS Clip # Reason: PAIN AND SWELLING BILATERAL LOWER EXTREM, R/O DVT MEDICAL CONDITION: 46 year old man with acute onset pleuritic chest pain, hemoptysis REASON FOR THIS EXAMINATION: rule out DVT WET READ: MNIa FRI 7:33 PM No DVT. LSCTA today, diminished @ bases. Over the course of this hospitalization the pat has had an escalating pain medication requirement for his right sided CP. Pupils pinpointResp: Lungs CTA bilaterally. | 9 | [
{
"category": "Radiology",
"chartdate": "2170-10-20 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 978612,
"text": " 1:00 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE\n Admitting Diagnosis: CHEST PAIN;RULE OUT TUBERCULOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with chest pain, hemoptysis, prior CTA unable to rule out PE\n REASON FOR THIS EXAMINATION:\n eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain, hemoptysis, prior CTA unable to rule out PE. Evaluate\n for PE.\n\n COMPARISON: CTA .\n\n TECHNIQUE: Axial MDCT images were obtained through the chest following the\n intravenous administration of Optiray in the pulmonary arterial phase.\n Additional coronal and sagittal reformatted images are provided.\n\n CONTRAST: Intravenous nonionic contrast was administered due to the rapid\n rate of bolus injection required for this examination.\n\n CTA OF THE CHEST: No filling defects are identified within the pulmonary\n arteries to suggest pulmonary embolus. The thoracic aorta is normal in\n caliber and contour. The heart and pericardium appear unremarkable. The\n central airways are patent. Numerous subcentimeter mediastinal, hilar, and\n axillary lymph nodes do not individually meet criteria for pathologic\n enlargement. Since the examination of one day prior, the patchy consolidation\n involving the right upper, middle, and lower lobes shows some interval\n improvement. There is minimal septal thickening and ground-glass opacity at\n the right costophrenic sulcus. A 3-mm nodule in the left upper lobe (2:28) is\n unchanged.\n\n The liver is hypodense, consistent with fatty infiltration. The imaged\n portion of the spleen, pancreas, adrenal glands, and upper poles of the\n kidneys appears unremarkable.\n\n Bone windows demonstrate no evidence of suspicious lytic or sclerotic osseous\n lesions.\n\n IMPRESSION:\n\n 1. No pulmonary embolus.\n\n 2. Mild interval improvement in right lung patchy consolidation and ground-\n glass opacity, possibly reflecting improving infectious or inflammatory\n process; aspiration and pulmonary hemorrhage are also considered.\n\n 3. 3-mm left upper lobe pulmonary nodule. If there is no known risk factor\n for pulmonary malignancy, this may be followed up in one year with chest CT.\n\n (Over)\n\n 1:00 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE\n Admitting Diagnosis: CHEST PAIN;RULE OUT TUBERCULOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-10-19 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 978521,
"text": " 6:55 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PAIN AND SWELLING BILATERAL LOWER EXTREM, R/O DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with acute onset pleuritic chest pain, hemoptysis\n REASON FOR THIS EXAMINATION:\n rule out DVT\n ______________________________________________________________________________\n WET READ: MNIa FRI 7:33 PM\n No DVT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old male with acute onset of chest pain.\n\n BILATERAL GRAYSCALE AND DOPPLER ULTRASOUND OF THE LOWER EXTREMITIES: Normal\n flow, compressibility, and augmentations are seen in bilateral common femoral,\n superficial femoral, and popliteal veins. There is no evidence of DVT.\n\n IMPRESSION: No evidence of DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-10-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 979361,
"text": " 1:10 PM\n CHEST (PA & LAT) Clip # \n Reason: ? PNA\n Admitting Diagnosis: CHEST PAIN;RULE OUT TUBERCULOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man admit=hemoptysis, rare AFB on concentrated smear, now\n tachy/pleuritic chest pain, had stopped levofloxacin avoiding levo-related\n suppression of AFB. Hypoxia after bronch\n REASON FOR THIS EXAMINATION:\n ? PNA,\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 1314 HOURS\n\n INDICATION: Hemoptysis.\n\n AP UPRIGHT PORTABLE CHEST: In comparison with films of , the patient\n has taken a very poor inspiration, which most likely accounts for the\n prominence of the transverse diameter of the heart. Although, the image is\n somewhat over-penetrated, there is no evidence of pneumonia. Nevertheless, if\n there is a significant clinical concern, a repeat study with better\n inspiration and lighter technique would be recommended.\n\n\n DR. \n"
},
{
"category": "Nursing/other",
"chartdate": "2170-10-26 00:00:00.000",
"description": "Report",
"row_id": 1674609,
"text": "In brief: 46 year old male with history of ETOH abuse, hemoptysis (1 tbsp) upon admission last ; transferred from CC7 after found to be somnolent by noon with RR 8-10, ABG suggest respiratory acidosis due to narcotic overdose. Patient has been receiving large amount of narcotics for his R pleuritic chest pain ( ruled out MI ). s/p brochoscopy positive for hyperemic mucosa but no nodules seen however CAT scan showed nodules LUL.\n\nNeuro: oriented x 3, ambulates with steady gait, moves with supervision. received 0.5 mg of Diluadid x 3 for R pleuritic pain with good effect, dc'd at 0230 after patient complained of itchiness. 25 mgs of Benadryl given x 1; patient refusing conversation when asked about history of allergy. Beame agitated and refusing explaination why he cant get pain medication early this shift can be verbally abusive to staff when agitated.\n\nRespi: lung sounds clear sats >95% at room air. on airborne precaution, awaiting for 3rd AFB sputum result.\n\nCV: hemodynamically stable ( see careview for details ) SR-ST 86-110's easily palpable pedal pulses. No edema noted. PIV @ R hand wnl\n\nGI: tolerating po's, bowel sounds present positive BM x 1\n\nGU: voiding clear urine adequate amount. - 400 since MN and - 1200 for LOS\n\nSkin: on issues, intact.\n\nSocial: patient constantly on phone early part of shift, very frustrated of not being given pain medication.\n\nplan:\n\nmonitor mental status, manage pain without respiratory compromise;\ncall out to floor in am\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2170-10-26 00:00:00.000",
"description": "Report",
"row_id": 1674610,
"text": "Nursing Progress Note.\n\nRESP: Pts third AFB for TB was negative and therefore resp isolation was d/c'ed. Pt received/maintained on RA c nl sats, RR & resp effort. LSCTA today, diminished @ bases. Pt s any episodes of SOB or dyspnea though pt essentially staying in bed all shift. No antibx cov provided for the pts presumed R sided CAP.\n\nMS: Pt cont to c/o pleuritic chest pain rated today, exacerbated by breathing. Pt was receiving 0.5mg IVP Dilaudid Q 3 hrs c fair/transient relief of pain per pt. However, following pain service consult the pt was taken off all IV analgesic agents and is now receiving 5.0mg PO Oxycodone PRN Q4 hr c first dose given @ 16:00. Pt refusing PO NSAID's, ice or hot packs for adjuctive pain cntl. Otherwise the pt is times three, utilizing call bell appropraitely, following commands, & ambulating in room s diff. Pt c/o feeling depressed this AM, broached c team whether the pt could benefit from an SSRI/psych eval. Psych eval performed @ 15:00, awaiting recs. Verbal support also provided to this pt. Team considering placing an Addiction consult to further manage pts analgesic needs.\n\nCV: Hemodynamically stable and afebrile. NSR c no ectopy. One 20# PIV in R wrist.\n\nGI: Excellent PO intake all shift. Stooling.\n\nGU: Excellent urine output today, AM serum Cr value of 0.8 noted. Renal US order subsequently d/c'ed by team.\n\nSOC: No calls or visitors today. Pt lives c parents/siblings @ home, however per SW they do not want him to move back home until he is clean. Also, the pts father is currently @ an OSH in an ICU setting.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions now in place. Pt c/o to floor awaiting placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2170-10-25 00:00:00.000",
"description": "Report",
"row_id": 1674608,
"text": "Nursing Admit Note 1600-1900\n\nThis is a 46 year old male who was admitted to the hosptial onm with pleuritic CP, hemoptysis and alcohol intoxication. Since admission his first AFB on a concentrated smear was positive for AFB. This sample is currently undergoing verification at the state lab. His CT demonstrated a patchy infiltrate and a 3 mm nodule in the LUL. He is s/p bronchoscopy that was negative for lesions but positive for for hyperemic mucosa. Over the course of this hospitalization the pat has had an escalating pain medication requirement for his right sided CP. (h/o being in detox for alcohol and narcotic abuse), he has been followed on a CIWA scale since admission and was recieving large amounts of oxycodone for his pain. His creatine hs also bumped from 1.2-2.0. At noon the pt was found to be somulent with a RR 8-10, ABG at that time was 7.29/62/110. He was given both IM/IV narcan with some response. His last dose of IV narcan was at 14:35 today. He was transferred to the MICU for closer monitoring.\n\nNeuro: A&Ox3, OOB to commode with supervision. Falling asleep frequently but easily arrousable. Pt with c/o pain but currently not recieving pain meds. Pupils pinpoint\n\nResp: Lungs CTA bilaterally. RR 7-14. + productive cough for tan/blood tinged secretions. Sats 90-95 on 2 LNC (sats decrease when asleep)\n\nCardiac: Hemodynamically stable. Tele SR-ST 90-100's. No edema pulses easily palpable\n\nGI: + BS in 4 quadrents abdomen soft. No BM since admission to the ICU on regular diet\n\nRenal: Voiding clear yellow urine via commode.\n\nID: temp 99.8 on admission, on airborne respiratory precautions. Not currently on antibiotics\n\nSkin: Intact no current issues\n\nSocial: Pt talked to Mother and fiance, full code\n\nPlan:\n\n1. Monitor resp status, hold all narcotics\n2. Monitor neuro status\n3. Routine ICU monitoring and care\n4. Emotional support to pt and family\n"
},
{
"category": "ECG",
"chartdate": "2170-10-19 00:00:00.000",
"description": "Report",
"row_id": 109286,
"text": "Sinus tachycardia with occasional atrial premature beats. Compared to\ntracing #2 sinus rhythm has replaced atrial fibrillation.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2170-10-19 00:00:00.000",
"description": "Report",
"row_id": 109287,
"text": "Atrial fibrillation with a rapid ventricular response. ST-T wave abnormalities\nwhich are non-specific. Compared to tracing #1 atrial fibrillation is new.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2170-10-19 00:00:00.000",
"description": "Report",
"row_id": 109288,
"text": "Sinus rhythm. Frequent atrial premature beats. Otherwise, within normal limits.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
|
66,507 | 170,621 | 63F admitted to the Neuro ICU under Neurosurgery for a SAH/ruptured aneurysm. A right EVD was placed at St. Vincents prior to transfer. Upon admission she was intubated and taken to INR for a cerebral angiogram with coiling of the L MCA/ACOMM aneurysm. Post-angio she remained stable. On , her EVD was not draining, after multiple attempts to trouble shoot, a Head CT was done to verify placement and TPA was given with good effect. Post-coiling, her SBP goal was > 160 but this demanded three pressors which she had maxed on so her SBP was liberalized to > 100. Her exam remained stable. On , she was extubated and her exam remained stable. She remained stable and so a clamping trial was pursued. On , her drain was raised to 10 cm H20 - then the following day to 20 cm H20. She was also given a bedside feeding trial. On , patient was tolerating raise in EVD to 10cmH2O and it was raised to 20. In the afternoon, a clamping trial of drain was done. On , exam was intact with EVD clamped. IVF were taped down and her blood pressure was liberalized. On , her exam remained stable and her ICPs remain wnl. A head CT was done which was stable and her EVD was discontinued. Overnight she was febrile and blood cultures and urine was sent which was negative for UTI. On , transfer orders to the SDU were written. A CXR was performed because of her fever the night prior, which showed no pneumonia. Her urine culture was negative but we opted to continue treating as her UA was positive. She remained stable over the weekend. On she was evaluated by PT who felt she would be suitable for home with PT services. She was discharged on with Nimodipine. | Right frontal periventricular hypodensity corresponds to the site track of the, now removed, ventriculostomy catheter. IMPRESSION: Redemonstration of unchanged intracranial hemorrhage and interval placement of endovascular emoblization coils, as above. COMPARISON: Conventional cerebral angiogram and head CTA dated . Left internal carotid artery arteriogram status post coiling reveals that the portion of the aneurysm that had possibly ruptured is obliterated with coils. There is a right frontal approach ventricular catheter, terminating in the third ventricle with a small amount of likely post-operative pneumocephalus. The right internal jugular central venous line terminates in the lower SVC. Subarachnoid hemorrhage occupying the bilateral sylvian fissures has resolved. Previously noted intraventricular hemorrhage has resolved. The previously noted right frontal approach intraventricular drain has been removed, with residual gliosis along its former path. Suboptimalimage quality as the patient was difficult to position.Conclusions:The left atrium and right atrium are normal in cavity size. There is mild non-calcified atherosclerotic plaquing of the right carotid artery at the bifurcation. Trace anterior and intraventricular pneumocephalus present. FINDINGS: A ventriculostomy catheter via a right frontal approach terminates within the third ventricle. A 2-mm outpouching of the paraclinoid left internal carotid artery (image 3:70) appears unchanged compared to the prior CT angiogram. Resolution of intraventricular hemorrhage. FINDINGS: A ventriculostomy catheter from a right frontal approach terminates in the third ventricle. Stable small area of cytotoxic edema in anterior medial right frontal lobe and stable small focus of relatively lower density in the right caudate heads, likely reflecting recent infarctions. Stable ventricular size status post removal of intraventricular drain. Evaluation for residual filling of the previously embolized anterior communicating artery aneurysm and left middle cerebral artery bifurcation aneurysm is limited due to streak artifact from the coil packs. FINDINGS: NON-CONTRAST HEAD CT: Previously noted bihemispheric subarachnoid hemorrhage has decreased in extent and density. A small focus of calcification is noted in the choroid plexus of the right side of 4th ventricle, unchanged. Sinus rhythm with borderline right axis deviation.Question left posterior fascicular block. Decreased subarachnoid hemorrhage. Subarachnoid and intraventricular hemorrhage is redemonstrated, unchanged in overall volume. small pneumocephalus likely related to ventriculostomy. small pneumocephalus likely related to ventriculostomy. Stable volume and distribution of subarachnoid hemorrhage. FINDINGS: A right ventriculostomy catheter with frontal approach is again noted terminating in the 3rd ventricle, at the right foramen . Ventriculostomy catheter terminating in the third ventricle with slightly decreased size of the lateral ventricles compared to . FINDINGS: Grayscale and color son were acquired of the bilateral common femoral, superficial femoral, popliteal, posterior tibial, and peroneal veins. There is a hypoplastic left A1 segment of the left anterior cerebral artery. Unchanged mild parafalcine subdural hemorrhage. Hypoplastic left A1 segment of the ACA and a diminutive basilar artery because of bilateral robust posterior communicating arteries. There is a persistent small focal area of /white matter blurring and sulcal effacement in the anterior medial right frontal lobe, likely representing a recent infarction. There is now a small amount of subarachnoid blood at the left parietovertex (2:21-22), not clearly present previously, perhaps re-distributional. Status post embolization of the anterior communicating artery aneurysm and partial embolization of the left middle cerebral artery aneurysm on . There is fluid in the nasal and oropharyngeal (Over) 1:52 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # Reason: ?progression of bleed Contrast: OPTIRAY Amt: 70 FINAL REPORT (Cont) cavities, likely from intubation. Intraventricular hemorrhage appears resolved over the same interval. TECHNIQUE: Following a non-contrast head CT, axial multidetector CT images of the head were obtained during intravenous contrast administration, with multiplanar maximal intensity projection reformatted images, volume rendered three-dimensional reformatted images, and curved reformatted images. There is decreased blood products layering within the occipital horns of the lateral ventricles bilaterally. 5:41 AM CT HEAD W/O CONTRAST Clip # Reason: eval for interval changes in ventricular size; Pls do at Admitting Diagnosis: INTRACRANIAL HEMORRHAGE FINAL ADDENDUM A hypodense area is noted in the right frontal lobe anteriorly ( se 2, im 13), unchanged from ; however, new since . Questionable short-segment vasospasm of the proximal A2 segment of the right anterior cerebral artery, versus an artifact related to the coil pack in the anterior communicating artery aneurysm. There may be a short-segment decrease in caliber of the proximal A2 segment of the right anterior cerebral artery adjacent to the coil pack in the anterior communicating artery (image 3:78). COMPARISON: CT head from from . SINGLE SEMI-UPRIGHT FRONTAL CHEST RADIOGRAPH: The endotracheal tube terminates approximately 4.6 cm above the carina. This may be related to removal of intraventricular drain since . The left middle cerebral artery aneurysm was coiled partially while the anterior communicating artery aneurysm was completely coiled. | 13 | [
{
"category": "Radiology",
"chartdate": "2132-06-27 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1200580,
"text": " 1:52 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: ?progression of bleed\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with xfer from OSH w/ SAH s/p ventriculostomy\n REASON FOR THIS EXAMINATION:\n ?progression of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RJab FRI 3:10 PM\n NECT: Diffuse SAH is stable from outside study at 9:14am. tiny amt of blood in\n the posterior of the left lateral ventricle is slightly increased.\n Interval placement of ventriculostomy catheter, ending in the 3rd ventricle.\n small pneumocephalus likely related to ventriculostomy. fluid in the nasal\n cavity likely related to intubation.\n\n CTA: ACOM aneurysm as well as L MCA aneursym at the bifurcation. Pending\n Reformats\n\n WET READ VERSION #1\n WET READ VERSION #2 MDAg FRI 2:57 PM\n NECT: Diffuse SAH is stable from outside study at 9:14am. tiny amt of blood in\n the posterior of the left lateral ventricle is slightly increased.\n Interval placement of ventriculostomy catheter, ending in the 3rd ventricle.\n small pneumocephalus likely related to ventriculostomy. fluid in the nasal\n cavity likely related to intubation.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman transferred from outside hospital with\n subarachnoid hemorrhage status post ventriculostomy. Question progression of\n bleed.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast material. Subsequently, rapid axial imaging was performed from the\n aortic arch through the brain during infusion of intravenous contrast\n material. Images were processed on a separate workstation with display of\n curved reformats, 3D volume-rendered images, and maximum-intensity projection\n images.\n\n COMPARISON: CT head from from .\n\n FINDINGS:\n\n CT HEAD: There is extensive bilateral subarachnoid hemorrhage, stable from\n prior study at 9 a.m. There is a small amount of intraventricular hemorrhage\n in bilateral occipital horns, which is new compared to the prior study. There\n is a right frontal approach ventricular catheter, terminating in the third\n ventricle with a small amount of likely post-operative pneumocephalus. The\n ventricles appear normal in size and configuration. There is no shift of the\n normally midline structures. There is fluid in the nasal and oropharyngeal\n (Over)\n\n 1:52 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: ?progression of bleed\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n cavities, likely from intubation. The visualized portion of the paranasal\n sinuses and mastoid air cells are clear. Bony structures are unremarkable.\n\n NECK CTA: There is a three-vessel aortic arch. The neck carotid and\n vertebral arteries are patent, with no evidence of stenosis. There is mild\n non-calcified atherosclerotic plaquing of the right carotid artery at the\n bifurcation. The distal cervical internal carotid arteries measure 4.0 mm in\n diameter on the left and 4.5 mm in diameter on the right. The visualized\n portion of the lung apices are unremarkable. There is an ET tube. The\n visualized soft tissue structures are unremarkable.\n\n CTA OF THE HEAD: There is an aneurysm of the anterior communicating artery,\n which measures 4.5 mm in diameter, as well as an aneurysm of the left middle\n cerebral artery at the bifurcation measuring 5.5 mm. Intracranial internal\n carotid and vertebral arteries and their major branches appear patent without\n evidence of occlusion. There is a hypoplastic left A1 segment of the left\n anterior cerebral artery. The basilar artery is diminutive because of\n bilateral robust posterior communicating arteries.\n\n IMPRESSION:\n 1. Bilateral extensive subarachnoid hemorrhage, with now small amount of\n bilateral intraventricular hemorrhage in the occipital horns when compared to\n prior study from at 9 a.m. There is no associated mass effect.\n 2. Ventricular catheter terminating in the third ventricle, with associated\n post-operative pneumocephalus.\n 3. Aneurysm of the anterior communicating artery measuring 4.5 mm in diameter\n and aneurysm of the left middle cerebral artery at the bifurcation measuring\n 5.5 mm in diameter.\n 4. Hypoplastic left A1 segment of the ACA and a diminutive basilar artery\n because of bilateral robust posterior communicating arteries.\n 5. Mild plaquing of the right carotid artery at the bifurcation, without any\n flow-limiting stenosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1200663,
"text": " 1:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate EVD placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with SAH s/p coiling\n REASON FOR THIS EXAMINATION:\n Please evaluate EVD placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subarachnoid hemorrhage status post aneurysm coiling.\n\n COMPARISON: CTA from and ( ) NECT from earlier the same\n date.\n\n TECHNIQUE: Contiguous axial CT images were acquired through the head without\n intravenous contrast. Coronal and sagittal reformatted images were also\n reviewed.\n\n FINDINGS: A ventriculostomy catheter via a right frontal approach terminates\n within the third ventricle. Trace anterior pneumocephalus and\n intraventricular gas is decreased from the most recent comparison.\n Subarachnoid and intraventricular hemorrhage is redemonstrated, unchanged in\n overall volume. There is no evidence of new intracranial hemorrhage. Subtle\n details at the level of the left MCA bifurcation and right anterior\n communicating artery are obscured related to endovascular coil packs in those\n locations. Ventricles and sulci are normal in size and in configuration.\n There is no fracture. Mastoid air cells are clear.\n\n IMPRESSION: Redemonstration of unchanged intracranial hemorrhage and interval\n placement of endovascular emoblization coils, as above.\n\n NOTE ADDED IN ATTENDING REVIEW:\n 1. There is evidence of further ventricular dilatation over the 11-hour\n interval, most evident in the lateral ventricular frontal and temporal horns,\n with ventriculostomy catheter abuting the floor of the III ventricle.\n 2. There is now a small amount of subarachnoid blood at the left parietovertex\n (2:21-22), not clearly present previously, perhaps re-distributional.\n\n These findings were discussed with Dr. (SICU houseofficer, covering\n the Neurosurgery service), via telephone (1000H, ).\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1200678,
"text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placed, please assess\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with SAH aneurysm\n REASON FOR THIS EXAMINATION:\n NGT placed, please assess\n ______________________________________________________________________________\n WET READ: ENYa SAT 7:05 PM\n 1. Tip of nasogastric tube in the stomach, but the side port is in the GE\n junction. Recommend advancing at least 2 to 3 cm for optimal placement.\n 2. Otherwise, no acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old woman, with subarachnoid hemorrhage. Now assess for\n nasogastric tube placement.\n\n COMPARISON: Multiple prior studies with the latest chest radiograph on , .\n\n SINGLE SEMI-UPRIGHT FRONTAL CHEST RADIOGRAPH: The endotracheal tube\n terminates approximately 4.6 cm above the carina. The new nasogastric tube is\n in the stomach but the side port is in the GE junction. The right internal\n jugular central venous line terminates in the lower SVC. The lungs are clear\n without pleural effusion, pneumothorax, or focal airspace consolidations. The\n cardiomediastinal silhouette, hilar contour and pulmonary vasculature are\n normal.\n\n IMPRESSION:\n 1. Tip of nasogastric tube in the stomach, but the side port near the GE\n junction. Recommend advancing at least 2 to 3 cm for optimal placement.\n 2. Otherwise, no acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1200709,
"text": " 11:37 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 yo healthy female who presents with SAH from OSH, found to have ACA and LMCA\n aneurysm s/p coiling.\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with subarachnoid hemorrhage found to have ACA and left\n MCA aneurysm, status post coiling. Please evaluate for interval change.\n\n COMPARISON: Comparison is made to head CT performed and , .\n\n TECHNIQUE: Non-contrast axial images obtained through the brain. No\n reformats were provided.\n\n FINDINGS: A right ventriculostomy catheter with frontal approach is again\n noted terminating in the 3rd ventricle, at the right foramen . Trace\n anterior and intraventricular pneumocephalus present. The bilateral\n subarachnoid hemorrhage is stable in volume and distribution including the\n more recently reported trace subarachnoid hemorrhage along the left parietal\n vertex. The intraventricular hemorrhage is again noted, particularly evident\n in the bilateral lateral ventricles and layering in the occipital .\n Hyperdensity noted in the right lateral ventricle is more prominent on current\n study, but may represent change in head position as well as redistribution of\n blood products rather than definitive new intraventricular hemorrhage. Again\n noted are endovascular coil packs along the anterior communicating and left\n MCA bifurcation with associated artifact.\n\n The ventricles particularly in the degree of the lateral ventricular frontal\n and temporal horns are less bulbous than prior study and likely represent\n slight interval decrease in size. The sulci are normal in size and\n configuration. No fracture identified. The mastoid air cells and middle ear\n cavities are clear. There is a small air-fluid level is noted in the left\n sphenoid sinus.\n\n IMPRESSION:\n 1. Stable volume and distribution of subarachnoid hemorrhage.\n 2. Slight interval decrease in ventricular dilatation, compared to study\n performed 10.5 hours earlier.\n 3. Slight redistribution of intraventricular blood products, though the\n overall volume appears unchanged.\n\n NOTE ADDED IN ATTENDING REVIEW: Over the 10 hr interval, the right\n transfrontal EVD has been partially-withdrawn, and now terminates in the\n region of the right foramen of , whereas, previously, it abutted the\n floor of the 3rd ventricle. This may explain the slight improvement in the\n (Over)\n\n 11:37 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n degree of lateral ventricular dilatation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1201895,
"text": " 8:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cause of fever\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with new fever - s/p coiling of aneurysm\n REASON FOR THIS EXAMINATION:\n eval for cause of fever\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever after surgery.\n\n FINDINGS: In comparison with study of , there is little change and no\n evidence of acute pneumonia, vascular congestion, or pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1201600,
"text": " 3:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evidence of consolidation?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with fevers\n REASON FOR THIS EXAMINATION:\n evidence of consolidation?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Fever.\n\n Comparison is made with prior study .\n\n There is no evidence of pneumonia, pneumothorax, pleural effusion. Cardiac\n size is top normal. There are low lung volumes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-06 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1201804,
"text": " 11:29 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: ACOMM ANEURYSM, EVALUATE FOR VASOSPASM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL ADDENDUM\n The 3D reformatted images of the CTA do not demonstrate evidence of\n short-segment vasospasm of the proximal A2 segment of the right anterior\n cerebral artery, which was suspected on the source data (image 3:78, not image\n 3:70, as mistyped in the findings). No evidence of vasospasm is seen in the\n anterior or posterior circulation.\n\n DFDkq\n\n\n 11:29 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: ACOMM ANEURYSM, EVALUATE FOR VASOSPASM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with L MCA (s/p coiling)\n and Acomm aneurysm\n REASON FOR THIS EXAMINATION:\n eval for vasospasm\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc SUN 12:52 PM\n Trace subarachnoid hemorrhage is decreased from . Intraventricular\n hemorrhage appears resolved over the same interval. Right frontal\n periventricular hypodensity corresponds to the site track of the, now removed,\n ventriculostomy catheter. More anterior right frontal parenchymal hypodensity\n is unchanged. Coil packs are noted, with expected adjacent streak artifact.\n Within that constraint, there is no definite change in vessel caliber since\n to suggest vasospasm\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CTA, \n\n INDICATION: Subarachnoid hemorrhage and multiple intracranial aneurysms.\n Status post embolization of the anterior communicating artery aneurysm and\n partial embolization of the left middle cerebral artery aneurysm on . Evaluate for vasospasm.\n\n COMPARISON: Conventional cerebral angiogram and head CTA dated .\n Non-contrast head CT dated .\n\n TECHNIQUE: Following a non-contrast head CT, axial multidetector CT images of\n the head were obtained during intravenous contrast administration, with\n multiplanar maximal intensity projection reformatted images, volume rendered\n three-dimensional reformatted images, and curved reformatted images.\n\n FINDINGS:\n\n NON-CONTRAST HEAD CT: Previously noted bihemispheric subarachnoid hemorrhage\n has decreased in extent and density. Small amount of subdural blood along the\n posterior falx is unchanged. Previously noted intraventricular hemorrhage has\n resolved. The ventricles remain normal in size. The previously noted right\n frontal approach intraventricular drain has been removed, with residual\n gliosis along its former path. There is a persistent small focal area of\n /white matter blurring and sulcal effacement in the anterior medial right\n frontal lobe, likely representing a recent infarction. There is also a\n persistent focus of slightly decreased density in the right caudate head,\n likely also related to a recent infarction. There is a small focus of right\n frontal pneumocephalus, new compared to , though pneumocephalus was\n previously present on . This may be related to removal of\n intraventricular drain since . Streak artifact is again noted adjacent\n (Over)\n\n 11:29 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: ACOMM ANEURYSM, EVALUATE FOR VASOSPASM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n to the coil packs in the anterior communicating artery and in the region of\n the left middle cerebral artery bifurcation.\n\n There is fluid, aerosolized secretions, and mucosal thickening in the left\n sphenoid sinus, similar to . Given the patient's prolonged\n hospitalization, this could be related to prolonged supine positioning.\n\n HEAD CTA: The intracranial internal carotid and vertebral arteries, and their\n major branches, appear patent. Evaluation for residual filling of the\n previously embolized anterior communicating artery aneurysm and left middle\n cerebral artery bifurcation aneurysm is limited due to streak artifact from\n the coil packs. A 2-mm outpouching of the paraclinoid left internal carotid\n artery (image 3:70) appears unchanged compared to the prior CT angiogram. The\n prior conventional angiogram also demonstrated a 2-mm aneurysm of the\n cavernous left internal carotid artery, but this is not well seen on the\n current or prior CT angiograms.\n\n There may be a short-segment decrease in caliber of the proximal A2 segment of\n the right anterior cerebral artery adjacent to the coil pack in the anterior\n communicating artery (image 3:78). However, this could be an artifact related\n to the streak artifact. The remainder of the anterior circulation\n demonstrates no change in caliber to suggest vasospasm. Small caliber of the\n basilar artery is unchanged and related to fetal configuration of the\n posterior cerebral arteries.\n\n IMPRESSION:\n 1. Decreased subarachnoid hemorrhage. Unchanged mild parafalcine subdural\n hemorrhage.\n\n 2. Resolution of intraventricular hemorrhage. Stable ventricular size status\n post removal of intraventricular drain.\n\n 3. Stable small area of cytotoxic edema in anterior medial right frontal lobe\n and stable small focus of relatively lower density in the right caudate heads,\n likely reflecting recent infarctions.\n\n 4. Questionable short-segment vasospasm of the proximal A2 segment of the\n right anterior cerebral artery, versus an artifact related to the coil pack in\n the anterior communicating artery aneurysm. No evidence of vasospasm\n elsewhere in the anterior or posterior circulation.\n\n 5. Evaluation for residual filling of the previously coiled anterior\n communicating artery aneurysm and left middle cerebral artery aneurysm is not\n possible due to streak artifact from the coil packs. The left paraclinoid\n internal carotid artery aneurysm is unchanged. The left cavernous internal\n (Over)\n\n 11:29 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: ACOMM ANEURYSM, EVALUATE FOR VASOSPASM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n carotid artery aneurysm is not well appreciated by CTA.\n\n 6. Persistent fluid and aerosolized secretions in the left sphenoid sinus,\n which may indicate acute sinusitis in an appropriate clinical setting.\n\n An addendum to this report may be issued when the three-dimensional\n reformatted images are finalized.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-05 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1201709,
"text": " 1:55 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: FEVERS AND HOSPITAL COURSE, EVAL FOR LE DVT BILATERAL\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with fever and hospital course\n REASON FOR THIS EXAMINATION:\n eval for LE DVT bilateral\n ______________________________________________________________________________\n WET READ: SAT 2:33 PM\n No evidence of DVT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and prolonged hospital course, evaluate for lower extremity\n DVT bilaterally.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color son were acquired of the bilateral common\n femoral, superficial femoral, popliteal, posterior tibial, and peroneal veins.\n There is normal compressibility, flow, and augmentation throughout.\n\n IMPRESSION: No evidence of DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-07-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1201354,
"text": " 5:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval changes in ventricular size; Pls do at\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL ADDENDUM\n A hypodense area is noted in the right frontal lobe anteriorly ( se 2, im 13),\n unchanged from ; however, new since . This can relate to\n ischemic changes/ trauma- correlate with MR if not ci; attention on followup.\n\n\n\n 5:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval changes in ventricular size; Pls do at\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with SAH, EVD clamped\n REASON FOR THIS EXAMINATION:\n eval for interval changes in ventricular size; Pls do at 6am\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old female with subarachnoid hemorrhage and EVD clamped.\n Evaluate for interval change in ventricular size.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without IV\n contrast. Coronal and sagittal reformats were displayed.\n\n FINDINGS: A ventriculostomy catheter from a right frontal approach terminates\n in the third ventricle. Compared to the prior study, the lateral ventricles\n are slightly decreased in size. There is decreased blood products layering\n within the occipital horns of the lateral ventricles bilaterally. Serpentine\n hyperdensity layering in the posterior parietal sulci is new compared to the\n prior study (2:25), and could represent redistribution of blood products, but\n new foci of hemorrhage is not excluded. There are persistent blood products\n layering along the posterior falx. Subarachnoid hemorrhage occupying the\n bilateral sylvian fissures has resolved. A small focus of calcification is\n noted in the choroid plexus of the right side of 4th ventricle, unchanged.\n There is no major vascular territory infarction, visualized paranasal sinuses\n and mastoid air cells are well aerated. There is no suspicious lytic or\n sclerotic osseous lesion. Artifacts from coiled aneurysms are noted at the\n skull base.\n\n IMPRESSION:\n\n 1. Ventriculostomy catheter terminating in the third ventricle with slightly\n decreased size of the lateral ventricles compared to .\n\n 2. Expected interval evolution and redistribution of subarachnoid hemorrhage\n in the bilateral cerebral hemispheres. New foci of hyperdensity in the sulci\n at the vertex could be related to redistribution of existing blood products;\n however, new hemorrhage cannot be excluded and attention on followup is\n recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-27 00:00:00.000",
"description": "EMBO TRANSCRANIAL",
"row_id": 1200574,
"text": " 1:39 PM\n CAROT/CEREB Clip # \n Reason: aneurysm rupture\n Contrast: OPTIRAY Amt: 192\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * VERT/CAROTID A-GRAM TRANSCATH EMBO THERAPY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with diffuse SAH with basal cisterns and b/l IVH\n REASON FOR THIS EXAMINATION:\n aneurysm rupture\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF SERVICE: .\n\n DIAGNOSIS: Subarachnoid hemorrhage with multiple aneurysms.\n\n PROCEDURE PERFORMED: Right internal carotid artery arteriogram, left internal\n carotid artery arteriogram, left vertebral artery arteriogram, right common\n femoral artery arteriogram and Angio-Seal closure of right common femoral\n artery puncture site.\n\n INTERVENTIONAL PROCEDURE PERFORMED:\n 1. Coil embolization of left middle cerebral artery aneurysm.\n 2. Coil embolization of anterior communicating artery aneurysm.\n\n INDICATION: The patient had presented with a subarachnoid hemorrhage and we\n decided to coil both aneurysms to prevent a re-hemorrhage, as it was not clear\n from the bleeding pattern as to which aneurysm had bled.\n\n ANESTHESIA: General.\n\n ATTENDING:\n ASSISTANT: ( Kashanipoor).\n\n DETAILS OF PROCEDURE: The patient was brought to the angiography suite.\n Anesthesia was induced in the supine position. Following this, both groins\n were prepped and draped in a sterile fashion. Access was gained to the right\n common femoral artery and a 6 French long vascular sheath was placed in the\n right common femoral artery extending into the distal aorta. We now\n catheterized the above-mentioned vessels and AP, lateral filming was done.\n This revealed a left middle cerebral artery aneurysm measuring approximately 7\n mm and an anterior communicating artery aneurysm measuring 5 mm. Since it was\n not clear from the bleeding pattern as to which aneurysm was responsible for\n the subarachnoid hemorrhage, I decided to coil both aneurysms. The left\n middle cerebral artery aneurysm was broad necked and we were only planning to\n partially coil this to prevent re-hemorrhage at this time.\n (Over)\n\n 1:39 PM\n CAROT/CEREB Clip # \n Reason: aneurysm rupture\n Contrast: OPTIRAY Amt: 192\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n We catheterized the left internal carotid artery with 2 catheter and\n the catheter was exchanged out and a 6 French Neuron catheter was placed in\n the left internal carotid artery. We now catheterized the left middle\n cerebral artery and attempted to place different coils including a 3.5 mm\n Micrusphere coil, a 4 and 5 mm 360 soft coil. Finally, we were successful in\n placing a 3 mm 360 Target Ultrasoft coil. Following this, additional 360\n UltraSoft coils were placed until the portion of the aneurysm which was\n responsible for the rupture was completely coiled. We now turned our\n attention to the right internal carotid artery. The A1 was dominant on the\n right side. The 2 catheter in the right internal carotid artery was\n exchanged out again for a 6 French Neuron catheter. We catheterized the\n aneurysm with an SL-10 microcatheter and a Synchro wire. Following this, the\n aneurysm was coiled starting with a 4 mm 360 UltraSoft coil. Other Target\n coils were placed until the aneurysm was completely obliterated. The patient\n tolerated the procedure well. A right common femoral artery arteriogram was\n done and a 6 French Angio-Seal was used for closure of the right common\n femoral artery puncture site.\n\n FINDINGS: Left internal carotid artery arteriogram shows that the left\n internal carotid artery fills well along the cervical, petrous, cavernous and\n supraclinoid portion. The carotid artery itself is fairly tortuous. There is\n a broad-based aneurysm at the ophthalmic segment in the paraclinoid area which\n is smooth and measures about 2 mm. There is also a smaller cavernous\n aneurysm. There is a fairly large left middle cerebral artery aneurysm\n measuring about 7 mm into 6 mm at the bifurcation. This is broad based.\n There is an inferiorly pointing area which appears to be the rupture site.\n The A1 is hypoplastic on the left side. Left internal carotid artery\n arteriogram status post coiling reveals that the portion of the aneurysm that\n had possibly ruptured is obliterated with coils. A portion of the aneurysm\n still fills. The PCA is fetal in origin on the left side.\n\n Right internal carotid artery arteriogram shows filling of the right internal\n carotid artery along the cervical, petrous, cavernous and supraclinoid\n portion. The PCA is again fetal. The A1 is dominant on the left side. There\n is a 5.5 to 6.5 mm ACOM aneurysm pointing inferiorly arising from the anterior\n communicating segment.\n\n Left vertebral artery arteriogram shows a rather small left vertebral artery\n which fills the basilar artery and refluxes into the right vertebral artery.\n Both anterior inferior cerebral arteries are visualized and seem to be fairly\n large. The posterior cerebral arteries are not well visualized. Given the\n fact that there are bilateral fetal PCAs, both superior cerebellar arteries\n are seen. There is a fairly large PICA on the right side which is seen on the\n reflux into the right vertebral artery.\n\n (Over)\n\n 1:39 PM\n CAROT/CEREB Clip # \n Reason: aneurysm rupture\n Contrast: OPTIRAY Amt: 192\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: underwent cerebral angiography which revealed\n multiple aneurysms. There was a 7 mm into 5.5 mm left middle cerebral artery\n aneurysm, a 2 mm broad-based paraclinoid aneurysm on the left side, a 2 mm\n cavernous aneurysm on the left side, and a 5.5 to 6.6 mm anterior\n communicating artery aneurysm fed by a dominant A1 on the right side. The\n larger aneurysms which could have been responsible for the subarachnoid\n hemorrhage were coiled. The left middle cerebral artery aneurysm was coiled\n partially while the anterior communicating artery aneurysm was completely\n coiled.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1200644,
"text": " 8:09 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p RIJ. Please assess line placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with SAH ruptured aneurysm\n REASON FOR THIS EXAMINATION:\n s/p RIJ. Please assess line placement\n ______________________________________________________________________________\n WET READ: JEKh SAT 12:12 AM\n 1. R IJ line tip in low SVC; no pneumothorax.\n 2. ET tube 4.5 cm above carina.\n 3. endogastric tube courses inferiorly out of view.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-ERECT CHEST FILM DATED AT .\n\n CLINICAL INDICATION: 63-year-old status post a subarachnoid hemorrhage due to\n a ruptured aneurysm status post right internal jugular placement. Assess line\n placement and pneumothorax.\n\n No comparison studies.\n\n Please note that comparison to old films would be helpful to assess for\n interval change.\n\n A single portable semi-erect chest film dated at is submitted.\n\n IMPRESSION:\n\n 1. Right internal jugular central line with its tip in the superior vena\n cava. Nasogastric tube courses below the diaphragm with the tip not\n identified on the current study. Endotracheal tube has its tip at the\n thoracic inlet.\n\n 2. Cardiac and mediastinal contours are within normal limits. Lungs appear\n well inflated without evidence of focal airspace consolidation, pleural\n effusion, or pneumothorax.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2132-06-30 00:00:00.000",
"description": "Report",
"row_id": 91658,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Subarachnoid hemorrhage.\nWeight (lb): 109\nBP (mm Hg): 140/50\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 15:33\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality as the patient was difficult to position.\n\nConclusions:\nThe left atrium 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\nappears structurally normal with trivial mitral regurgitation. There is no\nmitral valve prolapse. The pulmonary artery systolic pressure could not be\ndetermined. There is no pericardial effusion.\n\nIMPRESSION: Normal biventricular cavity sizes with preserved global and\nregional biventricular systolic function.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2132-07-03 00:00:00.000",
"description": "Report",
"row_id": 249662,
"text": "Localized artifact. Sinus rhythm with borderline right axis deviation.\nQuestion left posterior fascicular block. No previous tracing available for\ncomparison.\n\n"
}
] |
24,529 | 119,661 | Pt is a 79M with recent admission to stroke service on with LUE weakness thought to be related to embolic CVA, atrial fibrillation now on coumadin (which was recently increased to 7 mg), and a history as a "partial quad" with weakness primarily in /p C6-7 fractures from an MVA in who presented to the ED with inability to move his left leg. His INR at this time in the ED was 7. . In the ED, Neurology was consulted. On initial neurology exam he could not move his leg, but one hour later he was able to move his leg and he noticed that the strength was gradually returning. On physical exam, he was noted to have black/bloody OB+ stool. Denies melena or history of hemorrhoids. He underwent Abd/Pelvic CT to r/o retroperitoneal hematoma compressing plexus, causing leg sx. He also had an MRI with DWI (stroke protocol) brain to look for new area of infarct and MRA to look for likely ACA territory abnl (ie, occlusion). DWI images were significant for new embolic CVA in leg motor strip area. INR was reversed with 2U FFP and he was x-fered to the MICU for stabilization. . In the MICU, the patient was given vitamin K. GI evaluated the patient and will do a colonoscopy/EGD in the AM assuming that the INR is btw 1.6-2. Neurology also followed the patient and will take the patient on their service once the GI evaluation is complete and the INR is again in the therapeutic range. . PE: Vitals: 97.8, 143/93, 59, 15, 97% RA Gen: well-appearing man in NAD, talkative HEENT: NCAT, PERRL, EOMI, mmm, OP clear Neck: 2+ carotids bilaterally without bruits Lung: CTA bilaterally Cor: irregularly irregular, nml S1S2, no m/r/g Abd: +BS, S/NT/ND Ext: 2+ edema at right ankle Neuro: A&Ox3. Pt w/ increased tone diffusely in the LE. . A/P: 79 yo M with recent admission to Neurology for LUE weakness thought to be related to embolic CVA who presents with acute onset of LLE weakness found to have new CVA, likely embolic despite anticoagulation, also with GIB elevated INR while on coumadin found to have rectal mass on colonoscopy . . # Rectal Mass. 1.5 cm mass 4-5 cm in rectum found on colonoscopy; mass friable, heaped up borders. The patient was not a surgical candidate for LAR as he did not wish to persue this option. Transrectal sono showed lesion. Transanal resection on , which the patient tolerated well. He remained on telemetry from the operation to the time of discharge because of occasional PVCs. Post operatively, patient was started on a Heparin drip and PO coumadin (target INR ). On POD1 () pt tolerated a regular diet & voided adequately. No drainage from rectal area. Hct was 31.2 & PTT was 54.7. Pt had 7-beat run of PVCs. Mild depression was discussed with pt, who refused psychiatry consult. On POD2 (), patient OOB; passed gas but no stool; small amount of dark blood on pad noted. Hct was 32.2 & PTT was 37.1. On POD3 (), Low Na noted (130) and fluids restricted. PTT was 69.8. On POD4 (), patient passed 20-30cc of what appeared to be a peri-operative blood clot and dark blood per rectum. No active bleeding was noted. VS were stable and serial HCT suggested no acute loss of blood. The Heparin drip was halted. Later in the evening, patient had a 12-beat run of PVCs, without any symptom, EKG change or electrolyte abnormality. Patient was discharged on POD5 () to in good condition, afebrile, hemodynamically stable, able to eat and ambulate. # GIB. Stable at 31. No further bleeding likley to above. EGD negative. Patient has been passing some small clots per rectum with mucous. - Follow Hct!! . # CVA: Patient's symptoms and MRI/MRA suggest new stroke, likely in watershed distribution, embolic source despite anticoagulation. The patient was supratherapeutic with Coumadin (INR 7), on . Goal is to keep INR between in long term, required FFP for reversal prior to GI eval for GIB. Have restarted coumadin INR 1.9-2.0, lovenox x1, now have d/ced coumadin today and started hep gtt incase patient will have procedure done in house. Neuro eval recommends no further w/up, but possibilities inclue CTA of aorta, imaging of carotids to eval for source. - f/up anticardiolipin Ab, homocycteine - Bl cx x3 neg to date, final pending - Continue , . # AFib: Currently rate 80s off meds. Off dig. - continue to follow, consider adding beta blocker in rate increases - restarting coumadin for CVA/A.fib . FEN: Full diet, monitor and replace lytes prn. . PPX: Pneumoboots, heparin gtt, coumadin d/ced, PPI IV for GIB. . Full code | + pulses to lower ext. 0200-0700Received pt from EW admitted AM for inability to move LLE with + sensation. Pupils equal and reactive. + sensation to all ext. Lower ext edema noted. INR:3.9.GI/GU: Abd round soft + BS, denies N/V. + strong grasps to upper ext bilaterally. Lungs clear bilaterally.CV: NSR-S.Bradycardis without ectopy. PIV X2 intact. Atrial fibrillation with a controlled ventricular response and occasionalventricular ectopy. Low voltage. Poor R waveprogression. Pt has significant hx of C6-7fx with fusion in : "partial quad" from MVA, and afib.Neuro: Pt awake, alert, oriented. O2sat remain stable >98%. Diffuse ST segment abnormalities. Compared to the previous tracing no significant change. K: 3.9. Speech clear and appropriate. Skin intact with sacral area reddened-barrier cream applied. Movement purposeful. Follows commands consistently. HR 55-70, SBP 140s, afebrile. Low limb lead voltage.Compared to the previous tracing of no diagnostic interim change. Atrial fibrillation with ventricular premature beats. No BM noted. Foley from home intact pt requested not to placed to bedside drainage.PLan: Supportive care Pt last admitted 3 wks ago for multiple embolic CVA. Pt had ability to ambulate short distances at home using assistive devices as well as the us of a wheel chair to get around.Resp: Resp easy and regular with no difficulty. RLE moving on bed, LLE lifting and hold. | 3 | [
{
"category": "Nursing/other",
"chartdate": "2185-10-24 00:00:00.000",
"description": "Report",
"row_id": 1581010,
"text": "0200-0700\n\nReceived pt from EW admitted AM for inability to move LLE with + sensation. Pt last admitted 3 wks ago for multiple embolic CVA. CT scan negative at hospital, MRI + for embolic CVA @ . Pt has significant hx of C6-7fx with fusion in : \"partial quad\" from MVA, and afib.\n\nNeuro: Pt awake, alert, oriented. Follows commands consistently. Movement purposeful. + strong grasps to upper ext bilaterally. RLE moving on bed, LLE lifting and hold. + sensation to all ext. Pupils equal and reactive. Speech clear and appropriate. Pt had ability to ambulate short distances at home using assistive devices as well as the us of a wheel chair to get around.\n\nResp: Resp easy and regular with no difficulty. O2sat remain stable >98%. Lungs clear bilaterally.\n\nCV: NSR-S.Bradycardis without ectopy. HR 55-70, SBP 140s, afebrile. + pulses to lower ext. Lower ext edema noted. Skin intact with sacral area reddened-barrier cream applied. K: 3.9. PIV X2 intact. INR:3.9.\n\nGI/GU: Abd round soft + BS, denies N/V. No BM noted. Foley from home intact pt requested not to placed to bedside drainage.\n\nPLan: Supportive care\n"
},
{
"category": "ECG",
"chartdate": "2185-11-08 00:00:00.000",
"description": "Report",
"row_id": 274281,
"text": "Atrial fibrillation with ventricular premature beats. Low voltage. Poor R wave\nprogression. Compared to the previous tracing no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2185-10-23 00:00:00.000",
"description": "Report",
"row_id": 274282,
"text": "Atrial fibrillation with a controlled ventricular response and occasional\nventricular ectopy. Diffuse ST segment abnormalities. Low limb lead voltage.\nCompared to the previous tracing of no diagnostic interim change.\n\n"
}
] |
96,924 | 105,506 | 42 y/o female with metastatic ocular melanoma who was taken to the OR with Dr for Extended right hepatic lobectomy, cholecystectomy, anastomosis of left portal vein to main portal vein, portal vein thrombectomy, Roux-en-Y hepaticojejunostomy to the left hepatic duct and intraoperative ultrasound. Per Dr note, at the time of exploration, she had a large mass in the dome of the liver that was adherent and superficially growing into the right hemidiaphragm. This lesion was easily separated from the diaphragm and a small portion of the fibrous portion of the diaphragm removed without entering the right chest. There was a large amount of necrotic tumor in the segment VIII mass. Ultrasound also demonstrated the lesion in the medial segment of the left lobe. No other lesions were seen in the left lateral segment. This was a complicated surgery, she received 9000 mL of crystalloid, 9 units of packed red cells, 1250 mL of albumin, 1000 mL of Hespan, 1 unit fresh frozen and made 1100 mL of urine. Estimated blood loss was 5000 mL. She was transferred to the SICU for initial post op management. Please see the op note for surgical detail. She received an additional 5 units of RBCs while in the SICU, and the her Hct remained stable for the rest of the hospitalization. On POD 1 an ultrasound was obtained as liver enzymes bumped significantly to the 3000-4000 range. The ultrasound showed appropriate waveforms in the left portal vein, which is patent. Limited waveforms of the left hepatic artery appear normal. There is no fluid collection or ascites. IMPRESSION: Expected post-trisegmentectomy appearance of the left lobe of the liver. The liver enzymes started to trend down by POD 2 and continued to do so throughout the hospitalization. Although not normal they were much improved by day of discharge. She was transferred to the regular surgical floor on POD 3. Morphine dosing was backed down for oversedation. She was then able to start working with PT, start taking POs with good tolerance and having return of bowel function. JP medial drain had around 400 cc output, lateral drain was always less than 100. A T tube cholangio was done on POD 10 showing contrast filling the jejunostomy loop. The tip of the T-tube is directed away from the biliary system and has likely been dislodged. No extravasation of contrast was seen. The drain was capped. The lateral drain was removed, the medial drain was left to JP bulb drainage. Of note, the biopsy revealed: Liver, right lobe: Metastatic melanoma, extending to within 1 mm of posterior resection margin. Diaphragmatic nodule: Metastatic melanoma. The patient was discharged to a local hotel with VNA coverage as they live in northern . | Now s/pright hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy REASON FOR THIS EXAMINATION: s/p portal vein thrombosis, eval the the flow PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT 9:23 AM Expected post-multisegmentectomy appearance with normal left portal vein/hepatic artery waveforms. Now s/p right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy (had PVE preop, also embolic event intraop). Now s/p right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy (had PVE preop, also embolic event intraop). Now s/pright hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy REASON FOR THIS EXAMINATION: s/p portal vein thrombosis, eval the the flow PFI REPORT Expected post-multisegmentectomy appearance with normal left portal vein/hepatic artery waveforms. Now s/p right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy Chief complaint: right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy PMHx: HTN, metastatic ocular melanoma Current medications: PSH:C-section ', L cataract, phtoablation x 2 melnoma eye, s/p portal vein embolization 24 Hour Events: OR RECEIVED - At 07:30 PM INVASIVE VENTILATION - START 07:35 PM ARTERIAL LINE - START 08:00 PM TRIPLE INTRODUCER - START 08:00 PM - No event overnight Post operative day: POD#1 - Exp lap, Right hepatic trisegmentectomy. HEPATIC DUPLEX DOPPLER ULTRASOUND: There has been right hepatic lobectomy. Chief complaint: right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy PMHx: HTN, metastatic ocular melanoma Current medications: Acetaminophen, Artificial Tear Ointment, Brimonidine Tartrate 0.15% Ophth, Cyclopentolate, Famotidine (IV), Fentanyl Citrate, Heparin, Insulin, Morphine Sulfate, Ondansetron, Promethazine 24 Hour Events: ARTERIAL LINE - STOP 12:13 AM Post operative day: POD#3 - Exp lap, Right hepatic trisegmentectomy. Chief complaint: right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy PMHx: HTN, metastatic ocular melanoma Current medications: Acetaminophen, Artificial Tear Ointment, Brimonidine Tartrate 0.15% Ophth, Cyclopentolate, Famotidine (IV), Fentanyl Citrate, Heparin, Insulin, Morphine Sulfate, Ondansetron, Promethazine 24 Hour Events: ARTERIAL LINE - STOP 12:13 AM Post operative day: POD#3 - Exp lap, Right hepatic trisegmentectomy. Already on ms04 for operative pain control, and supplemental 02. she remain NPO for now on PPI -keep NGT Nutrition: NPO Renal: Foley, Adequate UO, Creat stable Hematology: Postop anemia -s/p portal vein thrombectomy may need US to eval the portal vein Endocrine: RISS, Goal BS<150, monitor closely given liver resection Infectious Disease: Afebrile, wbc Nl, no active issue for now Lines / Tubes / Drains: Foley, NGT, ETT, 2 jp, T tube, Aline Wounds: Imaging: CXR today Fluids: D5 1/2 NS, 100cc/h Consults: Transplant Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op) ICU Care Nutrition: Glycemic Control: Regular insulin sliding scale Lines: Arterial Line - 08:00 PM Triple Introducer - 08:00 PM 20 Gauge - 08:00 PM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI Comments: Communication: Patient discussed on interdisciplinary rounds Comments: Needs Consent Code status: Full code Disposition: ICU Total time spent: 35 minutes Patient is critically ill Action: Stripped JPs q8hrs, both w/ serosanguinous drainage, T-tube draining bilious fluid, Pt received 2 units FFP & 1U Cryo this ICU stay Response: JPs & t-tube patent, Pts INR currently 1.7; LFTs trending downwards but still elevated. Action: Stripped JPs q8hrs, both w/ serosanguinous drainage, T-tube draining bilious fluid, Pt received 2 units FFP & 1U Cryo this ICU stay Response: JPs & t-tube patent, Pts INR currently 1.7; LFTs trending downwards but still elevated. underwent right hepatic lobectomy, CCY, RNY hepaticojejunostomy and portal vein thrombectomy (had PVE preop, also embolic event intraop). underwent right hepatic lobectomy, CCY, RNY hepaticojejunostomy and portal vein thrombectomy (had PVE preop, also embolic event intraop). Now s/p right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy (had PVE preop, also embolic event intraop). Now s/p right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy (had PVE preop, also embolic event intraop). Now s/p right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy (had PVE preop, also embolic event intraop). Now s/p right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy Chief complaint: right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy PMHx: HTN, metastatic ocular melanoma Current medications: PSH:C-section ', L cataract, phtoablation x 2 melnoma eye, s/p portal vein embolization 24 Hour Events: OR RECEIVED - At 07:30 PM INVASIVE VENTILATION - START 07:35 PM ARTERIAL LINE - START 08:00 PM TRIPLE INTRODUCER - START 08:00 PM - No event overnight Post operative day: POD#1 - Exp lap, Right hepatic trisegmentectomy. Still coagulopathic, send coags in PM -s/p portal vein thrombectomy may need US to eval the portal vein Endocrine: RISS, Goal BS<150 Infectious Disease: Afebrile, wbc Nl, no active issue for now Lines / Tubes / Drains: Foley, NGT, ETT, 2 jp, T tube, Aline Wounds: Imaging: CXR today Fluids: D5 1/2 NS, 100cc/h KVO Consults: Transplant Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op) ICU Care Nutrition: Glycemic Control: Regular insulin sliding scale Lines: Arterial Line - 08:00 PM Triple Introducer - 08:00 PM 20 Gauge - 08:00 PM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI Comments: Communication: Patient discussed on interdisciplinary rounds Comments: Needs Consent Code status: Full code Disposition: ICU Total time spent: 20 minutes Patient is critically ill | 24 | [
{
"category": "Physician ",
"chartdate": "2168-03-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 663864,
"text": "SICU\n HPI:\n 42-year-old female who underwent proton beam therapy for an ocular\n melanoma in . She had a recurrence in and once again received\n proton beam radiation, on she was noted to\n have an elevated alkaline phosphatase at 189. A CT scan was performed\n on which demonstrated a 4-cm mass in the dome\n of the liver in the right lobe (Segment VII, VIII) and a second\n 5-cm lesion in Segment IVb (medial segment of the left lobe. Now s/p\n right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein\n thrombectomy\n Chief complaint:\n right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein\n thrombectomy\n PMHx:\n HTN, metastatic ocular melanoma\n Current medications:\n PSH:C-section ', L cataract, phtoablation x 2 melnoma eye, s/p portal\n vein embolization \n 24 Hour Events:\n OR RECEIVED - At 07:30 PM\n INVASIVE VENTILATION - START 07:35 PM\n ARTERIAL LINE - START 08:00 PM\n TRIPLE INTRODUCER - START 08:00 PM\n - No event overnight\n Post operative day:\n POD#1 - Exp lap, Right hepatic trisegmentectomy.\n cholecystectomy. Intra-op ultrasound\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Gentamicin\n Unknown;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 08:50 PM\n Famotidine (Pepcid) - 10:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 37\nC (98.6\n HR: 90 (78 - 93) bpm\n BP: 115/61(73) {98/59(70) - 142/85(106)} mmHg\n RR: 22 (12 - 22) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n CVP: 11 (11 - 12) mmHg\n Total In:\n 15,092 mL\n 1,252 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,751 mL\n 1,252 mL\n Blood products:\n 10,241 mL\n Total out:\n 6,800 mL\n 485 mL\n Urine:\n 380 mL\n 155 mL\n NG:\n Stool:\n Drains:\n 255 mL\n 330 mL\n Balance:\n 8,292 mL\n 767 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): 345 (345 - 345) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 60\n PIP: 22 cmH2O\n Plateau: 16 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 100%\n ABG: 7.40/43/182/24/1\n Ve: 5.3 L/min\n PaO2 / FiO2: 455\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), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: Dressing dry\n Neurologic: Intubated and sedated\n Labs / Radiology\n 138 K/uL\n 10.1 g/dL\n 180 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 13 mg/dL\n 106 mEq/L\n 141 mEq/L\n 28.2 %\n 10.1 K/uL\n [image002.jpg]\n 07:29 PM\n 07:45 PM\n 09:32 PM\n 11:57 PM\n 02:55 AM\n 03:06 AM\n WBC\n 11.8\n 10.1\n Hct\n 29.7\n 28.2\n Plt\n 164\n 138\n Creatinine\n 0.9\n 1.0\n TCO2\n 19\n 19\n 24\n 28\n Glucose\n 153\n 180\n Other labs: PT / PTT / INR:22.4/48.8/2.1, ALT / AST:1727/1608, Alk-Phos\n / T bili:46/3.4, Fibrinogen:83 mg/dL, Lactic Acid:5.4 mmol/L,\n Albumin:2.4 g/dL, Ca:8.3 mg/dL, Mg:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n .H/O LOBECTOMY OR WEDGE RESECTION\n Assessment and Plan: 42-year-old female s/p 42F s/p right hepatic\n lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy\n Neurologic: -Wean sedation to extubated\n -Start Morphine PRN pain\n Cardiovascular: HD stable of pressor\n Pulmonary: Wean the vent as tolerate to extubate today\n Encourage using Incentive spirometre\n Gastrointestinal / Abdomen: s/p right hepatic lobectomy, CCY, RNY\n hepaticojejunostomy, portal vein thrombectomy. she remain NPO for now\n on PPI\n -keep NGT\n Nutrition: NPO\n Renal: Foley, Adequate UO, Creat stable\n Hematology: Postop anemia\n -s/p portal vein thrombectomy may need US to eval the portal vein\n Endocrine: RISS, Goal BS<150, monitor closely given liver resection\n Infectious Disease: Afebrile, wbc Nl, no active issue for now\n Lines / Tubes / Drains: Foley, NGT, ETT, 2 jp, T tube, Aline\n Wounds:\n Imaging: CXR today\n Fluids: D5 1/2 NS, 100cc/h\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 - 08:00 PM\n Triple Introducer - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Needs Consent\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2168-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 663850,
"text": ".H/O lobectomy or wedge resection\n Assessment:\n Pt admitted to SICU B from OR s/p liver resection. Pt intubated ,\n sedated with Propofol drip. Pt on CMV mode on vent. ABG\ns metabolic\n acidosis. Pt on Neo gtt to keep Systolic BP >100. Syst BP > 100\n throut the night Large abd dressing dry and intact, 2 JP\ns to bulb\n suction and 1 bile bag in place. Urine output dropped 30cc or less\n x2 during the night.\n Action:\n Labs drawn as ordered, CXR done. Husband in to visit-updated by RN and\n Dr. . 2 amps of Sodium Bicarb given IV. NS 250cc fluid bolus\n given x2. Neo gtt weaned to off. Propofol gtt weaned down.\n Response:\n Met acidosis resolved. Lactate coming down. Urine output increased\n after volume given. Blood pressure stable off Neo gtt. Pt more\n rousable this am, will occas squeeze hands, opens eyes with\n stimulation.\n Plan:\n Wean vent to CPAP with 10 pressure support. ? extubate this am.\n Continue to monitor closely.\n"
},
{
"category": "Nutrition",
"chartdate": "2168-03-07 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 664114,
"text": "Patient has been NPO and/or on unsupplemented clear liquid diet for 3\n days. If patient's diet is not able to be advanced and tolerated,\n for nutrition support\n Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below.\n Comments:\n 42-year-old female s/p 42F s/p right hepatic lobectomy, CCY, RNY\n hepaticojejunostomy, portal vein thrombectomy.\n Pt on clears as of today, will monitor tolerance.\n If unable to advance diet further in 24-48hrs, pt may benefit from\n nutrition support.\n Will f/u\n Please page w/ questions #\n 12:37\n"
},
{
"category": "Physician ",
"chartdate": "2168-03-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 664103,
"text": "SICU\n HPI:\n 42-year-old female who underwent proton beam therapy for an ocular\n melanoma in . She had a recurrence in and once again received\n proton beam radiation, on she was noted to\n have an elevated alkaline phosphatase at 189. A CT scan was performed\n on which demonstrated a 4-cm mass in the dome\n of the liver in the right lobe (Segment VII, VIII) and a second\n 5-cm lesion in Segment IVb (medial segment of the left lobe. Now s/p\n right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein\n thrombectomy (had PVE preop, also embolic event intraop).\n Chief complaint:\n right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein\n thrombectomy\n PMHx:\n HTN, metastatic ocular melanoma\n Current medications:\n Acetaminophen, Artificial Tear Ointment, Brimonidine Tartrate 0.15%\n Ophth, Cyclopentolate, Famotidine (IV), Fentanyl Citrate, Heparin,\n Insulin, Morphine Sulfate, Ondansetron, Promethazine\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:13 AM\n Post operative day:\n POD#3 - Exp lap, Right hepatic trisegmentectomy.\n cholecystectomy. Intra-op ultrasound\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Gentamicin\n Unknown;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Famotidine (Pepcid) - 06:25 AM\n Other medications:\n Flowsheet Data as of 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 37.1\nC (98.8\n HR: 92 (84 - 121) bpm\n BP: 155/80(97) {125/65(84) - 164/86(103)} mmHg\n RR: 20 (15 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 114.3 kg (admission): 115.9 kg\n Height: 64 Inch\n CVP: 2 (1 - 12) mmHg\n Total In:\n 1,049 mL\n 806 mL\n PO:\n Tube feeding:\n IV Fluid:\n 401 mL\n 243 mL\n Blood products:\n 649 mL\n 563 mL\n Total out:\n 1,502 mL\n 585 mL\n Urine:\n 977 mL\n 430 mL\n NG:\n Stool:\n Drains:\n 525 mL\n 155 mL\n Balance:\n -453 mL\n 221 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///33/\n Physical Examination\n General Appearance: Anxious, Overweight / Obese\n HEENT: PERRL,\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Tender: post-op tenderness\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 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 111 K/uL\n 11.2 g/dL\n 145 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 37 mg/dL\n 109 mEq/L\n 147 mEq/L\n 30.7 %\n 12.9 K/uL\n [image002.jpg]\n 06:01 PM\n 07:38 PM\n 01:13 AM\n 06:39 AM\n 01:11 PM\n 04:22 PM\n 06:15 PM\n 09:52 PM\n 10:00 PM\n 02:42 AM\n WBC\n 10.5\n 12.8\n 12.0\n 12.9\n Hct\n 25.0\n 27.4\n 26.4\n 26.4\n 26.1\n 24.8\n 30.7\n Plt\n 117\n 125\n 129\n 111\n Creatinine\n 1.2\n 1.0\n 0.8\n 0.7\n TCO2\n 28\n Glucose\n 142\n 158\n 148\n 180\n 145\n Other labs: PT / PTT / INR:17.7/34.7/1.6, CK / CK-MB / Troponin\n T:8346/42/0.13, ALT / AST:1793/912, Alk-Phos / T bili:113/3.5,\n Fibrinogen:247 mg/dL, Lactic Acid:4.3 mmol/L, Albumin:2.8 g/dL, LDH:819\n IU/L, Ca:7.7 mg/dL, Mg:2.1 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR: Clear lungs. Tube and line placement as described.\n RUQ US: Normal left lobe vasculature, with no large fluid\n collection at site of right hepatic lobectomy. No significant change\n since earlier same day\n Microbiology: MRSA screen: pending\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), PROBLEM - ENTER\n DESCRIPTION IN COMMENTS, ANEMIA, OTHER, .H/O LOBECTOMY OR WEDGE\n RESECTION\n Assessment and Plan: 42-year-old female s/p 42F s/p right hepatic\n lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy\n Neurologic: AAOx3, watch for encephalopathy, minimize sedatives and\n analgesia for now, morphine ordered by surgery\n Cardiovascular: Hypertensive\n start b-blockers and diurese. Demand\n ischemia w/ troponin leak in setting of postop, acute blood loss.\n Patient has ongoing tachycardia and hypertension for which Dr. \n has specifically instructed that no beta blockade is to be given.\n Pulmonary: maintain SpO2 >95%\n Gastrointestinal / Abdomen: s/p right triseg / CCY / RNY\n hepaticojejunostomy / portal vein thrombectomy; monitor LFTs & coags\n daily; Famotidine\n Nutrition: NPO\n advance as tolerated\n Renal: Cr 1.0 (low 0.9 high 1.4), Start diuresis and keep negative 2 L\n today\n Hematology: postop anemia, q6h hct\n change to q 8 hrs.\n Endocrine: RISS\n increase RISS and keep < 150\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley, R CVL, PIV X1, 2 JP, biliary tube\n Wounds: Dry dressings\n Imaging: None\n Fluids: KVO\n Consults: Surgery W1\n Billing Diagnosis: Post-op complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Triple Introducer - 08:00 PM\n 20 Gauge - 08:00 PM\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: ICU\n Total time spent: 25 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2168-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 663953,
"text": "Anemia, other\n Assessment:\n Hct 20.7 (down from 28.2). INR 2.1 (stable). Fibrinogen 83\n Action:\n Discussed with transplant and sicu team.Received 1 unit cryo for\n fibrinogen. 2 units prbc for hct, and 1 unit ffp for inr in presence\n of hct drop. JP drainage sent for HCT.\n Response:\n Repeat fibrinogen 206, repeat hct and INR pending. JP hct pending.\n Plan:\n Monitor hct and coags, monitor jp output.\n .H/O lobectomy or wedge resection\n Assessment:\n Pt mechanically ventilated s/p liver resection.\n Action:\n Weaned to cpap 0/5 with good abg. Extubated without difficulty.\n Weaned to nasal cannula 2 liters. I/s and coughing/deep breathing\n encouraged.\n Response:\n Post extubation abg wnl.Tolerating extubation well, 02 sat 99-100% on 2\n liters n.c., resp rate 20\ns. LS clear and diminished.\n Plan:\n Continue to monitor resp status, encourage coughing and deep breathing,\n encourage i/s.\n Problem - Description In Comments\n Assessment:\n ST elevation noted on telemetry in lead II this morning. Pt. denies\n chest pain or s.o.b.\n Action:\n Sicu team notified, EKG obtained, cardiac enzymes cycled. Iv lorpessor\n started. Already on ms04 for operative pain control, and supplemental\n 02.\n Response:\n Cardiac enzymes elevated, but stable. Lopressor d/c\nd as per Dr.\n .\n Plan:\n Continue to cycle enzymes, monitor for chest pain, hold lopressor,\n supplemental 02\n"
},
{
"category": "Physician ",
"chartdate": "2168-03-07 00:00:00.000",
"description": "Intensivist Note",
"row_id": 664084,
"text": "SICU\n HPI:\n 42-year-old female who underwent proton beam therapy for an ocular\n melanoma in . She had a recurrence in and once again received\n proton beam radiation, on she was noted to\n have an elevated alkaline phosphatase at 189. A CT scan was performed\n on which demonstrated a 4-cm mass in the dome\n of the liver in the right lobe (Segment VII, VIII) and a second\n 5-cm lesion in Segment IVb (medial segment of the left lobe. Now s/p\n right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein\n thrombectomy (had PVE preop, also embolic event intraop).\n Chief complaint:\n right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein\n thrombectomy\n PMHx:\n HTN, metastatic ocular melanoma\n Current medications:\n Acetaminophen, Artificial Tear Ointment, Brimonidine Tartrate 0.15%\n Ophth, Cyclopentolate, Famotidine (IV), Fentanyl Citrate, Heparin,\n Insulin, Morphine Sulfate, Ondansetron, Promethazine\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:13 AM\n Post operative day:\n POD#3 - Exp lap, Right hepatic trisegmentectomy.\n cholecystectomy. Intra-op ultrasound\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Gentamicin\n Unknown;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:00 AM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Famotidine (Pepcid) - 06:25 AM\n Other medications:\n Flowsheet Data as of 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 37.1\nC (98.8\n HR: 92 (84 - 121) bpm\n BP: 155/80(97) {125/65(84) - 164/86(103)} mmHg\n RR: 20 (15 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 114.3 kg (admission): 115.9 kg\n Height: 64 Inch\n CVP: 2 (1 - 12) mmHg\n Total In:\n 1,049 mL\n 806 mL\n PO:\n Tube feeding:\n IV Fluid:\n 401 mL\n 243 mL\n Blood products:\n 649 mL\n 563 mL\n Total out:\n 1,502 mL\n 585 mL\n Urine:\n 977 mL\n 430 mL\n NG:\n Stool:\n Drains:\n 525 mL\n 155 mL\n Balance:\n -453 mL\n 221 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///33/\n Physical Examination\n General Appearance: Anxious, Overweight / Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Tender: post-op tenderness\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 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 111 K/uL\n 11.2 g/dL\n 145 mg/dL\n 0.7 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 37 mg/dL\n 109 mEq/L\n 147 mEq/L\n 30.7 %\n 12.9 K/uL\n [image002.jpg]\n 06:01 PM\n 07:38 PM\n 01:13 AM\n 06:39 AM\n 01:11 PM\n 04:22 PM\n 06:15 PM\n 09:52 PM\n 10:00 PM\n 02:42 AM\n WBC\n 10.5\n 12.8\n 12.0\n 12.9\n Hct\n 25.0\n 27.4\n 26.4\n 26.4\n 26.1\n 24.8\n 30.7\n Plt\n 117\n 125\n 129\n 111\n Creatinine\n 1.2\n 1.0\n 0.8\n 0.7\n TCO2\n 28\n Glucose\n 142\n 158\n 148\n 180\n 145\n Other labs: PT / PTT / INR:17.7/34.7/1.6, CK / CK-MB / Troponin\n T:8346/42/0.13, ALT / AST:1793/912, Alk-Phos / T bili:113/3.5,\n Fibrinogen:247 mg/dL, Lactic Acid:4.3 mmol/L, Albumin:2.8 g/dL, LDH:819\n IU/L, Ca:7.7 mg/dL, Mg:2.1 mg/dL, PO4:2.2 mg/dL\n Imaging: CXR: Clear lungs. Tube and line placement as described.\n RUQ US: Normal left lobe vasculature, with no large fluid\n collection at site of right hepatic lobectomy. No significant change\n since earlier same day\n Microbiology: MRSA screen: pending\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), PROBLEM - ENTER\n DESCRIPTION IN COMMENTS, ANEMIA, OTHER, .H/O LOBECTOMY OR WEDGE\n RESECTION\n Assessment and Plan: 42-year-old female s/p 42F s/p right hepatic\n lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy\n Neurologic: AAOx3, watch for encephalopathy, minimize sedatives and\n analgesia for now, morphine ordered by surgery\n Cardiovascular: demand ischemia w/ troponin leak in setting of postop,\n acute blood loss. Patient has ongoing tachycardia and hypertension for\n which Dr. has specifically instructed that no beta blockade is to\n be given\n Pulmonary: maintain SpO2 >95%\n Gastrointestinal / Abdomen: s/p right triseg / CCY / RNY\n hepaticojejunostomy / portal vein thrombectomy; monitor LFTs & coags\n daily; Famotidine\n Nutrition: NPO\n Renal: oliguria, low CVP, Cr 1.0 (low 0.9 high 1.4), if UOP < 30\n x2hours will bolus albumin\n Hematology: postop anemia, q6h hct, all blood products to be cleared by\n surgery, consider repeat imaging if concern for ongoing blood losses;\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley, R CVL, PIV X1, 2 JP, biliary tube\n Wounds: Dry dressings\n Imaging: None\n Fluids: KVO\n Consults: Surgery W1\n Billing Diagnosis: Post-op complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Triple Introducer - 08:00 PM\n 20 Gauge - 08:00 PM\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:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2168-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664085,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt restless in bed trying to lift head off of pillow, trying to get\n comfortable, tachycardic low 100s, calling out for nurse. Pt states\n pain RUQ, Dr at bedside to examine pt at 2300. Pt has\n difficulty turning onto rt side due to pain despite pain med.\n Action:\n Morphine sulfate 2mg IVP q2-3 hrs given.\n Pt repositioned for comfort\n Response:\n After morphine pt states pain 0-1/10\n Plan:\n Continue consistent pain med delivery\n Reposition for comfort\n Anemia, other\n Assessment:\n Hct down to 24 from 26\n Action:\n 2 units PRBCs over 1 hr each given per d.o.\n Response:\n Hct 30 this am\n Plan:\n Serial hcts q 6 hr next hct due 0800\n .H/O lobectomy or wedge resection\n Assessment:\n LFTs trending down\n Lateral JP still dark blood\n Medial JP serosang\n TTube draining bile\n Action:\n Post/op liver resec care\n Response:\n Tolerated\n Plan:\n Continue CDB, IS, OOB today\n"
},
{
"category": "Radiology",
"chartdate": "2168-03-05 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1067855,
"text": " 5:54 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n -76 BY SAME PHYSICIAN; DUPLEX DOP ABD/PEL LIMITED\n -59 DISTINCT PROCEDURAL SERVICE; -77 BY DIFFERENT PHYSICIAN\n : to reassess portal flows, HA flow, for hematoma at resection\n Admitting Diagnosis: METASTASIS OCCULAR MELANOMA TO LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with hepatic resection(R. lobectomy ), now with markedly\n incr. LFT's, HCT down to 21\n REASON FOR THIS EXAMINATION:\n to reassess portal flows, HA flow, for hematoma at resection site(r. border of\n liver)\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT 6:43 PM\n Normal left lobe vasculature, with no large fluid collection at site of right\n hepatic lobectomy. No significant change since earlier same day.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 42-year-old female with right hepatic resection one day prior with\n markedly increased LFTs.\n\n COMPARISON: Duplex Doppler ultrasound earlier the same day.\n\n HEPATIC DUPLEX DOPPLER ULTRASOUND: There has been right hepatic lobectomy. The\n left lobe of the liver is unremarkable. The left portal vein, left hepatic\n vein, and artery demonstrate normal waveforms. The diaphragm is identified in\n the post- lobectomy bed, grossly unremarkable.\n\n IMPRESSION: Normal-appearing post-lobectomy liver, with appropriate\n waveforms. No significant change since earlier the same day.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-03-05 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1067856,
"text": ", W. SICU-B 5:54 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n -76 BY SAME PHYSICIAN; DUPLEX DOP ABD/PEL LIMITED\n -59 DISTINCT PROCEDURAL SERVICE; -77 BY DIFFERENT PHYSICIAN\n : to reassess portal flows, HA flow, for hematoma at resection\n Admitting Diagnosis: METASTASIS OCCULAR MELANOMA TO LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with hepatic resection(R. lobectomy ), now with markedly\n incr. LFT's, HCT down to 21\n REASON FOR THIS EXAMINATION:\n to reassess portal flows, HA flow, for hematoma at resection site(r. border of\n liver)\n ______________________________________________________________________________\n PFI REPORT\n Normal left lobe vasculature, with no large fluid collection at site of right\n hepatic lobectomy. No significant change since earlier same day.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-03-05 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1067805,
"text": " 8:03 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: SP LIVER TRISEGMENTECTOMY ,EVAL LIVER FLOW\n Admitting Diagnosis: METASTASIS OCCULAR MELANOMA TO LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42-year-old female who underwent proton beam therapy for an ocular melanoma in\n . She had a recurrence in and once again received proton beam\n radiation, on she was noted tohave an elevated alkaline\n phosphatase at 189. A CT scan was performed on which\n demonstrated a 4-cm mass in the domeof the liver in the right lobe (Segment\n VII, VIII) and a second5-cm lesion in Segment IVb (medial segment of the left\n lobe. Now s/pright hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein\n thrombectomy\n REASON FOR THIS EXAMINATION:\n s/p portal vein thrombosis, eval the the flow\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT 9:23 AM\n Expected post-multisegmentectomy appearance with normal left portal\n vein/hepatic artery waveforms.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 42-year-old female with right hepatic lobectomy following metastatic\n melanoma.\n\n COMPARISON: CTA abdomen .\n\n DUPLEX DOPPLER LIVER ULTRASOUND: There has been trisegmentectomy of the\n liver. The left lobe of the liver appears unremarkable, without focal liver\n lesion identified. Appropriate waveforms are identified in the left portal\n vein, which is patent. Limited waveforms of the left hepatic artery appear\n normal. There is no fluid collection or ascites.\n\n IMPRESSION: Expected post-trisegmentectomy appearance of the left lobe of the\n liver.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-03-05 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 1067806,
"text": ", W. SICU-B 8:03 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: SP LIVER TRISEGMENTECTOMY ,EVAL LIVER FLOW\n Admitting Diagnosis: METASTASIS OCCULAR MELANOMA TO LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42-year-old female who underwent proton beam therapy for an ocular melanoma in\n . She had a recurrence in and once again received proton beam\n radiation, on she was noted tohave an elevated alkaline\n phosphatase at 189. A CT scan was performed on which\n demonstrated a 4-cm mass in the domeof the liver in the right lobe (Segment\n VII, VIII) and a second5-cm lesion in Segment IVb (medial segment of the left\n lobe. Now s/pright hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein\n thrombectomy\n REASON FOR THIS EXAMINATION:\n s/p portal vein thrombosis, eval the the flow\n ______________________________________________________________________________\n PFI REPORT\n Expected post-multisegmentectomy appearance with normal left portal\n vein/hepatic artery waveforms.\n\n"
},
{
"category": "ECG",
"chartdate": "2168-03-07 00:00:00.000",
"description": "Report",
"row_id": 239886,
"text": "Sinus rhythm. Short P-R interval. Consider inferior myocardial infarction.\nST-T wave abnormalities. Since the previous tracing of the rate is\nslower. ST-T wave abnormalities are more prominent. Clinical correlation is\nsuggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2168-03-05 00:00:00.000",
"description": "Report",
"row_id": 239887,
"text": "Sinus tachycardia. Non-specific ST-T wave changes.\n\n"
},
{
"category": "Physician ",
"chartdate": "2168-03-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 664010,
"text": "SICU\n HPI:\n 42-year-old female who underwent proton beam therapy for an ocular\n melanoma in . She had a recurrence in and once again received\n proton beam radiation, on she was noted to\n have an elevated alkaline phosphatase at 189. A CT scan was performed\n on which demonstrated a 4-cm mass in the dome\n of the liver in the right lobe (Segment VII, VIII) and a second\n 5-cm lesion in Segment IVb (medial segment of the left lobe. Now s/p\n right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein\n thrombectomy (had PVE preop, also embolic event intraop).\n Intraop fluids: IVF 9000ml, RBC 9u, FFP 1u, albumin 1250, hespan 1000,\n uop 1100 , EBL 5000 ml\n PMHx:\n PMH:HTN, metastatic ocular melanoma\n .\n PSH:C-section ', L cataract, photoablation x 2 melanoma eye, s/p\n portal vein embolization \n Current medications:\n standing: famotidine, SQH\n prn: tylenol, morphine, zofran, brimonidine gtt, compazine,\n cyclopentolate gtt\n scale: RISS\n 24 Hour Events:\n : extubated in AM. Received 1 unit cryo, then total 3 units PRBC in\n PM for hct drop (26->21 w/o increased JP drainage). JP hct <2 x 2.\n Leaked trop (?demand ischemia), given 2 doses lopressor, per primary\n team, pt is not to recieve beta-blocker secondary to demand ischemia.\n RUQ US x2 --> nl vasculature, no large fluid collection. Overnight w/\n some increase in JP drainage. Overnight with more agitation, AAOx2-3,\n question of early hepatic encephalopathy, primary team aware.\n Post operative day:\n POD#2 - Exp lap, Right hepatic trisegmentectomy.\n cholecystectomy. Intra-op ultrasound\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Gentamicin\n Unknown;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:33 PM\n Heparin Sodium (Prophylaxis) - 10:33 PM\n Morphine Sulfate - 02:09 AM\n Other medications:\n Flowsheet Data as of 05:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 35.8\nC (96.4\n HR: 112 (74 - 112) bpm\n BP: 144/84(112) {115/62(73) - 154/99(112)} mmHg\n RR: 19 (19 - 30) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n CVP: 11 (2 - 12) mmHg\n Total In:\n 4,158 mL\n 52 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,385 mL\n 52 mL\n Blood products:\n 1,773 mL\n Total out:\n 2,104 mL\n 511 mL\n Urine:\n 1,124 mL\n 291 mL\n NG:\n 50 mL\n Stool:\n Drains:\n 930 mL\n 220 mL\n Balance:\n 2,054 mL\n -459 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 446 (446 - 446) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 11 cmH2O\n SPO2: 96%\n ABG: 7.43/41/102/30/2\n Ve: 7.8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL, periorbital edema\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, obese habitus\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3, x 2), Follows simple\n commands, Moves all extremities\n Labs / Radiology\n 125 K/uL\n 10.1 g/dL\n 158 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.4 %\n 12.8 K/uL\n [image002.jpg]\n 03:06 AM\n 05:54 AM\n 08:59 AM\n 09:05 AM\n 10:33 AM\n 02:56 PM\n 03:25 PM\n 06:01 PM\n 07:38 PM\n 01:13 AM\n WBC\n 9.0\n 10.5\n 12.8\n Hct\n 20.7\n 21.1\n 25.0\n 27.4\n Plt\n 118\n 117\n 125\n Creatinine\n 1.4\n 1.2\n 1.0\n Troponin T\n 0.15\n 0.13\n TCO2\n 28\n 25\n 29\n 27\n 28\n Glucose\n 145\n 142\n 158\n Other labs: PT / PTT / INR:20.7/51.7/2.0, CK / CK-MB / Troponin\n T:8346/42/0.13, ALT / AST:2826/2412, Alk-Phos / T bili:109/4.2,\n Fibrinogen:202 mg/dL, Lactic Acid:4.3 mmol/L, Albumin:2.9 g/dL, Ca:7.9\n mg/dL, Mg:1.8 mg/dL, PO4:2.6 mg/dL\n Imaging: RUQ US: Normal left lobe vasculature, with no large fluid\n collection at site of right hepatic lobectomy. No significant change\n since earlier same day.\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ANEMIA, OTHER, .H/O\n LOBECTOMY OR WEDGE RESECTION\n Assessment and Plan: 42-year-old female s/p 42F s/p right hepatic\n lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, - AAOx3 though w/\n some agitation early this AM, consider early signs of encephalopathy.\n - minimize sedatives and analgesia for now.\n - trend ammonia level post liver resection.\n Cardiovascular:\n - demand ischemia w/ troponin leak in setting of postop, acute blood\n loss, and tachycardia - no beta-blockade per surgery. Would still\n recommend beta blockade if cont to have ST segment changes with\n tachycardia for presumed demand ischemia\n Pulmonary: IS, no active issues\n Gastrointestinal / Abdomen: s/p right triseg / CCT / RNY\n hepaticojejunostomy / portal vein thrombectomy\n - monitor LFTs & coags daily\n - Famotidine\n - NPO for now\n Nutrition: NPO\n Renal: Foley, Adequate UO, - oliguria, low CVP - improved UOP after\n albumin and lasix x 1, then with somewhat decreased UOP during the day.\n To monitor. Cr trending down. Recommend albumin for persistent\n oliguria.\n Hematology: - postop anemia - monitor hct closely, JP hct <2 and RUQ\n U/S w/o obvious large fluid collection, s/p 3 units PRBC on . To\n monitor serial Hct q6hrs today.\n Endocrine: RISS\n Infectious Disease: - complete periop course of unasyn\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), biliary\n drain, right CVL, a-line\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Transplant\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress:\n Insufficiency / Post-op), Liver failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:00 PM\n Triple Introducer - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Family meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2168-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664042,
"text": "Anemia, other\n Assessment:\n Hct 26.4, inr 2.0 u/o > 30cc\ns hr, sbp elevated.\n Action:\n Received 1 unit ffp followe by 1 unit prbc.\n Response:\n Repeat hct 26.4. (sicu team and transplant team notified)\n Plan:\n Continue to monitor q 4-6 hour hcts, monitor u/o, monitor sbp and other\n signs of bleeding. Transfuse prn.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o of abdominal pain, not able to describe location well or rate\n pain, however noted to be very tender/guarded in right lower quadrant.\n Action:\n Mso4 given, repositioned frequently. Dr. and Dr. \n and in to evaluate patient.\n Response:\n Pain improved with mso4 and repositioning, currently sleeping.\n Plan:\n Continue to monitor, prn morphine, frequent repositioning.\n"
},
{
"category": "Nursing",
"chartdate": "2168-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664004,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o back pain. Pt restless in bed. Asking for water and to get out\n of bed. Pt denies any abd pain. Pt unable to score pain level. At\n 4am pt very uncomfortable and restless in bed. Hr up to 120\ns and pt\n unable to state where pain is.\n Action:\n Pt medicated with morphine 1-2mg q3-4 hrs prn for pain. Pt examined by\n Dr. . Pt given 25mcgs of fentanyl with good response.\n Response:\n Pt appears more comfortable. Hr done to 109. pt sleeping comfortablely\n and states pain is improved.\n Plan:\n Continue to assess for pain. Medicate as needed.\n h/o anemia due to blood loss\n assessment: post transfusion hct 25.1, inr down to 1.9 after\n transfusion of ffp. Hepatology team aware and pt transfused with one\n additional unit of prbc. Post hct 27.1. lateral jp sent for hct and <\n 2. lateral and medial jp color unchanged. Medial more serous than\n lateral jp.\n Action: continue to monitor drains for bleeding. Monitor labs as\n ordered.\n Plan: repeat hct drawn this am and still pending. Monitor drains for\n change in drainage.\n"
},
{
"category": "Nursing",
"chartdate": "2168-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664005,
"text": "Anemia, other\n Assessment:\n Hct 25.1 after transfused 2units of prbc. Hepatology team aware and\n pt transfused with one unit of prbc. Jps continue to be\n serous/sanginous lateral jp hct <2. no change in color of drainage.\n Inr 1.9 after ffp.\n Action:\n Post hct 27.1. continue to monitor labs as ordered. Monitor jp\n drainage for changes.\n Response:\n Hct this 26.1. jp drainage color has not changed. Lateral remains\n slightly more sanginous than medial but no different.\n Plan:\n Continue to monitor Labs as ordered. Monitor for signs of bleeding from\n drains.\n Problem - \n Assessment:\n Pt c/o pain mostly back pain. And wanting water because throat hurts.\n Also asking to get out of bed to help with back pain. Pt denies any\n incisional pain\n Action:\n Pt medicated with morphine 1-2 mg prn for pain.\n Response:\n Pt seems more confused this am. States she is in but the year is\n and the month is . Pt reoriented. Pulling at gown. 4am pt\n more restless in bed. Hr up to 120;s. pt states he is more\n uncomfortable and wants to get out. Pt evaluated by Dr. \n :\n Pt medicated with 25mcgs of Fentanyl x1 with good response. Hr down to\n 109 and pt appears more comfortable and able to sleep.\n"
},
{
"category": "Nursing",
"chartdate": "2168-03-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 664140,
"text": "Pt is a 42 y/o female who underwent proton beam therapy for an ocular\n melanoma in ; recurrence in\n05 also treated with proton beam\n radiation. CT in demonstrated 4 cm mass in right lobe of liver and\n second mass in medial segment of the left lobe. underwent right\n hepatic lobectomy, CCY, RNY hepaticojejunostomy and portal vein\n thrombectomy (had PVE preop, also embolic event intraop).\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reported pain, constant/aching near surgical site,\n Action:\n repositioned, IV Morphine given PRN\n Response:\n Pt resting comfortably following pain meds, reporting pain \n Plan:\n Continue to monitor for pain and intervene as needed\n .H/O lobectomy resection\n Assessment:\n Medial & Lateral JP drains & T-tube in place w/ c/d/I dressing,\n surgical incision c/d with steri-strips in place, post-op INR 2.2, LFTs\n bumped.\n Action:\n Stripped JPs q8hrs, both w/ serosanguinous drainage, T-tube draining\n bilious fluid, Pt received 2 units FFP & 1U Cryo this ICU stay\n Response:\n JPs & t-tube patent, Pt\ns INR currently 1.7; LFTs trending downwards\n but still elevated.\n Plan:\n Continue to monitor, continue to strip drains q8hrs, continue to\n monitor surgical sites & maintain C/D/I dressing; continue to trend\n LFTs.\n Anemia, other\n Assessment:\n Intra-op EBL of 5L, Hct decreased 8 points post-op.\n Action:\n Pt received 3 U PRBCs Saturday, 1 unit PRBCs Sunday and 2 U PRBCs\n overnight into .\n Response:\n Hct has been above 30 last three checks; Hct currently 31.8\n Plan:\n Continue to monitor Hct and s/s bleeding.\n Post-op troponin leak\n Assessment:\n Troponin level 0.15 on AM labs, Team is aware & feels related to\n demand ischemia in the setting of post-op anemia, BP\ns 120-170s/60-80s\n Action:\n Monitored troponin levels, monitored EKGs, Transplant team doesn\nt want\n beta-blockade due to forward flow interference in setting of newly\n resected liver.\n Response:\n ST depression in V6 & Lead II\n appears to be improving per SICU\n Resident; Troponin level 0.13, BP lowers with Morphine\n Plan:\n Continue serial EKGs, cont to monitor Troponin level, continue without\n beta blockers\n"
},
{
"category": "Physician ",
"chartdate": "2168-03-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 664000,
"text": "SICU\n HPI:\n 42-year-old female who underwent proton beam therapy for an ocular\n melanoma in . She had a recurrence in and once again received\n proton beam radiation, on she was noted to\n have an elevated alkaline phosphatase at 189. A CT scan was performed\n on which demonstrated a 4-cm mass in the dome\n of the liver in the right lobe (Segment VII, VIII) and a second\n 5-cm lesion in Segment IVb (medial segment of the left lobe. Now s/p\n right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein\n thrombectomy (had PVE preop, also embolic event intraop).\n Intraop fluids: IVF 9000ml, RBC 9u, FFP 1u, albumin 1250, hespan 1000,\n uop 1100 , EBL 5000 ml\n Chief complaint:\n PMHx:\n PMH:HTN, metastatic ocular melanoma\n .\n PSH:C-section ', L cataract, phtoablation x 2 melnoma eye, s/p portal\n vein embolization \n Current medications:\n standing: famotidine, SQH\n prn: tylenol, morphine, zofran, brimonidine gtt, compazine,\n cyclopentolate gtt\n scale: RISS\n 24 Hour Events:\n : extubated in AM. Received 1 unit cryo, then total 3 units PRBC in\n PM for hct drop (26->21 w/o increased JP drainage). JP hct <2 x 2.\n Leaked trop (?demand ischemia), given 2 doses lopressor, per no\n BB and stopped. RUQ US x2 --> nl vasculature, no large fluid\n collection. Overnight w/ some increase in JP drainage. Overnight with\n more agitation, AAOx2-3, question of early hepatic encephalopathy,\n primary team aware.\n Post operative day:\n POD#2 - Exp lap, Right hepatic trisegmentectomy.\n cholecystectomy. Intra-op ultrasound\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Gentamicin\n Unknown;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:33 PM\n Heparin Sodium (Prophylaxis) - 10:33 PM\n Morphine Sulfate - 02:09 AM\n Other medications:\n Flowsheet Data as of 05:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 35.8\nC (96.4\n HR: 112 (74 - 112) bpm\n BP: 144/84(112) {115/62(73) - 154/99(112)} mmHg\n RR: 19 (19 - 30) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n CVP: 11 (2 - 12) mmHg\n Total In:\n 4,158 mL\n 52 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,385 mL\n 52 mL\n Blood products:\n 1,773 mL\n Total out:\n 2,104 mL\n 511 mL\n Urine:\n 1,124 mL\n 291 mL\n NG:\n 50 mL\n Stool:\n Drains:\n 930 mL\n 220 mL\n Balance:\n 2,054 mL\n -459 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 446 (446 - 446) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 11 cmH2O\n SPO2: 96%\n ABG: 7.43/41/102/30/2\n Ve: 7.8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL, periorbital edema\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, obese habitus\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3, x 2), Follows simple\n commands, Moves all extremities\n Labs / Radiology\n 125 K/uL\n 10.1 g/dL\n 158 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.4 %\n 12.8 K/uL\n [image002.jpg]\n 03:06 AM\n 05:54 AM\n 08:59 AM\n 09:05 AM\n 10:33 AM\n 02:56 PM\n 03:25 PM\n 06:01 PM\n 07:38 PM\n 01:13 AM\n WBC\n 9.0\n 10.5\n 12.8\n Hct\n 20.7\n 21.1\n 25.0\n 27.4\n Plt\n 118\n 117\n 125\n Creatinine\n 1.4\n 1.2\n 1.0\n Troponin T\n 0.15\n 0.13\n TCO2\n 28\n 25\n 29\n 27\n 28\n Glucose\n 145\n 142\n 158\n Other labs: PT / PTT / INR:20.7/51.7/2.0, CK / CK-MB / Troponin\n T:8346/42/0.13, ALT / AST:2826/2412, Alk-Phos / T bili:109/4.2,\n Fibrinogen:202 mg/dL, Lactic Acid:4.3 mmol/L, Albumin:2.9 g/dL, Ca:7.9\n mg/dL, Mg:1.8 mg/dL, PO4:2.6 mg/dL\n Imaging: RUQ US: Normal left lobe vasculature, with no large fluid\n collection at site of right hepatic lobectomy. No significant change\n since earlier same day.\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ANEMIA, OTHER, .H/O\n LOBECTOMY OR WEDGE RESECTION\n Assessment and Plan: 42-year-old female s/p 42F s/p right hepatic\n lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, - AAOx3 though w/\n some agitation early this AM, consider early signs of encephalopathy.\n - minimize sedatives and analgesia for now.\n - consider checking ammonia level.\n Cardiovascular:\n - demand ischemia w/ troponin leak in setting of postop, acute blood\n loss, and tachycardia - no BB per surgery. Would recommend beta\n blockade, asa when able. Consider TTE.\n - BP stable\n Pulmonary: IS, no active issues\n Gastrointestinal / Abdomen: s/p right triseg / CCT / RNY\n hepaticojejunostomy / portal vein thrombectomy\n - monitor LFTs & coags daily\n - Famotidine\n - NPO for now\n Nutrition: NPO\n Renal: Foley, Adequate UO, - oliguria, low CVP - improved UOP after\n albumin and lasix x 1, then with somewhat decreased UOP during the day.\n To monitor. Cr trending down. Recommend albumin for persistent\n oliguria.\n Hematology: - postop anemia - monitor hct closely, JP hct <2 and RUQ\n U/S w/o obvious large fluid collection, s/p 3 units PRBC on . To\n monitor Hct q6hrs today.\n Endocrine: RISS\n Infectious Disease: - complete periop course of unasyn\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), biliary\n drain, right CVL, a-line\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Transplant\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress:\n Insufficiency / Post-op), Liver failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:00 PM\n Triple Introducer - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Family meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2168-03-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 663899,
"text": "SICU\n HPI:\n 42-year-old female who underwent proton beam therapy for an ocular\n melanoma in . She had a recurrence in and once again received\n proton beam radiation, on she was noted to\n have an elevated alkaline phosphatase at 189. A CT scan was performed\n on which demonstrated a 4-cm mass in the dome\n of the liver in the right lobe (Segment VII, VIII) and a second\n 5-cm lesion in Segment IVb (medial segment of the left lobe. Now s/p\n right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein\n thrombectomy\n Chief complaint:\n right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein\n thrombectomy\n PMHx:\n HTN, metastatic ocular melanoma\n Current medications:\n PSH:C-section ', L cataract, phtoablation x 2 melnoma eye, s/p portal\n vein embolization \n 24 Hour Events:\n OR RECEIVED - At 07:30 PM\n INVASIVE VENTILATION - START 07:35 PM\n ARTERIAL LINE - START 08:00 PM\n TRIPLE INTRODUCER - START 08:00 PM\n - No event overnight\n Post operative day:\n POD#1 - Exp lap, Right hepatic trisegmentectomy.\n cholecystectomy. Intra-op ultrasound\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Gentamicin\n Unknown;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 08:50 PM\n Famotidine (Pepcid) - 10:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 37\nC (98.6\n HR: 90 (78 - 93) bpm\n BP: 115/61(73) {98/59(70) - 142/85(106)} mmHg\n RR: 22 (12 - 22) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n CVP: 11 (11 - 12) mmHg\n Total In:\n 15,092 mL\n 1,252 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,751 mL\n 1,252 mL\n Blood products:\n 10,241 mL\n Total out:\n 6,800 mL\n 485 mL\n Urine:\n 380 mL\n 155 mL\n NG:\n Stool:\n Drains:\n 255 mL\n 330 mL\n Balance:\n 8,292 mL\n 767 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): 345 (345 - 345) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 60\n PIP: 22 cmH2O\n Plateau: 16 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 100%\n ABG: 7.40/43/182/24/1\n Ve: 5.3 L/min\n PaO2 / FiO2: 455\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), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: Dressing dry\n Neurologic: Intubated and sedated\n Labs / Radiology\n 138 K/uL\n 10.1 g/dL\n 180 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 13 mg/dL\n 106 mEq/L\n 141 mEq/L\n 28.2 %\n 10.1 K/uL\n [image002.jpg]\n 07:29 PM\n 07:45 PM\n 09:32 PM\n 11:57 PM\n 02:55 AM\n 03:06 AM\n WBC\n 11.8\n 10.1\n Hct\n 29.7\n 28.2\n Plt\n 164\n 138\n Creatinine\n 0.9\n 1.0\n TCO2\n 19\n 19\n 24\n 28\n Glucose\n 153\n 180\n Other labs: PT / PTT / INR:22.4/48.8/2.1, ALT / AST:1727/1608, Alk-Phos\n / T bili:46/3.4, Fibrinogen:83 mg/dL, Lactic Acid:5.4 mmol/L,\n Albumin:2.4 g/dL, Ca:8.3 mg/dL, Mg:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n .H/O LOBECTOMY OR WEDGE RESECTION\n Assessment and Plan: 42-year-old female s/p 42F s/p right hepatic\n lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy\n Neurologic: -Wean sedation to extubated\n -Pain controlled with Morphine PRN\n Cardiovascular: HD stable of pressors\n Pulmonary: Extubate today after u/s results available.\n Encourage using Incentive spirometre\n Gastrointestinal / Abdomen: s/p right hepatic lobectomy, CCY, RNY\n hepaticojejunostomy, portal vein thrombectomy. she remain NPO for now\n on PPI\n -keep NGT\n Nutrition: NPO\n Renal: Foley, Adequate UO, Creat stable. Would diurese today 1-2 L\n negative\n Hematology: Postop anemia, mild thrombocytopenia. Still coagulopathic,\n send coags in PM\n -s/p portal vein thrombectomy may need US to eval the portal vein\n Endocrine: RISS, Goal BS<150\n Infectious Disease: Afebrile, wbc Nl, no active issue for now\n Lines / Tubes / Drains: Foley, NGT, ETT, 2 jp, T tube, Aline\n Wounds:\n Imaging: CXR today\n Fluids: D5 1/2 NS, 100cc/h\n KVO\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 - 08:00 PM\n Triple Introducer - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Needs Consent\n Code status: Full code\n Disposition: ICU\n Total time spent: 20 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2168-03-06 00:00:00.000",
"description": "Intensivist Note",
"row_id": 663980,
"text": "SICU\n HPI:\n 42-year-old female who underwent proton beam therapy for an ocular\n melanoma in . She had a recurrence in and once again received\n proton beam radiation, on she was noted to\n have an elevated alkaline phosphatase at 189. A CT scan was performed\n on which demonstrated a 4-cm mass in the dome\n of the liver in the right lobe (Segment VII, VIII) and a second\n 5-cm lesion in Segment IVb (medial segment of the left lobe. Now s/p\n right hepatic lobectomy, CCY, RNY hepaticojejunostomy, portal vein\n thrombectomy (had PVE preop, also embolic event intraop).\n Intraop fluids: IVF 9000ml, RBC 9u, FFP 1u, albumin 1250, hespan 1000,\n uop 1100 , EBL 5000 ml\n Chief complaint:\n PMHx:\n PMH:HTN, metastatic ocular melanoma\n .\n PSH:C-section ', L cataract, phtoablation x 2 melnoma eye, s/p portal\n vein embolization \n Current medications:\n standing: famotidine, SQH\n prn: tylenol, morphine, zofran, brimonidine gtt, compazine,\n cyclopentolate gtt\n scale: RISS\n 24 Hour Events:\n : extubated in AM. Received 1 unit cryo, then total 3 units PRBC in\n PM for hct drop (26->21 w/o increased JP drainage). JP hct <2 x 2.\n Leaked trop (?demand ischemia), given 2 doses lopressor, per no\n BB and stopped. RUQ US x2 --> nl vasculature, no large fluid\n collection. Overnight w/ some increase in JP drainage. Overnight with\n more agitation, AAOx2-3, question of early hepatic encephalopathy,\n primary team aware.\n Post operative day:\n POD#2 - Exp lap, Right hepatic trisegmentectomy.\n cholecystectomy. Intra-op ultrasound\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Gentamicin\n Unknown;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:33 PM\n Heparin Sodium (Prophylaxis) - 10:33 PM\n Morphine Sulfate - 02:09 AM\n Other medications:\n Flowsheet Data as of 05:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 35.8\nC (96.4\n HR: 112 (74 - 112) bpm\n BP: 144/84(112) {115/62(73) - 154/99(112)} mmHg\n RR: 19 (19 - 30) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 64 Inch\n CVP: 11 (2 - 12) mmHg\n Total In:\n 4,158 mL\n 52 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,385 mL\n 52 mL\n Blood products:\n 1,773 mL\n Total out:\n 2,104 mL\n 511 mL\n Urine:\n 1,124 mL\n 291 mL\n NG:\n 50 mL\n Stool:\n Drains:\n 930 mL\n 220 mL\n Balance:\n 2,054 mL\n -459 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 446 (446 - 446) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 11 cmH2O\n SPO2: 96%\n ABG: 7.43/41/102/30/2\n Ve: 7.8 L/min\n PaO2 / FiO2: 102\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL, periorbital edema\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, obese habitus\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3, x 2), Follows simple\n commands, Moves all extremities\n Labs / Radiology\n 125 K/uL\n 10.1 g/dL\n 158 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 107 mEq/L\n 142 mEq/L\n 27.4 %\n 12.8 K/uL\n [image002.jpg]\n 03:06 AM\n 05:54 AM\n 08:59 AM\n 09:05 AM\n 10:33 AM\n 02:56 PM\n 03:25 PM\n 06:01 PM\n 07:38 PM\n 01:13 AM\n WBC\n 9.0\n 10.5\n 12.8\n Hct\n 20.7\n 21.1\n 25.0\n 27.4\n Plt\n 118\n 117\n 125\n Creatinine\n 1.4\n 1.2\n 1.0\n Troponin T\n 0.15\n 0.13\n TCO2\n 28\n 25\n 29\n 27\n 28\n Glucose\n 145\n 142\n 158\n Other labs: PT / PTT / INR:20.7/51.7/2.0, CK / CK-MB / Troponin\n T:8346/42/0.13, ALT / AST:2826/2412, Alk-Phos / T bili:109/4.2,\n Fibrinogen:202 mg/dL, Lactic Acid:4.3 mmol/L, Albumin:2.9 g/dL, Ca:7.9\n mg/dL, Mg:1.8 mg/dL, PO4:2.6 mg/dL\n Imaging: RUQ US: Normal left lobe vasculature, with no large fluid\n collection at site of right hepatic lobectomy. No significant change\n since earlier same day.\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ANEMIA, OTHER, .H/O\n LOBECTOMY OR WEDGE RESECTION\n Assessment and Plan: 42-year-old female s/p 42F s/p right hepatic\n lobectomy, CCY, RNY hepaticojejunostomy, portal vein thrombectomy\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, - AAOx3 though w/\n some agitation early this AM, consider early signs of encephalopathy.\n - minimize sedatives and analgesia for now.\n - consider checking ammonia level.\n Cardiovascular: - demand ischemia w/ troponin leak in setting of\n postop, acute blood loss, and tachycardia - no BB per surgery, to\n monitor.\n - BP stable\n Pulmonary: IS, no active issues\n Gastrointestinal / Abdomen: s/p right triseg / CCT / RNY\n hepaticojejunostomy / portal vein thrombectomy\n - monitor LFTs & coags daily\n - Famotidine\n - NPO for now\n Nutrition: NPO\n Renal: Foley, Adequate UO, - oliguria, low CVP - improved UOP after\n albumin and lasix x 1, then with somewhat decreased UOP during the day.\n To monitor. Cr trending down.\n Hematology: - postop anemia - monitor hct closely, JP hct <2 and RUQ\n U/S w/o obvious large fluid collection, s/p 3 units PRBC on .\n Endocrine: RISS\n Infectious Disease: - complete periop course of unasyn\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), biliary\n drain, right CVL, a-line\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Transplant\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress:\n Insufficiency / Post-op), Liver failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:00 PM\n Triple Introducer - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Family meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2168-03-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 663845,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n 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 / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: RSBI=60; currently on cpap and appears comfortable.\n Plan is to extubate this morning.\n"
},
{
"category": "Nursing",
"chartdate": "2168-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 663951,
"text": "Anemia, other\n Assessment:\n Hct 20.7 (down from 28.2). INR 2.1 (stable). Fibrinogen 83\n Action:\n Discussed with transplant and sicu team.Received 1 unit cryo for\n fibrinogen. 2 units prbc for hct, and 1 unit ffp for inr in present of\n hct drop. JP drainage sent for HCT.\n Response:\n Repeat fibrinogen 206, repeat hct and INR pending. JP hct pending.\n Plan:\n Monitor hct and coags, monitor jp output.\n .H/O lobectomy or wedge resection\n Assessment:\n Pt mechanically ventilated s/p liver resection.\n Action:\n Weaned to cpap 0/5 with good abg. Extubated. Weaned to nasal cannula\n 2 liters. I/s and coughing/deep breathing encouraged.\n Response:\n Tolerating extubation well, 02 sat 99-100% on 2 liters n.c., resp rate\n 20\ns. LS clear and diminished.\n Plan:\n Continue to monitor resp status, encourage coughing and deep breathing,\n encourage i/s.\n"
},
{
"category": "Nursing",
"chartdate": "2168-03-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 664152,
"text": "Pt is a 42 y/o female who underwent proton beam therapy for an ocular\n melanoma in ; recurrence in\n05 also treated with proton beam\n radiation. CT in demonstrated 4 cm mass in right lobe of liver and\n second mass in medial segment of the left lobe. underwent right\n hepatic lobectomy, CCY, RNY hepaticojejunostomy and portal vein\n thrombectomy (had PVE preop, also embolic event intraop).\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reported pain, constant/aching near surgical site,\n Action:\n repositioned, IV Morphine given PRN\n Response:\n Pt resting comfortably following pain meds, reporting pain \n Plan:\n Continue to monitor for pain and intervene as needed\n .H/O lobectomy resection\n Assessment:\n Medial & Lateral JP drains & T-tube in place w/ c/d/I dressing,\n surgical incision c/d with steri-strips in place, post-op INR 2.2, LFTs\n bumped.\n Action:\n Stripped JPs q8hrs, both w/ serosanguinous drainage, T-tube draining\n bilious fluid, Pt received 2 units FFP & 1U Cryo this ICU stay\n Response:\n JPs & t-tube patent, Pt\ns INR currently 1.7; LFTs trending downwards\n but still elevated.\n Plan:\n Continue to monitor, continue to strip drains q8hrs, continue to\n monitor surgical sites & maintain C/D/I dressing; continue to trend\n LFTs.\n Anemia, other\n Assessment:\n Intra-op EBL of 5L, Hct decreased 8 points post-op.\n Action:\n Pt received 3 U PRBCs Saturday, 1 unit PRBCs Sunday and 2 U PRBCs\n overnight into .\n Response:\n Hct has been above 30 last three checks; Hct currently 31.8\n Plan:\n Continue to monitor Hct and s/s bleeding.\n Post-op troponin leak\n Assessment:\n Troponin level 0.15 on AM labs, Team is aware & feels related to\n demand ischemia in the setting of post-op anemia, BP\ns 120-170s/60-80s\n Action:\n Monitored troponin levels, monitored EKGs, Transplant team doesn\nt want\n beta-blockade due to forward flow interference in setting of newly\n resected liver.\n Response:\n ST depression in V6 & Lead II\n appears to be improving per SICU\n Resident; Troponin level 0.13, BP lowers with Morphine\n Plan:\n Continue serial EKGs, cont to monitor Troponin level, continue without\n beta blockers\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n METASTASIS OCCULAR MELANOMA TO LIVER/SDA\n Code status:\n Full code\n Height:\n 64 Inch\n Admission weight:\n 115.9 kg\n Daily weight:\n 114.3 kg\n Allergies/Reactions:\n Sulfa (Sulfonamide Antibiotics)\n Rash;\n Gentamicin\n Unknown;\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: Portal Vein Embolization \n Cataract Left eye\n Kidney Stone obesity\n Intra ocular melanoma , recurrance in \n - lesion in liver\n Surgery / Procedure and date: (11 hr case-EBL 5000) R hepatic\n lobectomy, cholecystectomy.\n Roux En Y, hepatojejunostomy.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:146\n D:76\n Temperature:\n 99.6\n Arterial BP:\n S:116\n D:103\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 1,654 mL\n 24h total out:\n 1,510 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 02:34 PM\n Potassium:\n 3.5 mEq/L\n 02:34 PM\n Chloride:\n 108 mEq/L\n 02:34 PM\n CO2:\n 25 mEq/L\n 02:34 PM\n BUN:\n 40 mg/dL\n 02:34 PM\n Creatinine:\n 0.7 mg/dL\n 02:34 PM\n Glucose:\n 179 mg/dL\n 02:34 PM\n Hematocrit:\n 31.8 %\n 02:34 PM\n Finger Stick Glucose:\n 217\n 04:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 10\n Date & time of Transfer: 12:00 AM\n"
}
] |
3,523 | 160,029 | The patient was admitted on . On he underwent an uncomplicated coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending coronary artery, reversed saphenous vein graft from the aorta to the right posterior descending coronary artery, reverse saphenous vein graft from the aorta to the obtuse marginal coronary artery. The patient tolerated the procedure well and was transferred to the cardiothoracic Intensive Care Unit intubated and in stable condition. On postoperative day #1 a Neo-Synephrine drip was started and the Nitroglycerin drip was discontinued. The patient spiked a fever to 101.7. Sputum cultures were sent. He was A-paced at a rate of 88. Over the course of the day he was weaned off the ventilator and extubated. He was also weaned off of all of his drips, his pacer was subsequently turned off and his Swan Ganz catheter was pulled back to a position to monitor his central venous pressure. On postoperative day #2 the patient's fever had spiked overnight again to 101.7 and he was subsequently started on a course of Levofloxacin. The patient was requiring nebulizer treatments and inhalers to manage his COPD. As his condition was stable, the patient was transferred to the floor on postoperative day #2. On the floor he continued to spike fevers, although his white count was trending downwards. On postoperative day #3 his chest tube output had decreased to about 100 cc over the course of the prior day and it was subsequently removed. He was seen by the respiratory service which administered his nebulizers and they felt that he was no longer in need of neb treatment and he was switched to MDI inhalers on postoperative day #3. At that time his incentive spirometer was 1250 sustained. His Lasix was increased to 40 mg po tid, his Foley and central lines were removed and the patient was out of bed and ambulating. Chest x-ray the day before had demonstrated a left lower lobe consolidation with the sputum cultures growing out hemophilus so it was thought that the patient was on adequate antibiotic treatment with the Levaquin. On postoperative day #4 the patient's fever curve continued to decline and his oxygen saturation continued to improve. As the patient's pneumonia seemed to be improving and he was stable from a cardiac standpoint, the patient was discharged to a rehab facility in good and stable condition with plans to continue the Levaquin for another 8 days. | GOOD C.O'S, SWAN PULLED BACK TO CVP. WHEEZES, ALBUTEROL NEBS. ABG'S BORDERLINE BUT PATIENT EXTUBATED AT 1435 AFTER BEING AMBUED, LAVAGED AND SUCTIONED. STARTED BACK ON HIS SEREVENT AND FLOVENT INHALERS. GOOD PULSES IN FEET.PLAN EXTUBATE WHEN ABLE WEAN NEO OFF. : UPPER CHEST WITH EXP. TEMP. ABG SHOWING PAO2 ONLY OF ~107, CT TEAM AWARE AWAITING CXRAY, INHALERS GIVEN, BS VERY DIMINISHED THRU-OUT. EARLY AM SPUTUM FOR C/S SENT BY STAFF, PT RECULTURED, FROM CENTRAL LINE AND URINE FOR C/S SENT. PT AND REMAINED DOWN UNTIL 0400 WHEN STARTING TO WEAN PROPOFOL. GIVEN Q4HRS. PT ON CARAFATE OVERNIGHT UNTIL EXTUBATION. SHIFT UPDATE.PT. GTT'S ARE ALTERNATING BETWEEN NEO/NITRO. PT AWOKE MUCH CALMER PROPOFOL OFF. R IJ SWAN DC'D, CORDIS LEAKING AND THAT WAS PULLED. NEEDS AGGRESIVE PULMONARY TOILET. DRAINAGE DEPENDING ON POSITIONC/V: PT REMAINS WITH UNDERLYING RHYTHM 50-60'S SINUS. FOLLOWING CUFF PRESSURES.GI: TOLERATING WATER PO. CT'S REMAIN IN, PLAN IS FOR THEM TO BE PULLED TODAY. with SIMV. ALERT AND ORIENTED X3.RESP. AUDIBLE WHEEZES WITH EXERTION. COPD History high pips. PT. SPOKE WITH SON- UPDATE GIVEN. GLUCOSES COVERED BY SLIDING SCALE.GU: STARTED ON LASIX IVP WITH GOOD DIURESIS.PAIN: MEDICATED WITH TORADOL AND MSO4 FOR INCISIONAL DISCOMFORT WITH EFFECT.MOBILITY: TURNED Q2HRS. O2 SATS 92% ABG SENT PT HAS HX OF COPD AND SLEEP APNEA. PT TO START ON LEVOQUIN 500MG IV QD X 7 DAYS, HAS ID APPROVAL.PATIENT AWAKE, APPEARS ALERT, FOLLOWS COMMANDS. UP TO 100.9, CULTURED ON DAYS. COUGHING AND RAISING WELL. NEURO: PT SEDATED OVERNIGHT ON PROPOFOL. WILL REACCESS NEED AND ABILITY TO GIVE DIURETICS.FAMILY IN AND MUTIPLE CALLS FROM OTHER FAMILY MEMBERS. DENIES PAIN, GOOD CONTROL WITH TORADOL. Plan to extubate when awake and alert. CHECK LABS IN AM. GOOD CO/CI.GI: OGT DRAINING LARGE AMOUNTS OF BILIOUS DRAINAGE. BP REQUIRING NEO TO MAINTAIN MAP>65. REQUIRE REGLAN.GU: URINE OUTPUTS GOOD.SKIN: INCISIONS INTACT NO DRAINAGE. DENIES NAUSEA. SUCTIONED FOR THICK TAN SECRETIONS, MULTIPLE TIMES PATIENT WAS AMBUED LAVAGED AND SUCTIONED. URINE OUTPUT 20+ BUT UP TILL EXTUBATION WAS ON IV NEO TO KEEP SB/P ^. PT FOLLOWING COMMANDS AND NODDING HEAD TO QUESTIONS.RESP: VENT INITIALLY ON PCV ON ARRIVAL FROM OR CHANGED TO IMV WITH GOOD ABG"S FIO2 WEANED TO 50% AND PEEP DOWN TO 7.5. WITH ASSIST.PLAN: TO GET OOB TO CHAIR IN AM. PACER ON AN ADEMAND OF 60,SENSING ONLY, NSR 70'S WITH A RARE PAC. PATIENT ORIENTED X 3, COOPERATIVE AND APPRECIATIVE.CS CLEAR, DIMINISHED IN BASES, SECRETIONS AS ABOVE, WILL ENCOURAGE TO COUGH AND DEEP BREATH.GLUCOSES HAVE BEEN ^, TX AND WILL CONTINUE TO MONITOR AND TX, SEE FLOW SHEET.PATIENT DENIES ANY PAIN, IS ON TORADOL 15 MG IV Q 6.CT'S PATENT FOR MODERATE TO SLOWING DRAINAGE. CHEST TUBES DRAINING 30-100CC/HR OF SANG. resp noterefer flow sheet patient on PCV/CMV. PATIENT STILL HAS HIS RIGHT AND LEFT ANTECUBITAL IN PLACE. MONITOR HEMODYNAMICS/ PULMONARY TOILET. OCCASIONAL APACE SINCE HE'S BEEN UP IN THE CHAIR. CONTINUES OF FM 50% WITH SATS ~95%.CV: TEMP. SEDATED WITH PROPOFOL AND SOFT WRIST RESTRAINTS APPLIED. NEURO. OFF ALL DRIPS. OOB TO CHAIR WITH 2 ASSISTS, TOL. IN ON THE DECLINE. WELL. ARRIVING FROM OR AT ~1815PM. C/O A "ZAPPING" FEELING NEAR HIS ATRIAL PW SITE, MA DECREASED AND THE FEELING HAS ALSO SUBSIDED. IS ON THE FAST TRACK. : INTACT. PIP UP TO 50-60'S. PATIENT HAS BEEN OOB IN CHAIR PRIOR TO MY ARRIVAL, APPEARS COMFORTABLE, DENIES HAVING PAIN AT THIS TIME. ATE BREAKFAST AND TOLERATED WELL, STATES THAT HE FEELS RUMBLING IN HIS STOMACH. DIFFICULT TO VENT. PT SUCTIONED FOR COPIOUS AMOUNTS OF CREAMY YELLOW TAN SECRETIONS. CS WHEEZY AND DIMINISHED IN BASES, STRONG PRODUCTIVE COUGH, C/R THICK YELLOW (USES TONSIL TIP).USES FACE MASK AT 50%, WHEN OFF O2 SAT DROPS TO 88%. UPON ARRIVAL, VENT CHANGED TO AC WITH PRESSURE CONTROL VENT SET AT 35. CONGESTED COUGH AND RAISING THICK TAN/YELLOW SECRETIONS. GLUCOSE AT 1100 WAS TX WITH 9 UNITS IV INSULIN, WILL NEED TO BE FOLLOWED WITHIN 4 HOURS. PLACED ON FACE MASK AT 50%, O2 SAT 90%. ALINE OUT DURING BED BATH. PT PRESENTLY ON CPAP WITH 15 IPS WITH GOOD TV IN THE 500'S. PLEASANT MAN. PATIENT HAS NO HX OF BEING A DIABETIC, NEED WORKUP. | 7 | [
{
"category": "Nursing/other",
"chartdate": "2171-10-27 00:00:00.000",
"description": "Report",
"row_id": 1307995,
"text": "NEURO.: INTACT. PLEASANT MAN. ALERT AND ORIENTED X3.\n\nRESP.: UPPER CHEST WITH EXP. WHEEZES, ALBUTEROL NEBS. GIVEN Q4HRS. STARTED BACK ON HIS SEREVENT AND FLOVENT INHALERS. CONGESTED COUGH AND RAISING THICK TAN/YELLOW SECRETIONS. NEEDS AGGRESIVE PULMONARY TOILET. CONTINUES OF FM 50% WITH SATS ~95%.\n\nCV: TEMP. UP TO 100.9, CULTURED ON DAYS. TEMP. IN ON THE DECLINE. OFF ALL DRIPS. PACER ON AN ADEMAND OF 60,SENSING ONLY, NSR 70'S WITH A RARE PAC. GOOD C.O'S, SWAN PULLED BACK TO CVP. ALINE OUT DURING BED BATH. FOLLOWING CUFF PRESSURES.\n\nGI: TOLERATING WATER PO. DENIES NAUSEA. GLUCOSES COVERED BY SLIDING SCALE.\n\nGU: STARTED ON LASIX IVP WITH GOOD DIURESIS.\n\nPAIN: MEDICATED WITH TORADOL AND MSO4 FOR INCISIONAL DISCOMFORT WITH EFFECT.\n\nMOBILITY: TURNED Q2HRS. WITH ASSIST.\n\nPLAN: TO GET OOB TO CHAIR IN AM. MONITOR HEMODYNAMICS/ PULMONARY TOILET. CHECK LABS IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-25 00:00:00.000",
"description": "Report",
"row_id": 1307991,
"text": "resp note\nrefer flow sheet patient on PCV/CMV. COPD History high pips. with SIMV. Plan to extubate when awake and alert.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-27 00:00:00.000",
"description": "Report",
"row_id": 1307996,
"text": "DENIES PAIN, GOOD CONTROL WITH TORADOL. OOB TO CHAIR WITH 2 ASSISTS, TOL. WELL. AUDIBLE WHEEZES WITH EXERTION. COUGHING AND RAISING WELL. C/O A \"ZAPPING\" FEELING NEAR HIS ATRIAL PW SITE, MA DECREASED AND THE FEELING HAS ALSO SUBSIDED. OCCASIONAL APACE SINCE HE'S BEEN UP IN THE CHAIR. PT. IS ON THE FAST TRACK.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-27 00:00:00.000",
"description": "Report",
"row_id": 1307997,
"text": "PATIENT HAS BEEN OOB IN CHAIR PRIOR TO MY ARRIVAL, APPEARS COMFORTABLE, DENIES HAVING PAIN AT THIS TIME. CS WHEEZY AND DIMINISHED IN BASES, STRONG PRODUCTIVE COUGH, C/R THICK YELLOW (USES TONSIL TIP).USES FACE MASK AT 50%, WHEN OFF O2 SAT DROPS TO 88%. ATE BREAKFAST AND TOLERATED WELL, STATES THAT HE FEELS RUMBLING IN HIS STOMACH. R IJ SWAN DC'D, CORDIS LEAKING AND THAT WAS PULLED. PATIENT STILL HAS HIS RIGHT AND LEFT ANTECUBITAL IN PLACE. GLUCOSE AT 1100 WAS TX WITH 9 UNITS IV INSULIN, WILL NEED TO BE FOLLOWED WITHIN 4 HOURS. PATIENT HAS NO HX OF BEING A DIABETIC, NEED WORKUP. CT'S REMAIN IN, PLAN IS FOR THEM TO BE PULLED TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-25 00:00:00.000",
"description": "Report",
"row_id": 1307992,
"text": "SHIFT UPDATE.\nPT. ARRIVING FROM OR AT ~1815PM. SEDATED WITH PROPOFOL AND SOFT WRIST RESTRAINTS APPLIED. GTT'S ARE ALTERNATING BETWEEN NEO/NITRO. DIFFICULT TO VENT. UPON ARRIVAL, VENT CHANGED TO AC WITH PRESSURE CONTROL VENT SET AT 35. ABG SHOWING PAO2 ONLY OF ~107, CT TEAM AWARE AWAITING CXRAY, INHALERS GIVEN, BS VERY DIMINISHED THRU-OUT. SPOKE WITH SON- UPDATE GIVEN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-26 00:00:00.000",
"description": "Report",
"row_id": 1307993,
"text": "NEURO: PT SEDATED OVERNIGHT ON PROPOFOL. ATTEMPT TO WEAN OFF LAST EVENING BUT PT THRASHING IN BED MOVING ALL EXTREMITIES AND NOT FOLLOWING COMMANDS. PIP UP TO 50-60'S. PT AND REMAINED DOWN UNTIL 0400 WHEN STARTING TO WEAN PROPOFOL. PT AWOKE MUCH CALMER PROPOFOL OFF. PT FOLLOWING COMMANDS AND NODDING HEAD TO QUESTIONS.\nRESP: VENT INITIALLY ON PCV ON ARRIVAL FROM OR CHANGED TO IMV WITH GOOD ABG\"S FIO2 WEANED TO 50% AND PEEP DOWN TO 7.5. PT PRESENTLY ON CPAP WITH 15 IPS WITH GOOD TV IN THE 500'S. O2 SATS 92% ABG SENT PT HAS HX OF COPD AND SLEEP APNEA. PT SUCTIONED FOR COPIOUS AMOUNTS OF CREAMY YELLOW TAN SECRETIONS. CHEST TUBES DRAINING 30-100CC/HR OF SANG. DRAINAGE DEPENDING ON POSITION\nC/V: PT REMAINS WITH UNDERLYING RHYTHM 50-60'S SINUS. BP REQUIRING NEO TO MAINTAIN MAP>65. GOOD CO/CI.\nGI: OGT DRAINING LARGE AMOUNTS OF BILIOUS DRAINAGE. PT ON CARAFATE OVERNIGHT UNTIL EXTUBATION. REQUIRE REGLAN.\nGU: URINE OUTPUTS GOOD.\nSKIN: INCISIONS INTACT NO DRAINAGE. GOOD PULSES IN FEET.\nPLAN EXTUBATE WHEN ABLE WEAN NEO OFF.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-26 00:00:00.000",
"description": "Report",
"row_id": 1307994,
"text": "EARLY AM SPUTUM FOR C/S SENT BY STAFF, PT RECULTURED, FROM CENTRAL LINE AND URINE FOR C/S SENT. PT TO START ON LEVOQUIN 500MG IV QD X 7 DAYS, HAS ID APPROVAL.\nPATIENT AWAKE, APPEARS ALERT, FOLLOWS COMMANDS. SUCTIONED FOR THICK TAN SECRETIONS, MULTIPLE TIMES PATIENT WAS AMBUED LAVAGED AND SUCTIONED. ABG'S BORDERLINE BUT PATIENT EXTUBATED AT 1435 AFTER BEING AMBUED, LAVAGED AND SUCTIONED. PLACED ON FACE MASK AT 50%, O2 SAT 90%. PATIENT ORIENTED X 3, COOPERATIVE AND APPRECIATIVE.\nCS CLEAR, DIMINISHED IN BASES, SECRETIONS AS ABOVE, WILL ENCOURAGE TO COUGH AND DEEP BREATH.\nGLUCOSES HAVE BEEN ^, TX AND WILL CONTINUE TO MONITOR AND TX, SEE FLOW SHEET.\nPATIENT DENIES ANY PAIN, IS ON TORADOL 15 MG IV Q 6.\nCT'S PATENT FOR MODERATE TO SLOWING DRAINAGE. URINE OUTPUT 20+ BUT UP TILL EXTUBATION WAS ON IV NEO TO KEEP SB/P ^. WILL REACCESS NEED AND ABILITY TO GIVE DIURETICS.\nFAMILY IN AND MUTIPLE CALLS FROM OTHER FAMILY MEMBERS.\n"
}
] |
24,129 | 169,004 | 1. Right thigh hematoma. The patient initially presented to an outside hospital (OSH) on with several days of vomiting (but had continued to take her coumadin) and this is the likely etiology of her supratherapeutic INR. This was her second admission recently for bleed while supratherapeutic on her coumadin. The day after her admission to the OSH, she complained of right thigh pain and was found to have a large hematoma. A CT done there (and her admission CT on ) showed no retroperitoneal bleed, but showed two hematomas in the right thigh, one in the vastus medialis muscle and one in the medial soft tissues; there was also a resolving hematoma in her left buttock from a previous admission. Objectively, while on the medicine service (starting on ) her right thigh hematomas appeared stable, and the patient was neurovascularly intact distally. The thigh was very painful to the patient initially but once her pain medications were switched she was comfortable. On , the patient underwent a right sided LENI to ensure that there was no DVT in that extremity complicating the picture. This study was negative for DVT and showed interval stability of the hematomas when compared to the admission CT. She was discharged home with her hematoma stable and her pain well controlled. 2. Coagulopathy and h/o PE. The patient had a DVT/PE last while therapeutic on coumadin (2.5) and on lovanox. She had an IVC filter placed and has been on coumadin since that time. Partial hypercoagulability workup done was negative. She has had two bleeds while supratherapeutic in the past two months. This time she was given 15g of VitK and her INR became subtherapeutic, and her coumadin was held. Hematology was consulted regarding her anticoagulation and suggested at least two weeks off of coumadin. Dr. in the clinic felt that her IVC filter should be kept in and that she should either be taken off of anticoagulation altogether, or that anticoagulation with lovanox was a possibility (though expensive). He did not feel that he needed to see the patient in follow up. During hospitalization the patient had pneumoboots in place and worked with physical therapy to increase her ambulation and physical therapy felt that she was capable of home without PT services. Her primary care physician was notified of the hematology recommendations. 3. Anemia. While the patient was hospitalized her HCT remained volatile in the high 20s. However, her CT did not show evidence of continued bleeding into her thigh. While she was in the ICU she was premedicated and transfused 2 units with an appropriate response in her hematocrit from 25.8 to 27.9. On transfer to the floor her HCT was 27.9. On the floor her hematocrit ranged from 25-29, and was followed q8 hours. She did not get transfused. On discharge her hematocrit was 27. 4. Respiratory Distress. In the context of FFP transfusion at the OSH, the patient desatted to the 80s and was intubated. She was given benedryl and solumedrol for presumed transfusion reaction and on arrival at was stable. She was extubated the same day without difficulty. Solumedrol was dc'd on transfer to floor. She was premedicated with benadryl and Tylenol before blood products were given during this admission (only needed in unit). On a left subclavian line was placed, afterwards the patient was noted to have small PTX on CXR. Her oxygen saturation was stable, and she received serial CXRs to follow PTX, which showed stability/resolution. During hospitalization she was continued on combivent, advair as per home COPD regimen. 5. Blood pressure. In the context of the presumed transfusion reaction, the patient's SBP went into the 70s at OSH. Her BP after this episdode remained stable in the 100-110/60-70s. Random a.m. cortisols were performed to exclude the possibility of adrenal insufficiency given chronic steroid therapy. Her outpatient beta blocker was held, and her blood pressures remained within the normal range. Over , the patient's BP rose into the 130s/90s. She was restarted on Metoprolol 12.5bid. She was discharged on 12.5mg metoprolol . 6. Altered mental status: On transfer to the floor, the patient had a great deal of difficulty concentrating, and though arousable seemed sedated during examination. On reviewing her medications, she was given two doses of fentanyl that morning, one right before transfer from ICU. This was thought to explain her sedation and confusion. Her trazodone was nevertheless decreased to 50bid, and her valium discontinued. Her mental status cleared over the next several hours and she remained lucid throughout her hospitalization. Her trazodone was increased to 50qAm and 100qPM and she was discharged on this regimen. 7. Hyponatremia. Her Na was found to be 129 at OSH. After transfer to , her Na was followed closely and improved, remaining in the normal range during her hospitalization. 8. CAD. On , the patient complained of chest pain and shortness of breath. Her vital signs were stable during this time and an EKG was done, showing some possible lateral ST depressions. Cardiac enzymes were cycled and were negative, 12 hours apart. The patient described this chest pain as similar to her anxiety. 9. F/E/N. The patient's oral intake was poor. She was s/p gastric bypass done for obesity done in ', complicated by an eating disorder resulting in NJ and ultimately J tube feedings. During a previous admission she removed her j tube, possibly while delirious. During this admission she tolerated an oral diet. Nutrition was consulted and worked with the patient to increase oral intake. 10. SLE. The patient was continued on her home regimen of prednisone 5mg qd. 11. UTI. The patient has a foley in place on transfer to the floor. It was discontinued and subsequently the patient complained of some urge incontinence. A U/A was sent which was +WBC and small leuk esterase. The U/A was repeated the following day and was negative, urine cultures were pending. The patient has multiple antibiotic allergies and was already being treated with keflex for her cellulitis . The patient was discharged with pyridium as needed, and had an appointment with her primary doctor the day after discharge to follow up on the urine culture and to begin treatment of her urinary symptoms if needed. 12. Hypothyroidism. The patient was continued on her home regimen of levothyroxine 75 mcg qd. 13. Pain control. On transfer, the patient's pain from her right thigh hematomas was significant. She was tried on vicodin 2 tab Q4 hours prn without relief of her symptoms. She asked for percocet instead and was tried on RTC percocet and ibuprofen 600 tid with better pain relief. She was discharged with ibuprofen and a one week supply of percocet until she follows up with her physician. 14. Access. The patient had a left subclavian line placed in the ICU and had a right periperhal IV as well. This infiltrated on and was removed. She subsequently developed redness and pus around the IV site, and was placed on Keflex for cellulitis. She was discharged with a 7 day course of Keflex. The IV nurse evaluated the patient and felt that her peripheral access was poor. Therefore, the patient had access through her central line during her hospitalization. The central line was removed on and the tip sent for culture. The culture was pending on discharge. 15. Prophylaxis. While hospitalized, the patient was on MRSA precautions, she was maintained on a PPI given poor oral intake and was kept on pneumoboots. Ambulation was encouraged. She was ambulatory with her walker on discharge. | There is a new tiny left apical pneumothorax. Small left pneumothorax after CVL placement. Tiny left apical pneumothorax. Stable appearance of the tiny left apical pneumothorax. CT OF THE ABDOMEN WITHOUT CONTRAST: There is dependent atelectasis of the lung bases. The pancreas is atrophied. Left hemidiaphragm is elevated. FINAL REPORT CHEST AP PORTABLE SINGLE VIEW. SLIGHT ECCHYMOSIS NOTED. CT OF THE PELVIS WITH AND WITHOUT CONTRAST: There is contrast within a dilated distal right ureter and within the urinary bladder, all receded from the prior study. Left ventricular hypertrophy byvoltage. Unchanged elevation of the left hemidiaphragm and gaseous distention of the colon. FINDINGS: The heart size is within normal limits. These hematomas are unchanged in transverse dimension when compared to a prior CT from . There is unchanged elevation of the left hemidiaphragm and gasous distention of the colon. The left hemidiaphragm is elevated. She was supratherapeutic on Coumadin. A tiny left apical pneumothorax is noted and is stable in size. Borderline short P-R interval isnon-specific and probably within normal limits. RESP: BS'S DIMINISHED. Resolving hematoma in the left buttock. OptEase IVC filter is again noted. Left subclavian CVL tip is at the distal SVC. FINDINGS: scale and color Doppler son examination of the right lower extremity venous system was performed. A subclavian line is seen in unchanged position. All these findings have normalized with the exception of the local linear densities which most likely represent some pleural scar formations. Dilated bowel in the left upper quadrant. Sinus rhythm. Sinus rhythm. Clinical correlation is suggested.Since the previous tracing of diffuse ST-T wave changes are seen.TRACING #1 Evalute for pneumothorax. r/o PTX FINAL REPORT INDICATION: Status post left subclavian line placement. CHEST PORTABLE: Comparison is made to a prior study of . TECHNIQUE: Initially a noncontrast scan was performed through the abdomen and pelvis. HEMATOMA SLIGHTLY INCREASED IN R INNER THIGH.-MARKED. CHEST AP: Cardiac, mediastinal and hilar contours are stable in appearance. AREA STILL SWOLLEN, BUT LESS SO ON RIGHT OUTER THIGH.GIVEN FENTYNL 100MCQS Q2HR FOR DISCOMFORT. There is evidence of normal compressibility, waveform, color flow, and augmentation within the right common femoral vein, superficial femoral vein, and popliteal vein. REPEAT HCT 27.TRANSFUSION CANCELLED.R THIGH EDEMATOUS AND MARKED RETROPERITONEAL BLEED? There is an IVC filter unchanged in position. Linear densities exist in the left mid lung field laterally probably related to the pleura. The IVC filter is again noted. ischemiaSince previous tracing, T wave inversions more pronounced There are dilated bowel loops in the left upper quadrant, not changed. HAS A SWOLLEN LEFT HIP SITE FROM A FX. Borderline short P-R interval is non-specific and probably withinnormal limits. Evaluate size of hematoma. Available for comparison is a previous portable chest examination dated . Left ventricular hypertrophy by voltage. Hematomas within anterior and medial right thigh. The new left subclavian central venous catheter tip is at the cavoatrial junction. Thoracotomy changes at the left mid ribs are again noted. At that time, significant cardiac enlargement existed and perivascular haze as well as bilateral pleural effusions were consistent with CHF. NPN 1900-0700ADMIT NOTE:RECIEVED PT 3 , INTUBATED ABLE TO COMMUNICATE NEEDS NON VERBALLY. RESUME COUMADIN ? USED INHALERS. Evaluate for DVT. The previously visualized large hematoma in the soft tissues of the left buttock has decreased in size and currently measures 6.2 x 4.5 cm. Continued elevation of left hemidiaphragm and dilation of the large bowel. A second fluid collection representing hematoma within the medial right thigh measures 4.5 x 1.9 x 5.3 cm. The patient has had a splenectomy with a small rounded soft tissue density seen in the left upper quadrant presumably a hypertrophied splenule. 2:47 AM CHEST (PORTABLE AP) Clip # Reason: evaluate line placement. Clinicalcorrelation is suggested. ST-T waveabnormalities are diffuse and non-specific. A hematoma is identified within the anterior right thigh measuring 6.9 x 2.3 x 3.8 cm. Osseous and soft tissue structures are otherwise unremarkable. due to left ventricular hypertrophyEarly transitionAnterolateral T wave inversions - ? IMPRESSION: 1. IMPRESSION: 1. The pelvic bowel loops are unremarkable. The upper bowel loops are unremarkable. Dilation of the large bowel is again noted. ST-T wave abnormalities are diffuse and non-specific. GIVEN 2GMS MG+ IVPB.NEURO: ALERT AND ORIENTATED. The left sixth rib has been partially resected. AFTER RSBI AND SPONTANIOUS BREATHING TRIAL PT WAS SUCCESSFULLY EXTUBATED TO 2 LITERS NC.INITIALLY HAD LOOSE COUGH , WAS ABLE TO SPEAK, NO DIFFACULTY SWALLOWING.PRESENTLY:NEURO: AXOX3, MAE.C/O LEG PAING W/ MOVEMENT. Sinus rhythmShort PR intervalLeft ventricular hypertrophy with ST-T wave changesQ waves in leads l, aVL - ? CHEST, AP PORTABLE RADIOGRAPH: The cardiac, mediastinal, and hilar contours are unremarkable. This may suggest a component of renal insufficiency. CT SCAN DONE AND VERIFIED THIS. (Over) 10:33 AM CT ABD W&W/O C; CT PELVIS W&W/O C Clip # CT 100CC NON IONIC CONTRAST Reason: evalaute for retroperitoneal hematoma, thigh hematoma Admitting Diagnosis: THIGH HEMATOMA; TRANSFUSION REACTION Field of view: 40 Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) IMPRESSION: 1. DENIES ABD PAIN OR TENDERNESS.RESP: LUNGS CLEAR , FINE CRACKLES AT BASES, MAINTAING SATS HIGH 90'S ON 2 LITERS NC.C/V: SR -ST NO VEA RECIEVED 250CC NSS BOLUS POST LINE PLACEMENT FOR MILD HYPOTENSION / TACHYCARDIA.RECIEVED 12 MG TOTAL OF VERSED FOR PROCEDURE.INTIAL HCT WAS 19, DRAWN OFF IV WAS DILUTIONAL. | 13 | [
{
"category": "Nursing/other",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 1576958,
"text": "NPN 1900-0700\n\nADMIT NOTE:\nRECIEVED PT 3 , INTUBATED ABLE TO COMMUNICATE NEEDS NON VERBALLY. VSS. HR 90-100'S BP 100'S OVER 60'S , MAINTAINING SATS IN HIGH 90'S. AFTER RSBI AND SPONTANIOUS BREATHING TRIAL PT WAS SUCCESSFULLY EXTUBATED TO 2 LITERS NC.INITIALLY HAD LOOSE COUGH , WAS ABLE TO SPEAK, NO DIFFACULTY SWALLOWING.\n\nPRESENTLY:\n\nNEURO: AXOX3, MAE.C/O LEG PAING W/ MOVEMENT. DENIES ABD PAIN OR TENDERNESS.\n\nRESP: LUNGS CLEAR , FINE CRACKLES AT BASES, MAINTAING SATS HIGH 90'S ON 2 LITERS NC.\n\nC/V: SR -ST NO VEA RECIEVED 250CC NSS BOLUS POST LINE PLACEMENT FOR MILD HYPOTENSION / TACHYCARDIA.RECIEVED 12 MG TOTAL OF VERSED FOR PROCEDURE.INTIAL HCT WAS 19, DRAWN OFF IV WAS DILUTIONAL. REPEAT HCT 27.TRANSFUSION CANCELLED.R THIGH EDEMATOUS AND MARKED RETROPERITONEAL BLEED??\n\nF/E/N: UO 50-80CC/HR, ABD SOFT NON TENDER, TOL ICE CHIPS.NO STOOL OVER NOC\n\nSKIN: URTICARA LIMITED TO ARMS AND LEGS, STATES THIS HAS BEEN PRESENT FOR . 3 DAYS RELATES IT TO LUPUS DISEASE.\n\nPLAN : REPEAT CT OF ABD PELVIS AND THIGH FOR EXTENT OF HEMATOMA,FOLLOW HCT TRANSFUSE PRN, KEEP INR < 1.5 ?? RESUME COUMADIN ??\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 1576959,
"text": "RESP: BS'S DIMINISHED. USED INHALERS. O2 SATS 94-98%. ON RA.\nGI: APPETITE IMPROVED.\nRENAL: ADEQUATE U/O'S. IV KVO.\nCV: GIVEN 1X NS BOLUS FOR HR IN 90'S THIS AM.\nENDOC; MG+ REPEAT 1.7. GIVEN 2GMS MG+ IVPB.\nNEURO: ALERT AND ORIENTATED. VERY . PT. HAS ANXIETY DISORDER, AND DISPLAYS HAND TREMORS WHEN NERVOUS.\nHEM: GIVEN 1U PC'S FOR HCT OF 24.5. REPEAT HCT SENT AT 14PM.\nCOAGS: INR 1.8. HEMATOMA SLIGHTLY INCREASED IN R INNER THIGH.-MARKED. SLIGHT ECCHYMOSIS NOTED. CT SCAN DONE AND VERIFIED THIS. AREA STILL SWOLLEN, BUT LESS SO ON RIGHT OUTER THIGH.\nGIVEN FENTYNL 100MCQS Q2HR FOR DISCOMFORT. PT. NORMALLY TAKES VICODEN AT HOME.\nPT. HAS A SWOLLEN LEFT HIP SITE FROM A FX. WHICH ISN'T NEW. MULTIPLE AREAS ON SKIN (RASH) FROM LUPUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 1576960,
"text": " pm npn\nRESP: pt on 2 l n/p rr~20-28 O2 sats 98-100% lungs clear , crackles @ base on inhalers. started on steroids.\n\nNEURO: pt A+Ox3 c/ right thight pain constantly, on a scale of () pt medicated with 125 mcg Fentanyl q 2 hrs with good affect - pt able to sleep in short naps.\n\nCV/FLUIDS: CVP~ bp drop in the 80's - pt given 500 cc NS bolus x 2, repeat Hct 25.1 pt given her 2nd unit PRBC (premedicated with Tylenol 650 mg, and 50 mg Benadryl po) infusing without incident. VSS\npedal pulses 3+, feet warm and dry. uo~30 cc/hr\n\nGI: pt on diet as tolerated, small frequent, decreased appetite, taking small bites of mac and cheese, taking in po's no stool\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-30 00:00:00.000",
"description": "Report",
"row_id": 1576961,
"text": "NPN 1900-0700\n\nNEURO: SLEPT THROUGHOUT MOST OF THE NIGHT. WOKE DURING 4 AM ASSESSMENT. STATED SHE HAD \"BAD \" LEG PAIN AND ANXIETY. 2 MG VALIUM AND FENTYNAL 100MCG IV W/ GOOD EFFECT.\n\nRESP:LCTA DIMINISHED AT BASES, MAINTAINING SATS @ 100% ON 2L NC.\n\nC/V: SR-ST NO VEA RECIEVED 2 UNITS PRBC BY EVENING NURSE. 27.9 .\nNO S/S ACTIVE BLEEDING .NO CHANGE IN R THIGH EDEMA OR COLOR.\n\nF/E/N: uo 50-100c hr,TOL REG DIET NO STOOL OVER NOC.\n\nPLAN: FOLLOW HCTS,TRANSFUSE AS NEEDED, MONITOR FOR S/S BLEEDING.\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-01 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 834954,
"text": " 1:14 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: RT LEG PAIN AND SWELLING. HX HEMATOMA\n Admitting Diagnosis: THIGH HEMATOMA; TRANSFUSION REACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with right thigh hematoma, larger today on clinical exam and\n more painful\n REASON FOR THIS EXAMINATION:\n r/o DVT, evaluate size of hematoma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old female with right thigh hematoma. Evaluate for DVT.\n Evaluate size of hematoma.\n\n FINDINGS: scale and color Doppler son examination of the right\n lower extremity venous system was performed. There is evidence of normal\n compressibility, waveform, color flow, and augmentation within the right\n common femoral vein, superficial femoral vein, and popliteal vein. No\n intraluminal thrombus is identified.\n\n A hematoma is identified within the anterior right thigh measuring 6.9 x 2.3 x\n 3.8 cm. A second fluid collection representing hematoma within the medial\n right thigh measures 4.5 x 1.9 x 5.3 cm. On the prior CT examination, the\n anterior fluid collection measures 4.8 x 4.5 cm in greatest transverse\n dimension. The medial fluid collection measured 3.6 x 4.0 cm in transverse\n dimension.\n\n IMPRESSION:\n 1. No evidence of DVT within the right lower extremity.\n 2. Hematomas within anterior and medial right thigh. These hematomas are\n unchanged in transverse dimension when compared to a prior CT from .\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 834480,
"text": " 10:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for pulmonary edema, other acute processees.\n Admitting Diagnosis: THIGH HEMATOMA; TRANSFUSION REACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with thigh hematoma, transfusion rxn.\n REASON FOR THIS EXAMINATION:\n Evaluate for pulmonary edema, other acute processees.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW.\n\n INDICATION: Thigh hematoma transfusions, evaluate for pulmonary edema.\n\n FINDINGS: The heart size is within normal limits. Thoracic aorta unremarkable\n and no mediastinal abnormalities are present.\n\n Linear densities exist in the left mid lung field laterally probably related\n to the pleura. The lateral pleural sinuses are free and there is no evidence\n of any other acute parenchymal abnormalities. Relatively high positioned\n diaphragm is related to gas distended large bowel loop. Available for\n comparison is a previous portable chest examination dated . At\n that time, significant cardiac enlargement existed and perivascular haze as\n well as bilateral pleural effusions were consistent with CHF. All these\n findings have normalized with the exception of the local linear densities\n which most likely represent some pleural scar formations. No evidence of\n pneumothorax.\n\n IMPRESSION: No evidence of acute CHF or infiltrates.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-30 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 834686,
"text": " 2:43 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for change in L apical PTX\n Admitting Diagnosis: THIGH HEMATOMA; TRANSFUSION REACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with h/o PE/DVT admitted with hypotension and hypoxia now\n with L apical PTX s/p L subclavian line placement.\n REASON FOR THIS EXAMINATION:\n evaluate for change in L apical PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 49 year old woman with history of PE and DVT admitted with\n hypotension and hypoxia, now with left apical pneumothorax following\n subclavian line placement. Evaluate for change.\n\n CHEST PORTABLE: Comparison is made to a prior study of . The heart is\n normal in size. The mediastinal and hilar contours are unremarkable. The\n pulmonary vasculature is normal. The lungs are clear. A tiny left apical\n pneumothorax is noted and is stable in size. The left hemidiaphragm is\n elevated. A subclavian line is seen in unchanged position. The left sixth\n rib has been partially resected.\n\n IMPRESSION: No change in comparison to the prior study. Stable appearance of\n the tiny left apical pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 834792,
"text": " 10:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf, r/o worsening ptx\n Admitting Diagnosis: THIGH HEMATOMA; TRANSFUSION REACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49F h/o PE/DVT/IVC filter p/w bleed into thigh, small ptx when L SC line\n placed, now with chest pain\n REASON FOR THIS EXAMINATION:\n r/o chf, r/o worsening ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 49-year-old woman with PE, DVT, and IVC filter. Small left\n pneumothorax after CVL placement. Now with worsening chest pain.\n\n COMPARISON: .\n\n CHEST AP: Cardiac, mediastinal and hilar contours are stable in appearance.\n Pulmonary vasculature is normal. The lungs are clear. There is no evidence of\n pneumothorax. Left hemidiaphragm is elevated. There are no pleural effusions.\n Dilation of the large bowel is again noted. Left subclavian CVL tip is at the\n distal SVC. OptEase IVC filter is again noted. Thoracotomy changes at the left\n mid ribs are again noted. Osseous and soft tissue structures are otherwise\n unremarkable.\n\n IMPRESSION: No pneumothorax or other acute cardiopulmonary process. Continued\n elevation of left hemidiaphragm and dilation of the large bowel.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 834487,
"text": " 2:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate line placement. r/o PTX\n Admitting Diagnosis: THIGH HEMATOMA; TRANSFUSION REACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with thigh hematoma, transfusion rxn. NOw s/p L subclavian\n line placement\n REASON FOR THIS EXAMINATION:\n evaluate line placement. r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post left subclavian line placement. Evalute for\n pneumothorax.\n\n Comparison is .\n\n CHEST, AP PORTABLE RADIOGRAPH: The cardiac, mediastinal, and hilar contours\n are unremarkable. The right lung is clear. There is a new tiny left apical\n pneumothorax. The new left subclavian central venous catheter tip is at the\n cavoatrial junction. There is unchanged elevation of the left hemidiaphragm\n and gasous distention of the colon. The IVC filter is again noted. The\n osseous structures are again remarkable for the thoracotomy changes in the\n left lung and bony fusion of the left ribs.\n\n IMPRESSION:\n 1. Tiny left apical pneumothorax.\n 2. Unchanged elevation of the left hemidiaphragm and gaseous distention of\n the colon.\n\n These findings were communicated with Dr. shortly after the\n study was performed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-29 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 834528,
"text": " 10:33 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: evalaute for retroperitoneal hematoma, thigh hematoma\n Admitting Diagnosis: THIGH HEMATOMA; TRANSFUSION REACTION\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with hematoma R thigh\n REASON FOR THIS EXAMINATION:\n evalaute for retroperitoneal hematoma, thigh hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old woman with a right thigh hematoma status post fall.\n She was supratherapeutic on Coumadin. Assess for size and active\n extravasation.\n\n COMPARISON: .\n\n TECHNIQUE: Initially a noncontrast scan was performed through the abdomen and\n pelvis. This was followed by a 40-second delayed scan through the pelvis.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: There is dependent atelectasis of the lung\n bases. The patient has had a splenectomy with a small rounded soft tissue\n density seen in the left upper quadrant presumably a hypertrophied splenule.\n This is not changed since the prior study. There is a large simple cyst in the\n lower pole of the right kidney. There is contrast within the renal collecting\n system on the right more so than the left. This was from a CT scan performed\n yesterday at an outside institution. The noncontrast images of the liver\n demonstrate no lesions. The pancreas is atrophied. There is streak artifact\n from a metallic object which is on the patient's skin obscuring the LUQ. The\n upper bowel loops are unremarkable. There is an IVC filter unchanged in\n position. There are dilated bowel loops in the left upper quadrant, not\n changed.\n\n CT OF THE PELVIS WITH AND WITHOUT CONTRAST: There is contrast within a dilated\n distal right ureter and within the urinary bladder, all receded from the prior\n study. The pelvic bowel loops are unremarkable. The urinary bladder is\n collapsed around a Foley.\n\n The previously visualized large hematoma in the soft tissues of the left\n buttock has decreased in size and currently measures 6.2 x 4.5 cm. There are\n two new large acute hemorrhages one of which within the vastus medialis muscle\n on the right. This expands the muscle and measures 4.6 x 3.7 cm in AP\n dimensions. The other large acute hematoma is seen in the soft tissues of the\n medial right thigh just inferior to the intramusclar hematoma and this one\n measures 3.6 x 5.0 cm. After the administration of contrast there is no\n evidence of active extravasation into either of these lesions. There is\n extensive subcutaneous edema/hemorrhage tracking between the muscles and into\n the soft tissues. There is no evidence of a retroperitoneal hematoma.\n\n Bone windows demonstrate no suspicious lytic or blastic lesions.\n (Over)\n\n 10:33 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: evalaute for retroperitoneal hematoma, thigh hematoma\n Admitting Diagnosis: THIGH HEMATOMA; TRANSFUSION REACTION\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Two acute hematomas within the right thigh, one within the medial soft\n tissue, the other within the vastus medialis muscle. There is no evidence of\n active extravasation into either of these.\n 2. Resolving hematoma in the left buttock.\n 3. Persistent contrast within the renal collecting system from a CT scan\n performed at an outside institution as well as contrast in the urinary\n bladder. This may suggest a component of renal insufficiency.\n 4. Dilated bowel in the left upper quadrant. This is not significantly changed\n compared to the prior study.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2112-08-31 00:00:00.000",
"description": "Report",
"row_id": 154541,
"text": "Sinus rhythm\nShort PR interval\nLeft ventricular hypertrophy with ST-T wave changes\nQ waves in leads l, aVL - ? due to left ventricular hypertrophy\nEarly transition\nAnterolateral T wave inversions - ? ischemia\nSince previous tracing, T wave inversions more pronounced\n\n"
},
{
"category": "ECG",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 154542,
"text": "Sinus rhythm. Borderline short P-R interval is non-specific and probably within\nnormal limits. Early precordial QRS transition. Left ventricular hypertrophy by\nvoltage. ST-T wave abnormalities are diffuse and non-specific. Clinical\ncorrelation is suggested. Since the previous tracing earlier this date no\nsignificant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 154543,
"text": "Lead VI was not obtained. Sinus rhythm. Borderline short P-R interval is\nnon-specific and probably within normal limits. Early precordial\nQRS transition. Left ventricular hypertrophy by voltage. ST-T wave\nabnormalities are diffuse and non-specific. Clinical correlation is suggested.\nSince the previous tracing of diffuse ST-T wave changes are seen.\nTRACING #1\n\n"
}
] |
32,160 | 157,094 | The patient is a 21 year old woman with DM I controlled with an insulin pump who was initially managed in the MICU for acute DKA with an AG of 21 after removing her insulin pump for 3-4 hours. She was then stabilized on her insulin pump and transferred to the medical floor where her blood sugar, and electrolytes were watched overnight before discharge with adjustments on her insulin pump. | PERL.CV: Remains tachy, although improved with rate 110-115. Lungs clear, Sats 100% on RA.GI/GU: NPPO, abd soft, non-distended, + BS. Cooperative.CV: ST with HR 100-110's. AP UPRIGHT CHEST: The cardiac, mediastinal and hilar contours are within normal limits. 10:57 PM CHEST (PORTABLE AP) Clip # Reason: cough? Hypoglycemic to 58 @ 1600; asymptomatic. Sinus tachycardiaShort P-R intervalST junctional depression is nonspecificRepolarization changes may be partly due to rateNo previous tracing available for comparison BP improved 100-115/ 60's. Mentates with low bp. NBP high 70's-110. Continuing Q hourly fingersticks until glucose is stablized. Voided in ED but has not voided yet since in micu.SKIN: no breakdown.ENDO: on insulin gtt at 2.9units/hr md-pt with own insulin gtt which is off.social: mother came down from to be with pt.PLAN: -cont insulin gtt and attempt to close gap -serial labs as ordered -transition to own insulin pump when appropriate -cont med regimen and icu supportive care The pulmonary vasculature is normal. Received 1L LR bolus, currently with LR @ 125cc/hr. No ectopy. No pain, no nauseau. Nursing Progress Note 1900-0700 hours:** full code** allergy: nkda** access: left hand piv, left FA pivPls see FHP /admit note for hx and presentationNEURO: A & O x3. OOB to toilet with steady gait. Incontinent large liquid stool x1 this shift.Endo: Insulin gtt off @ 1500. IMPRESSION: No radiographic evidence of pneumonia. No pleural effusion or pneumothorax is identified. MD ordered patient's home dose of Ativan 1mg PO daily.Resp: Lung sounds clear, SAT 97-99% on room air.GI: Tolerated diet for lunch. Initiated D5 1/2 NS with 20meq kcl at 250cc/hr but changed back to NS due to tachycardia.RESP: rr 20-32. No bm. The lungs are clear. COMPARISON: None. Gave juice, peanut butter and crackers with glucose to 86 @ 1600. Neuro: alert, oriented x3. FINAL REPORT INDICATION: 21-year-old female with cough and hyperglycemia. MEDICAL CONDITION: 21 year old woman with cough and hyperglycemia REASON FOR THIS EXAMINATION: cough? MD consulted to reveiw pump settings and make changes if needed. ? if caused by anxiety. Patient is managing her glucose with her insulin pump. Encouraged patient to order dinner.GU: Voiding clear yellow urine.Social: Mother remained at bedside this shift.Plan: Called out to floor, awaiting bed. | 4 | [
{
"category": "Radiology",
"chartdate": "2138-12-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 995361,
"text": " 10:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: cough?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old woman with cough and hyperglycemia\n REASON FOR THIS EXAMINATION:\n cough?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21-year-old female with cough and hyperglycemia.\n\n COMPARISON: None.\n\n AP UPRIGHT CHEST: The cardiac, mediastinal and hilar contours are within\n normal limits. The lungs are clear. No pleural effusion or pneumothorax is\n identified. The pulmonary vasculature is normal.\n\n IMPRESSION: No radiographic evidence of pneumonia.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2138-12-24 00:00:00.000",
"description": "Report",
"row_id": 1669926,
"text": "Nursing Progress Note 1900-0700 hours:\n** full code\n\n** allergy: nkda\n\n** access: left hand piv, left FA piv\n\nPls see FHP /admit note for hx and presentation\n\nNEURO: A & O x3. Cooperative.\n\nCV: ST with HR 100-110's. No ectopy. NBP high 70's-110. Mentates with low bp. Initiated D5 1/2 NS with 20meq kcl at 250cc/hr but changed back to NS due to tachycardia.\n\nRESP: rr 20-32. Lungs clear, Sats 100% on RA.\n\nGI/GU: NPPO, abd soft, non-distended, + BS. No bm. No pain, no nauseau. Voided in ED but has not voided yet since in micu.\n\nSKIN: no breakdown.\n\nENDO: on insulin gtt at 2.9units/hr md-pt with own insulin gtt which is off.\n\nsocial: mother came down from to be with pt.\n\nPLAN: -cont insulin gtt and attempt to close gap\n -serial labs as ordered\n -transition to own insulin pump when appropriate\n -cont med regimen and icu supportive care\n"
},
{
"category": "Nursing/other",
"chartdate": "2138-12-24 00:00:00.000",
"description": "Report",
"row_id": 1669927,
"text": "Neuro: alert, oriented x3. Sleeping on and off most of shift. OOB to toilet with steady gait. PERL.\n\nCV: Remains tachy, although improved with rate 110-115. BP improved 100-115/ 60's. Received 1L LR bolus, currently with LR @ 125cc/hr. ? if caused by anxiety. MD ordered patient's home dose of Ativan 1mg PO daily.\n\nResp: Lung sounds clear, SAT 97-99% on room air.\n\nGI: Tolerated diet for lunch. Incontinent large liquid stool x1 this shift.\n\nEndo: Insulin gtt off @ 1500. Patient is managing her glucose with her insulin pump. MD consulted to reveiw pump settings and make changes if needed. Hypoglycemic to 58 @ 1600; asymptomatic. Gave juice, peanut butter and crackers with glucose to 86 @ 1600. Encouraged patient to order dinner.\n\nGU: Voiding clear yellow urine.\n\nSocial: Mother remained at bedside this shift.\n\nPlan: Called out to floor, awaiting bed. Continuing Q hourly fingersticks until glucose is stablized.\n"
},
{
"category": "ECG",
"chartdate": "2138-12-23 00:00:00.000",
"description": "Report",
"row_id": 216105,
"text": "Sinus tachycardia\nShort P-R interval\nST junctional depression is nonspecific\nRepolarization changes may be partly due to rate\nNo previous tracing available for comparison\n\n"
}
] |
26,130 | 143,303 | He was admitted to and transferred to the TSICU for some respiratory distress. He had O2 sats in the low 80%. He responded well to a nonrebreather face mask. He was transfered back to the floor on . Thoracics: On , he went for a Left VATS with decortication. He had drained 1500cc of serous fluid. Pleural fluid cx - pansensitive Klebsiella. Post-operatively he did well from the VATS. He was followed by Thoracics for care of the CT.He had serial CXR to evaluate his effusion and the CT were sequentially removed. Apical anterior d/c'd , apical posterior d/c'd , basilar d/c'd . . Pain: He had a PCA for pai control after the VATS. He was using it appropriately and had good control. After his abdominal procedure: 1. Distal pancreatectomy with splenectomy. 2.. Peustow procedure. 3. Drainage of retroperitoneal/intra-abdominal abscess. 4. Feeding jejunostomy tube placement, he had an epidural Pt comfortable on APS 10 solution. No change. Pt comfortable on APS 10 soln at 6 cc/hr. No change. Plan for removal tomorrow. comfortable. ng tube still in place. on APS 10. will likely take out epidural epidural out. He was then switched to PO Percocet and had good pain control. | FINDINGS: Multiple left-sided chest tubes are unchanged in position. Again are seen three pleural tubes on the left side together with a right-sided subclavian line which are unchanged in position. Trace left and small right pleural effusions unchanged since . IMPRESSION: Tubes and lines unchanged except for extubation. Small amount of ascites, in keeping with recent surgery. Cont hyponatremic. IMPRESSION: Slight decrease in pleural effusions. INDICATION: Discontinuation of chest tubes. Chest tube which had previously been seen in the left apex has been removed. Visualized portion of the splenic vein appears patent. Contrast reaches the distal jejunum. Non-specific septal ST-T wave changes.Compared to the previous tracing of ventricular premature beats areabsent. Right internal jugular central venous catheter is unchanged. A small amount of contrast remains within the left anterior pleural cavity, likely related to prior surgery. A tiny amount of fluid within the left upper quadrant is consistent with recent surgery. REASON FOR THIS EXAMINATION: interval CXR FINAL REPORT PA AND LATERAL CHEST INDICATION: Left pleural effusion. left lungs sounds diminished > absent, right side coarse, diminished. Small left pleural effusion with loculated component laterally appears minimally decreased in size. Pleural thickening or loculated fluid remains in the left lower lateral chest. INDICATION: Status post VATS. The gallbladder appears normal. hypoactive bowel sounds. Two chest tubes remain in place in the lower left hemithorax. Unchanged position of multiple lines and tubes. Followed by Consult.A: pancreatitis w/ left pleural effusion. BS CTA right fields, course upper airwat, diminished left base. abd softly distended, tender to palpation. A tiny left pneumothorax smaller than on prior exam. lytes repleted as indicated.ENDO: BS covered with RiSS as indicated.ID: afebrile. IMPRESSION: Essentially stable appearances with no large pneumothorax identified. Cardiomediastinal contour is unchanged. using dilaudid PCA appropriately. Small right pleural effusion has also decreased. Persistent small amount of contrast within the left anterior pleural space, likely related to recent surgery. meropenum as ordered.SKIN: intactplan: cont. hep sq as orderedRESP: ABG good. Further clearing of left lung. Atelectasis in the lingula and left lower lobe is without change. Left chest tube and two intra-abdominal drains as positioned above. Surgical sutures along the distal tip are seen without adjacent fluid collection. Cont DM control, CIWA, prn dilaudid, lyte repletion. The tube is in unchanged position since prior exam, and a tiny left pleural effusion is stable. Biapical bullous emphysema is noted. Sinus tachycardia. Status post splenectomy and distal pancreatectomy, prominent tissue stranding in left upper quadrant, but no focal fluid collections or abscesses. The patient has been extubated. DM poorly cnontrolled. CT ABDOMEN WITH ORAL, WITHOUT AND WITH INTRAVENOUS CONTRAST: A left chest tube entering between the left seventh and eighth lateral ribs. IMPRESSION: No pneumothorax after removal of one of two chest tubes. The right costophrenic sulcus is now blunted consistent with a small effusion. Small nonhemorrhagic right pleural effusion layers posteriorly. FINDINGS: Compared with , the left chest tube has been removed. The tip of a right IJ central venous catheter terminates in the mid SVC. FINDINGS: Multiple left-sided chest tubes are unchanged. A nasogastric tube has been withdrawn. Moderate right pleural effusion. Allowing for differences in projection and technique, the hazy focal density projecting over the left lateral lower lung field is probably unchanged and probably pleural in location, as seen on the patient's recent chest CT. FINDINGS FOR CT OF THE ABDOMEN WITH AND WITHOUT CONTRAST: Limited imaging of the lung bases demonstrates a moderate right-sided pleural effusion, adjacent relaxation atelectasis. There is persistent left basilar opacity with a left effusion. There is limited imaging of two chest tubes within the left pleural space. IMPRESSION: Sizable left-sided pleural effusion, mild mediastinal shift towards the right. COMPARISON: CT chest dated . Three right-sided chest tubes are unchanged. Subcapsular fluid collection which may represent old subcapsular hematoma or pseudocyst. Right IJ central venous catheter is unchanged. Small hematoma above the spleen. HISTORY: Pancreatic pseudocyst and left effusion. Small apical pneumothorax is present. New evidence for small right pleural effusion. IMPRESSION: Small apical and basal components of left pneumothorax after decortication with decreased pleural effusion and re-expanding of the underlying lung. 7.4x3.7cm collection with rim enhancement lateral to the spleen and additional adjacent similar tiny foci most likely representing pseudocysts. REASON FOR THIS EXAMINATION: r/o pneumothorax FINAL REPORT PA AND LATERAL CHEST. A central venous catheter remains in place. One drainage tube appears to be below the left hemidiaphragm in this patient with known pancreatic pseudocyst. Left chest tubes are unchanged in standard positions. There is evidence of a left-sided pleural effusion, which obliterates the contour of the left diaphragm completely, blunts the left lateral pleural sinus and extends upwards along the left lateral wall resulting in a small pleural cap around the apex. Unchanged chest tubes. Persistent bilateral pleural effusions, left greater than right and left lower lobe atelectasis. Small area of contrast extravasation into the left anterior pleural cavity which most likely is related to recent surgery. Moderate left and small right layering pleural effusions are without change. FINAL REPORT EXAMINATION: CTA of the abdomen with and without contrast with reconstructions dated . A new right internal jugular double-lumen central venous catheter terminates at the cavoatrial junction. There may be a small residual right pleural effusion. There is persistent left retrocardiac consolidation. CHEST, SUPINE AP: The nasogastric tube terminates in the stomach. There is a small amount of pelvic ascites. Decreased small left pleural effusion, with improved aeration at the left base. | 23 | [
{
"category": "Radiology",
"chartdate": "2138-12-23 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 945309,
"text": " 10:58 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: PT WITH PICC LINE ONLY / NO IV ACCSESS POST LEAKING PSEUDOCYST ABLE TO TOLERAT PO'S WITH DISTENSION ? RESIDUAL FLUID\n Admitting Diagnosis: PANCREATITIS\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with chronic pancreatitis c/b leaking pseudocyst. s/p distal\n pancreatectomy, splenectomy\n REASON FOR THIS EXAMINATION:\n evaluate abdomen post-op for residual fluid collections\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with chronic pancreatitis complicated by leaking\n pseudocyst. Patient is now status post distal pancreatectomy and splenectomy.\n Evaluate for residual fluid collections.\n\n COMPARISON: CT abdomen and pelvis dated .\n\n TECHNIQUE: MDCT imaging of the abdomen was performed before and after the\n administration of 130 cc of intravenous Optiray. Coronal and sagittal\n reformatted images were obtained.\n\n CT ABDOMEN WITH ORAL, WITHOUT AND WITH INTRAVENOUS CONTRAST: A left chest\n tube entering between the left seventh and eighth lateral ribs. The tube is\n in unchanged position since prior exam, and a tiny left pleural effusion is\n stable. There is also a stable small right pleural effusion. A tiny left\n pneumothorax smaller than on prior exam.\n\n The patient is status post splenectomy and distal pancreatectomy. Two drains\n entering from the left lower quadrant terminate below the diaphragm, and\n anterior to the pancreatic body. A tiny amount of fluid within the left upper\n quadrant is consistent with recent surgery. There is no fluid collection or\n abscess identified. A small amount of contrast remains within the left\n anterior pleural cavity, likely related to prior surgery.\n\n The liver enhances normally. The gallbladder appears normal. The pancreas is\n atrophic with diffuse calcifications consistent with chronic pancreatitis.\n Surgical sutures along the distal tip are seen without adjacent fluid\n collection. No pseudocysts are identified. The adrenal glands and both\n kidneys are normal. Contrast reaches the distal jejunum. The imaged loops of\n large and small bowel are normal in caliber and contour. Small amount of free\n fluid is seen throughout the peritoneal cavity, while this is slightly\n increased since prior exam, it is consistent with recent surgery. There is no\n free air. Prominent vascular calcifications line the abdominal aorta and\n proximal mesenteric vessels. Clot within the distal SMV seen on prior exam is\n not clearly visualized on today's study due to the phase of contrast\n injection. Visualized portion of the splenic vein appears patent.\n\n CT PELVIS WITH ORAL, WITH INTRAVENOUS CONTRAST: The sigmoid, rectum,\n prostate, bladder are unremarkable. There is a small amount of intrapelvic\n free fluid. Prominent inguinal lymph nodes do not meet CT criteria for\n (Over)\n\n 10:58 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: PT WITH PICC LINE ONLY / NO IV ACCSESS POST LEAKING PSEUDOCYST ABLE TO TOLERAT PO'S WITH DISTENSION ? RESIDUAL FLUID\n Admitting Diagnosis: PANCREATITIS\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pathologic enlargement. There is no free air.\n\n BONE WINDOWS: Unremarkable.\n\n IMPRESSION:\n\n 1. Status post splenectomy and distal pancreatectomy, prominent tissue\n stranding in left upper quadrant, but no focal fluid collections or abscesses.\n\n 2. Persistent small amount of contrast within the left anterior pleural\n space, likely related to recent surgery.\n\n 3. Left chest tube and two intra-abdominal drains as positioned above.\n\n 4. Small amount of ascites, in keeping with recent surgery.\n\n 5. Trace left and small right pleural effusions unchanged since .\n\n 6. The previously noted thrombosis of the distal SMV is not clearly\n visualized on today's study, possibly related to the phase of contrast\n injection. The portal vein remains patent. The imaged portion of the splenic\n vein is also patent.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 945073,
"text": " 10:54 AM\n CHEST (PA & LAT) Clip # \n Reason: Interval change. Assess for pneumo and effusion\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with pancreatic pseudocyst draining into left pleura s/p VATS\n with decortication, now with 2 chest tubes d/c'd.\n REASON FOR THIS EXAMINATION:\n Interval change. Assess for pneumo and effusion\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST OF \n\n COMPARISON: .\n\n INDICATION: Discontinuation of chest tubes.\n\n Two chest tubes remain in place in the lower left hemithorax. Small left\n pleural effusion with loculated component laterally appears minimally\n decreased in size. Small right pleural effusion has also decreased.\n Atelectasis in the lingula and left lower lobe is without change. Biapical\n bullous emphysema is noted.\n\n IMPRESSION: Slight decrease in pleural effusions.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2138-12-09 00:00:00.000",
"description": "Report",
"row_id": 1602786,
"text": "7a-7p Admission Note\n\nPT is a 61 yo male from ; at hospital for pancreatitis flare, pt c/o L quadrant pain and L lower chest wall pain, pleural effusion found on LLL, thoracentesis performed and 900cc of drainage removed testing positive for amylase and lipase, sent to for GI team eval, sne to 9, Resp Trigger called due to low sats and dim breathsounds in bases, sent to ICU for further monitoring, possible intubation, probable CT on L.\n\nN: alert and oriented to person place time and situation, no neurological defecits noted.\n\nCV: ST decreasing from 130's to 110's, BP decreadsing from 160 sbp to 110's sbp, HTN and takes meds at home for HTN, PICC R and PIV L.\n\nResp: Sats 81% on arrival off O2 for 60 sec, nonrebreather mask at 15L with gradual increase in sats to 91%, repositioned pt on R side for more perfusion with good results and sats in high 90's, gradual decline in RR from 30's to 14; LLL absent breathsounds, RUL, RLL, LUL course, ABG sent, CXR with reaccumulation of fluid in LLL (viscous).\n\nGI: Pancreatitis with tender abdomen, hypoactive BS, last BM 2 days ago, no flatus, TTP R and L upper quadrants.\n\nGU: Foley with light yellow drainage.\n\nEndo: DM type II with oral hypoglycemics\n\nHeme: labs sent at 1830\n\nID: febrile at outside hospital, 99.6 on admission, antibiotics ordered, elev WBC, elevated amylase and lipase.\n\nAssesment: Acute resp distress, viscous fluid accumulation LLL, pancreatitis.\n\nPlan: Monitor and Assess as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2138-12-10 00:00:00.000",
"description": "Report",
"row_id": 1602787,
"text": "npn 1900-0730\nROS: see carevue for details\n\nNeuro: patient A&Ox3, pleasant & cooperative with care. c/o constant dull pain to abdomen, worsening with coughing, deep breathing & movement. using dilaudid PCA appropriately. mae, moves well in bed with minimal assistance.\n\nCV: ST 100-120s, BP stable. +pp. hep sq as ordered\n\nRESP: ABG good. O2 weaned from NRB to simple face mask at 4 liters. left lungs sounds diminished > absent, right side coarse, diminished. O2 sats 96-985 on simple face mask. strong productive cough, thick yellow/white sputum.\n\nGI: NPO maintained. abd softly distended, tender to palpation. hypoactive bowel sounds. denies n/v\n\nGU: foley catheter with adequate urine out. urine dark yellow>orangey with sediment noted. lytes repleted as indicated.\n\nENDO: BS covered with RiSS as indicated.\n\nID: afebrile. meropenum as ordered.\n\nSKIN: intact\n\nplan: cont. to monitor respiratory status, wean O2 if tolerated. ? need for CT placement if effusion worsens. monitor & support as indicated. ? transfer to floor if appropriate.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2138-12-10 00:00:00.000",
"description": "Report",
"row_id": 1602788,
"text": "7a - 7p NPN\n\nEvents: Thoracics consulted; Diabetes Team Consulted; Potential surgery verses chest tube to remove viscous fluid in L lung.\n\nN: A and O x 4, no neuro defecits.\n\nCV: ST-NSR, metoprolol q 6 hrs, blp WNL's, palp pedal pulses.\n\nResp: Course LS LUL and Diminished/ Absent LS LLL; Insp-Exp wheezing R UL and R LL, albuterol PRN, FM with 8L/min, sats 94-98%, RR WNL's and shallow, dyspnea with exertion, increased perfusion/respiration on R side.\n\nGI: abdomen tender to palp, mild distention, no BM in 3 days, NPO.\n\nGU: Foley, oliguria 30-40cc/hr, clear and yellow, urine sample sent, IVF 115 NS, hyponatremia (126).\n\nEndo: DM type II, sliding scale with some coverage required.\n\nID: afebrile, gram neg rods in LLL , meropenim given IV.\n\nPain: Hydromorphone PCA with adequate pain control.\n\nAssessment: Pancreatitis, LLL hemothorax/fluid collection, pseudocyst pancrease, ? spleenic inflammation.\n\nPlan: Place chest tube or surgical evacuation on viscous fluid in LLL; Continue to monitor and assess as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2138-12-11 00:00:00.000",
"description": "Report",
"row_id": 1602789,
"text": "NPN, 1900-0700\nneuro: Awake, alert, oriented to person and place; calm and cooperative. No focal deficits; fine bilateral hand tremors. CIWA as high as 11, med w/ ativan 1 mg which ? caused increased confusion vs increased CIWA signs.\n\nCV: ST, no VEA; lopressor increased from 5mg to 7.5mg IV q6hrs. Pulses palpable throughout.\n\nPulm: NP @ 4-5 l to maintain sats>95%. BS CTA right fields, course upper airwat, diminished left base. Course, non-productive cough. CDB, IS w/ much encouragement.\n\nGI: abd soft, very tender to gentle palp. C/O significant pain over left upper wuadrant radiating to left flank. Dilaudid PCA provides adequate control. NPO; TPN started @ 42cc/hr No stool, + flatus. No N/V. Cont hyponatremic. NS and TPN combined total 115cc/hr.\n\nGU: F/C urine cloudy amber, adequate OP.\n\nSkin: intact. PICC RAC. PIV x 2 LLA\n\nID: WBC wnl; tmax 100.6po. Cont on meripenum\n\nEndo: labile BG, controlled by RISS. Followed by Consult.\n\nA: pancreatitis w/ left pleural effusion. DM poorly cnontrolled. ? ETOH withdrawal.\n\nP: to be seen by thoracic to decide on CT vs surgery. Cont DM control, CIWA, prn dilaudid, lyte repletion.\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2138-12-17 00:00:00.000",
"description": "Report",
"row_id": 206610,
"text": "Sinus tachycardia. Baseline artifact. Non-specific septal ST-T wave changes.\nCompared to the previous tracing of ventricular premature beats are\nabsent. Otherwise, no significant diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2138-12-14 00:00:00.000",
"description": "Report",
"row_id": 206611,
"text": "Baseline artifact\nSinus rhythm\nVentricular premature complexes\nOtherwise may be normal ECG but baseline artifact makes assessment difficult\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 943927,
"text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with pancreatitis s/p L VATS\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Status post VATS.\n\n Single AP view of the chest is obtained on at 08:05 hours and is\n compared with the prior radiograph of . The patient has been\n extubated. Tubes and lines are otherwise unchanged. No convincing\n pneumothorax is demonstrated on the current image. Decrease in pulmonary\n vascular congestion in the left lung is apparent. No significant adverse\n interval change is seen.\n\n IMPRESSION: Tubes and lines unchanged except for extubation. Further\n clearing of left lung. No obvious pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-19 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 944793,
"text": " 3:19 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumothorax\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with pancreatic pseudocyst draining into left pleura s/p VATS\n with decortication, now with 2 chest tubes d/c'd.\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Pancreatic pseudocyst draining to left pleura status post\n VATS, chest tubes removed.\n\n Three tubes are seen in the region of the left hemidiaphragm, one probably\n within the chest, the other probably representing a drain and the other\n representing the nasogastric tube. Chest tube which had previously been seen\n in the left apex has been removed. No definite pneumothorax is present. Some\n blunting of the left costophrenic angle is seen. Right lung remains clear.\n\n IMPRESSION: No pneumothorax after removal of one of two chest tubes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-15 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 944168,
"text": " 1:29 PM\n CHEST (PA & LAT) Clip # \n Reason: interval CXR\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with chest tubes to water seal.\n\n REASON FOR THIS EXAMINATION:\n interval CXR\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST\n\n INDICATION: Left pleural effusion.\n\n PA and lateral views of the chest are obtained on at approximately\n 13:30 hours and compared with the prior day's radiographs. Again are seen\n three pleural tubes on the left side together with a right-sided subclavian\n line which are unchanged in position. No pneumothorax is identified. Pleural\n thickening or loculated fluid remains in the left lower lateral chest. Patchy\n increase in lung markings remains unchanged in the left base.\n\n IMPRESSION:\n\n Essentially stable appearances with no large pneumothorax identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 944439,
"text": " 12:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: collapsed lung?\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with pancreatitis s/p distal pancreatectomy and\n splenectomy, chest tubes x3\n REASON FOR THIS EXAMINATION:\n collapsed lung?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST RADIOGRAPH\n\n INDICATION: 61-year-old male with pancreatitis status post distal\n pancreatectomy and splenectomy and three chest tubes.\n\n COMPARISON: .\n\n FINDINGS: Multiple left-sided chest tubes are unchanged in position. There\n is no pneumothorax. Right internal jugular central venous catheter is\n unchanged. Nasogastric tube courses below the diaphragm and out of view.\n Left effusion and adjacent atelectasis have improved slightly. The right lung\n is clear and fully expanded. No right pleural effusion is present.\n Cardiomediastinal contour is unchanged.\n\n IMPRESSION:\n 1. Unchanged position of multiple lines and tubes. No pneumothorax.\n 2. Slight interval improvement in left pleural effusion and adjacent\n atelectasis in the left lower lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 944559,
"text": " 8:57 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumothorax, effusion\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p VATS on and pancreatectomy/splenectomy on . 3\n chest tubes placed, currently to water seal.\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old male status post VATs and pancreatectomy/splenectomy\n and three chest tubes.\n\n COMPARISON: .\n\n FINDINGS: Multiple left-sided chest tubes are unchanged. Nasogastric tube\n courses below the diaphragm and out of view. Right IJ central venous catheter\n is unchanged. Right PICC line is unchanged. Small left pleural effusion is\n slightly improved, and there is improved aeration at the left base. The right\n lung is generally clear and well expanded. There may be a small residual\n right pleural effusion. There is no pneumothorax. Cardiomediastinal\n silhouette is unchanged.\n\n IMPRESSION:\n\n 1. Unchanged position of multiple lines and tubes. No pneumothorax.\n\n 2. Decreased small left pleural effusion, with improved aeration at the left\n base.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 943792,
"text": " 10:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval PTX, chest tubes\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with pancreatitis s/p L VATS, decort\n REASON FOR THIS EXAMINATION:\n eval PTX, chest tubes\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of patient after decortication and left\n VATS.\n\n Portable AP chest radiograph compared to .\n\n The heart size is normal. The mediastinal position, contour and width are\n unremarkable. The ETT tube terminates 8 cm above the carina. Two chest tubes\n are inserted on the left. There is slight decrease in pleural effusion with\n re-expanding of the underlying lung. Small apical pneumothorax is present.\n The basal component of the pneumothorax is also demonstrated. The third lower\n chest tube tip terminates most likely in the low posterior pleura.\n\n IMPRESSION:\n\n Small apical and basal components of left pneumothorax after decortication\n with decreased pleural effusion and re-expanding of the underlying lung.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 944361,
"text": " 6:33 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: evaluate line placement\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with pancreatitis s/p distal pancreatectomy and splenectomy\n REASON FOR THIS EXAMINATION:\n evaluate line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 61-year-old man with pancreatitis status post splenectomy and\n distal pancreatectomy. Question line placement.\n\n CHEST, SUPINE AP: The nasogastric tube terminates in the stomach. Three\n right-sided chest tubes are unchanged. There is persistent left basilar\n opacity with a left effusion. A new right internal jugular double-lumen\n central venous catheter terminates at the cavoatrial junction. There is no\n pneumothorax.\n\n IMPRESSION:\n 1. New central venous catheter terminating in the superior vena cava.\n 2. Unchanged chest tubes.\n 3. Similar left basilar opacity and effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 944507,
"text": " 7:16 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval s/p chest tubes to water seal\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with pancreatitis s/p distal pancreatectomy and splenectomy,\n chest tubes x3 now to water seal\n REASON FOR THIS EXAMINATION:\n eval s/p chest tubes to water seal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest tubes to waterseal.\n\n COMPARISON: Multiple priors, the most recent from earlier the same date at\n 12:52 hours\n\n AP SEMI-UPRIGHT CHEST: There is no short interval change. The tip of a right\n IJ central venous catheter terminates in the mid SVC. A right PICC tip\n projects over the upper SVC. A nasogastric tube courses below the diaphragm\n and out of view. Left chest tubes are unchanged in standard positions.\n Moderate left and small right layering pleural effusions are without change.\n There is persistent left retrocardiac consolidation. No pneumothorax is\n identified. The cardiomediastinal silhouette is without change.\n\n IMPRESSION:\n 1. Unchanged position of multiple lines and tubes. No pneumothorax.\n 2. Persistent bilateral pleural effusions, left greater than right and left\n lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 945355,
"text": " 10:33 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumothorax\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with pancreatic pseudocyst draining into left pleura s/p VATS\n with decortication, now with all chest tubes d/c'd.\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST.\n\n INDICATION: Status post VATS with decortication. Evaluate for pneumothorax\n status post tube removal.\n\n FINDINGS: Compared with , the left chest tube has been removed. One\n drainage tube appears to be below the left hemidiaphragm in this patient with\n known pancreatic pseudocyst. No pneumothorax is seen.\n\n There has been mild improvement in the scattered left lower lobe linear\n atelectasis. Allowing for differences in projection and technique, the hazy\n focal density projecting over the left lateral lower lung field is probably\n unchanged and probably pleural in location, as seen on the patient's recent\n chest CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-15 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 944139,
"text": " 9:37 AM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n Reason: (for surgical planning) please eval vasculature around pancr\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with chronic pancreatitis c/b leaking pseudocyst. Pre-op for\n Tues \n REASON FOR THIS EXAMINATION:\n (for surgical planning) please eval vasculature around pancreatic pseudocyst\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JCT MON 12:06 PM\n Atrophic calcified pancreas and dilated duct c/w chronic pancreatitis.\n 7.4x3.7cm collection with rim enhancement lateral to the spleen and additional\n adjacent similar tiny foci most likely representing pseudocysts.\n\n 3D vascular recons pending. No mesenteric vascular anomalies identified.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CTA of the abdomen with and without contrast with\n reconstructions dated .\n\n COMPARISON: CT chest dated .\n\n INDICATION: 61-year-old male with chronic pancreatitis and _____ pseudocyst\n preop, please evaluate vasculature and pancreatic pseudocyst.\n\n TECHNIQUE: Axial imaging was obtained through the abdomen before and after\n the administration of IV contrast in the arterial and venous phases. In\n addition, coronal, sagittal, and 3D reconstructions were performed.\n\n FINDINGS FOR CT OF THE ABDOMEN WITH AND WITHOUT CONTRAST: Limited imaging of\n the lung bases demonstrates a moderate right-sided pleural effusion, adjacent\n relaxation atelectasis. There is enhancement of the pleura on the left\n consistent with recent surgical drainage and decortication. In the anterior\n left pleural space on images 1 through 10, there is a small fluid collection\n which contains gas which on sequential imaging demonstrates increased\n enhancement in the pleural cavity and consistent with contrast extravasation,\n likely related to recent surgery. The area of extravasation measures\n approximately 1.9 cm x 0.8 cm. There is limited imaging of two chest tubes\n within the left pleural space. High density is seen above the spleen\n consistent with a hematoma, most likely related to recent surgery as well.\n There is an 8 cm x 3.6 cm subcapsular fluid collection which may represent old\n hematoma or a pseudocyst. The pancreas is atrophic and contains multiple\n coarse calcifications and a dilated duct consistent with chronic pancreatitis.\n The liver, adrenal glands, kidneys, and gallbladder are unremarkable. Fluid\n is seen within the pericolic gutters bilaterally. The bowel is of normal\n caliber. There is atherosclerotic calcification of the abdominal aorta.\n\n CT OF THE PELVIS: Delayed imaging of the pelvis was performed, and\n demonstrates a folded balloon catheter within the bladder. There is gas-fluid\n (Over)\n\n 9:37 AM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n Reason: (for surgical planning) please eval vasculature around pancr\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n level within the bladder likely due to catheterization. There is a small\n amount of pelvic ascites. The bowels are normal in caliber and appearance.\n There is no lymphadenopathy or free intraperitoneal gas.\n\n Review of bone windows demonstrates no suspicious lytic or blastic lesions.\n\n CTA: The celiac axis, SMA, and are widely patent. Single renal arteries\n are seen bilaterally, both of which are widely patent. The main portal vein\n is patent. The distal SMV is occluded. The _____ vein is occluded. Multiple\n mesenteric collaterals converge and reconstitute the portal vein. The\n gastroduodenal artery is patent without evidence of pseudoaneurysm. The\n splenic artery is patent.\n\n IMPRESSION:\n\n 1. Small area of contrast extravasation into the left anterior pleural cavity\n which most likely is related to recent surgery.\n\n 2. Small hematoma above the spleen.\n\n 3. Subcapsular fluid collection which may represent old subcapsular hematoma\n or pseudocyst.\n\n 4. Thrombosed distal SMV and splenic veins, multiple mesenteric collaterals\n are present which reconstitute the portal vein.\n\n 5. Moderate right pleural effusion.\n\n 6. Ascites.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 944039,
"text": " 10:19 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumothorax\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with chest tubes to water seal.\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS, ON \n\n HISTORY: Chest tubes to Water-Seal.\n\n REFERENCE EXAM: .\n\n FINDINGS: Again seen are three left-sided chest tubes and a right subclavian\n line with tip in the SVC. There continues to be left lower lobe patchy\n infiltrate and volume loss. No pneumothorax is identified. Compared to the\n prior day, there has been no significant interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 944885,
"text": " 12:30 PM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate for L pleural effusion\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with pancreatic pseudocyst draining into left pleura s/p VATS\n with decortication, now with 2 chest tubes d/c'd.\n REASON FOR THIS EXAMINATION:\n Evaluate for L pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Status post VATS, chest tube removed on the left, evaluate for left\n effusion.\n\n One view. Comparison with . A small left effusion persists. A chest\n tube remains in place at the left base. The right costophrenic sulcus is now\n blunted consistent with a small effusion. A central venous catheter remains\n in place. A nasogastric tube has been withdrawn. Mediastinal structures\n appear stable.\n\n IMPRESSION: Small left pleural effusion not significantly changed. New\n evidence for small right pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-11 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 943656,
"text": " 11:39 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval L effusion\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with pancreatic pseudocyst and L effusion\n REASON FOR THIS EXAMINATION:\n eval L effusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF CHEST ON .\n\n HISTORY: Pancreatic pseudocyst and left effusion.\n\n TECHNIQUE: Multidetector helical scanning of the chest was performed without\n intravenous contrast reconstructed as contiguous 5 and 1.25 mm thick\n axial images. There are no prior chest CTs for comparison.\n\n FINDINGS: There is a large multiloculated nonhemorrhagic left pleural\n effusion producing collapse of the left lower lobe and lingula and displacing\n the mediastinum to the right. A component of fluid medial to the left hilus\n is inseparable from both mediastinal pleura and the adjacent pericardium,\n although there is no mediastinal or pericardial collection elsewhere. Small\n nonhemorrhagic right pleural effusion layers posteriorly.\n\n This study is not designed for subdiaphragmatic evaluation except to note\n extensive calcification in the pancreas and an enlarged low-density tail\n extending to the splenic hilus. The only large fluid collection in the upper\n abdomen is a subcapsular collection in the spleen which could be abscess or\n old hematoma. Its contiguity with the left pleural collection suggests that\n both may be infected.\n\n Mild emphysema is recognized in the right lung which has minimal\n bronchiectasis at the base and mild relaxation atelectasis but is otherwise\n clear.\n\n Central lymph nodes are enlarged up to 10 mm in the left upper paratracheal,\n 11 mm in the left lower paratracheal, 9 mm in the prevascular aortopulmonic\n window and 19 mm in the subcarinal right paraesophageal stations. There may\n also be substantial adenopathy in the left hilus, although the adenopathy does\n not appear to narrow bronchial lumens. Abrupt cutoff to the superior\n segmental left lower lobe bronchus may be due to combination of mass effect\n from pleural effusion and retained secretions. Heavy atherosclerotic\n calcification is present in the left main anterior descending circumflex and\n right coronary arteries.\n\n IMPRESSION:\n 1. Large multiloculated left pleural effusion, likely exudate, infected until\n proved otherwise, may be related to large, subcapsular splenic fluid\n collection and, ultimately, to chronic, calcific pancreatitis.\n\n (Over)\n\n 11:39 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval L effusion\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Severe relaxation atelectasis and cental adenopathy, due to left pleural\n abnormality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 943401,
"text": " 4:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?Effusion\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with coarse breath sounds and O2 sat 89%\n REASON FOR THIS EXAMINATION:\n ?Effusion\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Coarse breath sounds and oxygen saturation at 89%, evaluate for\n effusion.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting upright position. There is evidence of a left-sided pleural effusion,\n which obliterates the contour of the left diaphragm completely, blunts the\n left lateral pleural sinus and extends upwards along the left lateral wall\n resulting in a small pleural cap around the apex. Left-sided lung parenchyma\n is difficult to evaluate because of the diffuse pleural densities but a\n diagonal contour line in the left lower lung field suggests the presence of a\n left lower lobe atelectasis. There appears to be a mild degree of mediastinal\n shift towards the right, but the right hemithorax is well ventilated with\n normal appearance of the pulmonary vasculature and absence of any significant\n parenchymal infiltrate. Also the right lateral pleural sinus is free and\n there is no evidence of pneumothorax. The presence of a right-sided PICC line\n is noted and its course can be followed in the SVC to the level of the\n carina. It is uncertain, however, if this line continues further down as the\n wire apparently has been removed already and the line is very little\n radiopaque.\n\n Our records do not include a previous chest examination available for\n comparison.\n\n IMPRESSION: Sizable left-sided pleural effusion, mild mediastinal shift\n towards the right. No significant abnormality in right hemithorax as seen on\n AP single view chest examination. Chest CT is recommended for further\n detailed diagnosis. Telephone report delivered to covering physician.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 943457,
"text": " 7:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval L effusion\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with pancreatitis coarse breath sounds and O2 sat 89%\n\n REASON FOR THIS EXAMINATION:\n eval L effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:03 A.M. ON \n\n HISTORY: Pancreatitis and coarse breath sounds.\n\n IMPRESSION: AP chest compared to :\n\n Large left pleural effusion has increased slightly producing more rightward\n mediastinal shift as well as persistent collapse of the left lower lobe.\n Right lung is grossly clear.\n\n\n"
}
] |
98,220 | 158,851 | The patient was admitted to the General Surgical Service on for evaluation of the aforementioned problem. was continued on a regular diet with supplements, cycled tubefeeds via the J-Tube, which enters the duodenum via a EC fistual, on home medications and oral antibiotics, the latter consisting of Ciprofloxacin, Clindamycin, and Linezolid. These antibiotics were prescribed during his last admission for abdominal abscesses, which grew out Pseudomonas, MRSA and beta Strep. Upon admission, his HGB was 7.5 and HCT 22.7, for which he was transfused 2 units of PRBCs without adverse event. Nutrition, Ostomy Nurse, Physical Therapy, and Occupational Therapy were consulted early during this admission. Infectious Disease also followed the patient during the admission. Overall, the patient was hemodynamically stable. On HD#2, the patient received an additional unit of PRBCs responding with a HGB of 10.4 and HCT of 31.4. Urine and blood cultures were sent. He was given supplemental hydration with Lactated Ringer's via the J-Tube. Tolerated tubefeeds at goal, but only fair intake of his diet. Early on , the patient became hypotensive, acutely confused and briefly unresponsive. He was transferred to the SICU. A CXR, ECG, labwork, and blood cultures were performed. A foley catheter and A-line were placed. The EKG was unremarkable, and the CXR showed moderate (R) pleural effusion increased, rightward mediastinal shift with opacification in (R) lower lobe most likely representing atelectasis. He was given a 1L LR bolus with good response. He was started on IV Flagyl for possible colitis. A Abdominal/pelvic CT with contrast demonstrated interval improvement in the hepatic fluid collection and a few small new collection less than 1.8cm in size. Trophic tubefeeds were started. The next SICU day, his diet was restarted and trophic tubefeeds continued. He experienced another episode of hypotension on , and was again bolused with a total of 725mL LR with good response. Tubefeeds were again held. A CVL was placed, and IV Cefepime was added for temperature spikes to cover Pseudomonas. On , he remained hemodynamically stable. He was restarted on tubefeeds, this time continuous advancing to goal, which he tolerated. Given that he continued stable into , he was transferred back to the inpatient floor. Early on , the patient again experienced an episode of confusion. Heart rate was tachy between 104-125, other vital signs were stable. No fever or leukocytosis. Labwork, blood and urine cultures were sent. Later that morning, his mental status returned to baseline. On , the patient underwent MRCP, which revealed multiple hepatic abscesses, but not significantly changed in size given differences in technique, and no new fluid collections. Given these finding demonstrating overall improvement and potential risks of interventional biospy, it was ultimately determined in consultation with Infectious Disease to forego planned ultrasound-guided aspiration and biopsy of one or more of the liver abscesses. Infectious Disease continued to follow along, updating antibiotic recommendations. On , Cefepime, Clindamycin, and Cipro were discontinued, with the patient continued on Flagyl. The Lineolid was completed on . The Flagyl will be continued until outpatient Infectious Disease follow-up appointment on . Other than that mentioned above, the hospital course back on the floor was unremarkable. He ambulated early and frequently with Nursing or Physical Therapy, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. His labwork was monitored regularly; electolytes repleted when needed. After his foley was discontinued, he voided without problem with an adequate urine output. He tolerated cycled tubefeeds via the J-Tube and a regular diet. Marinol was added on to stimulate his appetite. He was also started on Viokase and Imodium PRN for loose stools with improvement. At the time of discharge on , the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, although with poor intake, ambulating, voiding without assistance, and pain was well controlled. He was tolerating cycled tubefeeds via the J-Tube, placed through the EC fistula. The ostomy appliance as ordered remained intact. The patient was discharged to an extended care facility. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. | s/p Hepatic drains placed on -- removed s/p Right-sided thoracentesis on . +diarrhea, check CDiff w/BM. +diarrhea, check CDiff w/BM. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube placed through enterocutaneous fistula now with hypotension and change in MS. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube placed through enterocutaneous fistula now with hypotension and change in MS. . Since the previous tracingof marked tachycardia is now present and modest ST-T wave changes areseen. Chief complaint: Hypotension, change in MS : PMH: duodenal adenocarcinoma, HTN, PUD, ECF . Hx of diarrhea- will check cdiff. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube placed through enterocutaneous fistula now with hypotension and change in MS. Chief complaint: PMHx: PMH: duodenal adenocarcinoma, HTN, PUD, ECF . Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube placed through enterocutaneous fistula now with hypotension and change in MS. Chief complaint: PMHx: PMH: duodenal adenocarcinoma, HTN, PUD, ECF . Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube placed through enterocutaneous fistula now with hypotension and change in MS. Chief complaint: Hypotension, change in MS : PMH: duodenal adenocarcinoma, HTN, PUD, ECF PSH: s/p gastric resection for PUD s/p revision with Roux-en-Y and partial gastrectomy in s/p whipple, as above s/p takeback for repair of pancreaticojejunostomy Sepsis without organ dysfunction Assessment: Afebrile WBC 9 Post transfusion Hct 28 SBP 100s-120s Large brown loose stool x 1 Action: Multi abx given per orders C-Diff sent Did not give pts banana flakes ? Hx of diarrhea- will check c.diff. Chief complaint: Change in ms, anemia PMHx: PMH: duodenal adenocarcinoma, HTN, PUD, ECF PSH: s/p gastric resection for PUD s/p revision with Roux-en-Y and partial gastrectomy in s/p whipple, as above s/p takeback for repair of pancreaticojejunostomy, as above Hypotension (not Shock) Assessment: Received from 9 for hypotension, low grade fever and changes in mental status-Temp98.8 orally Initial sbp 104/50 100 no ectopics sbp trending down 70s to 90 sbp shortly after adm. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube placed through enterocutaneous fistula now with hypotension and change in MS. . Hx of diarrhea, check CDiff w/BM. Hx of diarrhea, check CDiff w/BM. Hypotensive requiring fluid boluses, now on aztreonam, cipro, and flagyl Chief complaint: PMHx: PMH: duodenal adenocarcinoma, HTN, PUD, ECF . Hypotensive requiring fluid boluses, now on aztreonam, cipro, and flagyl Chief complaint: PMHx: PMH: duodenal adenocarcinoma, HTN, PUD, ECF . Chief complaint: Hypotension, change in MS : PMH: duodenal adenocarcinoma, HTN, PUD, ECF . Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube placed through enterocutaneous fistula now with hypotension and change in MS. Chief complaint: Hypotension, change in MS : PMH: duodenal adenocarcinoma, HTN, PUD, ECF PSH: s/p gastric resection for PUD s/p revision with Roux-en-Y and partial gastrectomy in s/p whipple, as above s/p takeback for repair of pancreaticojejunostomy Sepsis without organ dysfunction Assessment: Afebrile WBC 9 Post transfusion Hct 28 SBP 100s-120s Large brown loose stool x 1 Action: Multi abx given per orders C-Diff sent Did not give pts banana flakes ? +diarrhea, check CDiff w/BM. +diarrhea, check CDiff w/BM. Hx of diarrhea, check CDiff w/BM. Hx of diarrhea, check CDiff w/BM. Chief complaint: Hypotension, change in MS : PMH: duodenal adenocarcinoma, HTN, PUD, ECF . Chief complaint: Hypotension, change in MS : PMH: duodenal adenocarcinoma, HTN, PUD, ECF . Chief complaint: Hypotension, change in MS : PMH: duodenal adenocarcinoma, HTN, PUD, ECF . Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube placed through enterocutaneous fistula now with hypotension and change in MS. . Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube placed through enterocutaneous fistula now with hypotension and change in MS. . Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube placed through enterocutaneous fistula now with hypotension and change in MS. . Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube placed through enterocutaneous fistula now with hypotension and change in MS. . Hypotensive requiring fluid boluses, now on aztreonam, cipro, and flagyl Chief complaint: Hypotension PMHx: duodenal adenocarcinoma, HTN, PUD, ECF . Hypotensive requiring fluid boluses, now on aztreonam, cipro, and flagyl Chief complaint: Hypotension PMHx: duodenal adenocarcinoma, HTN, PUD, ECF . Endocrine: Hypoglycemia, resolved. Endocrine: Hypoglycemia, resolved. Likely heme repressed in part d/t Linezolid. ABDOMEN: Again noted are postsurgical changes from a Whipple procedure, and left-sided pneumobilia is noted. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H:PRN pain Order date: @ 0346 8. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H:PRN pain Order date: @ 0346 8. | 46 | [
{
"category": "ECG",
"chartdate": "2173-10-28 00:00:00.000",
"description": "Report",
"row_id": 220848,
"text": "Sinus tachycardia. Compared to previous tracing of the heart rate is\nfaster. The Q-T interval has normalized.\n\n"
},
{
"category": "ECG",
"chartdate": "2173-10-17 00:00:00.000",
"description": "Report",
"row_id": 220849,
"text": "TRACING SUBMITTED LATE AND OUT OF SEQUENCE. Rhythm is probably sinus\ntachycardia but consider also possible atrial tachycardia given the markedly\nrapid rate. Probable left anterior fascicular block. QTc interval may be\nprolonged but is difficult to measure. Modest ST-T wave changes. Findings are\nnon-specific. Clinical correlation is suggested. Since the previous tracing\nof marked tachycardia is now present and modest ST-T wave changes are\nseen.\n\n"
},
{
"category": "ECG",
"chartdate": "2173-10-18 00:00:00.000",
"description": "Report",
"row_id": 220850,
"text": "Sinus rhythm. The Q-T interval is prolonged. Compared to the previous tracing\nthe Q-T interval is longer.\n\n"
},
{
"category": "ECG",
"chartdate": "2173-10-15 00:00:00.000",
"description": "Report",
"row_id": 220851,
"text": "Sinus rhythm. Since the previous tracing the rate is slower and the axis is\nless leftward.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2173-10-15 00:00:00.000",
"description": "Report",
"row_id": 221066,
"text": "Baseline artifact. Sinus rhythm. Left axis deviation. Since the previous\ntracing the rate is slower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2173-10-15 00:00:00.000",
"description": "Report",
"row_id": 221067,
"text": "Baseline artifact. Sinus tachycardia. Left axis deviation. Since the previous\ntracing of the rate is faster, axis is somewhat more leftward and\nST-T wave abnormalities are more prominent. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "Physician ",
"chartdate": "2173-10-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 486446,
"text": "SICU\n HPI:\n 69 yo M s/p whipple c/b biliary enteric and enterocutaneous fistulas\n now with fevers/ FTT, likely cholangitis\n HPI: PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p whipple\n complicated by biliary enteric and\n enterocutaneous fistula. Pt is s/p redo of jejeunal-hepatic anastamosis\n x 2 and j tube placed through enterocutaneous fistula, with recurrent\n cholangitis thought secondary to reflux of enteric contents into\n biliary tree, now s/p biliary drain, with fevers, elevated WBC, rising\n Tbili, all suggestive of cholangitis. Hypotensive requiring fluid\n boluses, now on aztreonam, cipro, and flagyl\n Chief complaint:\n Change in ms, anemia\n PMHx:\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy, as above\n Current medications:\n Active Medications ,\n 1. IV access: Peripheral line Order date: @ 0314 9. Heparin 5000\n UNIT SC BID Order date: @ 0314\n 2. IV access: Peripheral line Order date: @ 0314 10. Linezolid\n 600 mg PO Q12H\n to end Order date: @ 0314\n 3. 1000 mL NS\n Continuous at 100 ml/hr Order date: @ 0319 11. Metoprolol\n Tartrate 5 mg IV Q6H prn hr >100\n hold for sbp<100 or Hr>60 Order date: @ 0339\n 4. Ciprofloxacin 400 mg IV Q12H Order date: @ 0339 12.\n Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 0314\n 5. Clindamycin 600 mg IV Q8H Order date: @ 0339 13. 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: @ 0314\n 6. Famotidine 20 mg IV Q24H Order date: @ 0339 14. 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: @ 0314\n 7. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0314 15.\n Triamcinolone Acetonide 0.1% Cream 1 Appl TP :PRN pruritus Order\n date: @ 0314\n 8. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H:PRN pain Order date: \n @ 0346 16. Ursodiol 600 mg PO BID Order date: @ 0314\n 24 Hour Events:\n Admitted to sicu for change in ms, unresponsive, hypotension\n 80s, bolused 1L. Given amp for hypoglycemia, aline\n Allergies:\n Azithromycin\n Rash;\n Zosyn (Intraven) (Piperacillin Sodium/Tazobactam)\n Rash;\n Meropenem\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.2\nC (98.9\n HR: 104 (104 - 104) bpm\n BP: 104/60(71) {104/60(71) - 104/60(71)} mmHg\n RR: 19 (19 - 20) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 42 mL\n PO:\n Tube feeding:\n IV Fluid:\n 42 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 42 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Non-distended, Bowel sounds present, Tender: Throughout with\n palpation, no r/g, + BS. ECF with yellowing tf material. Former PTC\n drain wound c/d/i.\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n [image002.jpg]\n Imaging: CT abd: Unchanged position of two right lobe percutaneous\n drainage catheters within hepatic abscesses. three new collections up\n to 2 cm in diameterare present in the right lobe at the hepatic dome.\n Rigtt-sided pleural effusion with pleural enhancement; bilateral renal\n hypodensities.\n Microbiology: Blood Culture P\n Blood Culture P\n SWAB No PMN, No Micro\n Urine Cx P\n Blood Culture P\n Blood Culture P\n Blood Culture P\n Assessment and Plan\n Assessment and Plan: 69M s/p Whipple, revision, r/w anemia Hct 22. with\n change in ms hypotension.\n Neuro: fentanyl patch, dilaudid PRN\n CVS: Hypotension, s/p IVF bolus 500cc x2 with resolution into the igh\n 90s low 100s systolic bps.\n Pulm: No active issues, R plueral effusion on cxr\n GI: Ecf with ostomy appliace surrounding, On Cipro, linazolid, clinda\n for hepatic abscesses will d/w preimary team Ct in am, possible\n drainage procedure . Tender abdomen with hx of recurrent cholangitis\n FEN: Tube feeds on hold, NPO , NS 100/hr\n Renal: Cr 1.2 ~baseline , hyperkalemia will monitor.\n Heme: HCT 22.8--> transfuse 2u PRBC , f/u post transfusion hct now\n 31.5 stable/\n Endo: Hypoglycemia to 70s given amp d50.\n ID: Pancultured. History of Enterococci bacteremia s/p rx\n with Vanc/gent/cipro/flagyl. Slight luekocytosis with left shift.\n Tender abdomen. Hx of diarrhea- will check cdiff.\n Wounds: enterocutaneous fistula\n Consults: West2\n Billing Diagnosis:\n ICU Care\n Nutrition: NPO\n Glycemic Control: none\n Lines:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Radiology",
"chartdate": "2173-10-23 00:00:00.000",
"description": "MRCP (MR ABD W&W/OC)",
"row_id": 1100891,
"text": " 10:04 AM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Eval. for biliary stricture\n Admitting Diagnosis: ANEMIA\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with pneumobilia, liver abscesses\n REASON FOR THIS EXAMINATION:\n Eval. for biliary stricture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DBzc SAT 3:49 PM\n -status post-Whipple's\n -multiple hepatic abscesses are again visualized as on prior CT\n -no new hepatic lesions are seen\n -no intra or extrahepatic biliary duct dilatation\n -no definite biliary stricture or filling defect is evident\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of Whipple procedure with postoperative\n anastomotic leak and hepatic abscesses. Please evaluate for biliary\n stricture.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained on a 1.5\n Tesla magnet including dynamic imaging obtained prior to, during, and\n following the uneventful administration of 17 mL of gadolinium-DTPA.\n Multiplanar 2D and 3D reformations and subtraction images were performed on an\n independent workstation.\n\n Correlation is made with prior CT performed on .\n\n FINDINGS: Again noted are multiple peripherally enhancing hepatic fluid\n collections containing foci of gas consistent with abscesses. Allowing for\n differences in technique, these are not significantly changed in size, and no\n new collections are identified. For example, the collection within segment\n VII posteriorly measures 2.9 x 3.3 cm in its entirety, with the central fluid\n component measuring 1.7 x 1.1 cm. The central fluid component on prior CT\n measured 1.6 x 1.5 cm. The collection within segment measures 2.7 x 1.9\n cm in its entirety, with the anterior central fluid component measuring 0.9 x\n 0.9 cm. This is difficult to compare to the prior CT, but appears stable to\n smaller. There are two foci of enhancement within the right lateral abdominal\n wall in the site of prior drainage catheter tracts. There are no focal fluid\n collections within the abdominal wall.\n\n Again noted are postsurgical changes from Whipple procedure. There is no\n intra- or extra-hepatic biliary dilatation. MRCP images are limited, but\n there is no obvious focal stricture. The remaining pancreas is atrophic and\n the pancreatic duct is mildly prominent. There are stable retroperitoneal\n lymph nodes. There are bilateral nonenhancing renal cysts. A cyst within the\n posterior left renal mid pole is bright on T1 pre-contrast images, consistent\n with hemorrhagic or proteinaceous fluid. The left kidney is mildly atrophic\n compared to the right. There is mild diffuse anasarca. Susceptibility\n (Over)\n\n 10:04 AM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Eval. for biliary stricture\n Admitting Diagnosis: ANEMIA\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n artifact is noted in the anterior abdominal wall from multiple surgical clips.\n The spleen and adrenal glands are normal.\n\n The visualed abdominal bowel loops are nondilated, and there is no ascites or\n new focal fluid collection.\n\n Limited images of the lower chest demonstrate loculated right pleural fluid\n and atelectasis and minimal left pleural fluid. The visualized bone marrow\n signal is unremarkable. A percutaneous jejunostomy tube is identified.\n\n Multiplanar reformations and subtraction images provided multiple perspectives\n for the dynamic series.\n\n IMPRESSION:\n\n 1. Multiple hepatic abscesses, not significantly changed in size given\n differences in technique. No new fluid collections are identified. There is\n enhancement within the right lateral abdominal wall in the region of prior\n drainage catheters, without focal fluid collection.\n\n 2. Stable post-surgical changes from Whipple, with no evidence of biliary\n dilatation.\n\n 3. Bilateral renal cysts.\n\n\n\n"
},
{
"category": "Physician ",
"chartdate": "2173-10-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 487749,
"text": "SICU\n HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula now with hypotension and change\n in MS.\n Chief complaint:\n PMHx:\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n .\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy\n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:42 PM\n STOOL CULTURE - At 12:44 AM\n CALLED OUT\n Wants to take PO.\n Allergies:\n Azithromycin\n Rash;\n Zosyn (Intraven) (Piperacillin Sodium/Tazobactam)\n Rash;\n Meropenem\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 08:00 PM\n Ciprofloxacin - 08:32 PM\n Linezolid - 10:23 PM\n Metronidazole - 12:21 AM\n Clindamycin - 02:06 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 04:42 PM\n Hydromorphone (Dilaudid) - 12:00 AM\n Other medications:\n :\n Ursodiol 600 mg po bid\n Metoprolol 50mg po BID\n Metoclopramide 5mg po QID\n Hydromorphine hcl 2mg po Q4H prn pain\n Iron\n Albuterol\n Ipratropium\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36\nC (96.8\n T current: 35.8\nC (96.4\n HR: 79 (63 - 87) bpm\n BP: 117/57(72) {95/45(57) - 117/67(78)} mmHg\n RR: 12 (11 - 20) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 60.5 kg (admission): 58.2 kg\n Height: 71 Inch\n CVP: 5 (-1 - 7) mmHg\n Total In:\n 4,994 mL\n 747 mL\n PO:\n Tube feeding:\n 171 mL\n 168 mL\n IV Fluid:\n 4,448 mL\n 579 mL\n Blood products:\n 375 mL\n Total out:\n 2,290 mL\n 1,070 mL\n Urine:\n 2,285 mL\n 970 mL\n NG:\n Stool:\n Drains:\n 5 mL\n 100 mL\n Balance:\n 2,704 mL\n -323 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Soft, Tender: , G tube\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3)\n Labs / Radiology\n 236 K/uL\n 9.0 g/dL\n 70 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 105 mEq/L\n 135 mEq/L\n 27.3 %\n 9.3 K/uL\n [image002.jpg]\n 03:19 AM\n 02:38 AM\n 05:57 AM\n 12:20 PM\n 12:56 PM\n 02:47 AM\n 03:02 AM\n 08:36 PM\n 02:34 AM\n WBC\n 18.3\n 9.7\n 5.3\n 8.1\n 22.1\n 11.2\n 9.3\n Hct\n 29.2\n 28.0\n 28.9\n 30.7\n 24.0\n 27.9\n 27.3\n Plt\n 233\n 221\n 250\n \n 236\n Creatinine\n 1.1\n 0.9\n 1.0\n 1.2\n 1.3\n 1.0\n Troponin T\n 0.01\n 0.02\n TCO2\n 17\n 23\n Glucose\n 167\n 87\n 80\n 61\n 82\n 70\n Other labs: PT / PTT / INR:12.6/26.5/1.1, CK / CK-MB / Troponin\n T:11//0.02, ALT / AST:14/16, Alk-Phos / T bili:447/2.7, Amylase /\n Lipase:139/61, Differential-Neuts:91.8 %, Band:15.0 %, Lymph:4.8 %,\n Mono:2.6 %, Eos:0.5 %, Lactic Acid:2.7 mmol/L, Albumin:2.0 g/dL,\n LDH:108 IU/L, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:3.5 mg/dL\n Imaging: CXR moderate R pleural effusion increased, rightward\n mediastinal shift ?opacification in R lower lobe is atelectasis.\n CT abd/pelv = Interval decrease in size of collections. New\n ill-defined hypodense lesions @ lateral right hepatic lobe. Tiny new\n fluid collection in the right lateral abdominal wall @ prior drain.\n Microbiology: SWAB No PMN, No Micro prelim NG\n Blood Culture P\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, MALNUTRITION, .H/O CANCER (MALIGNANT\n NEOPLASM), PANCREAS\n Assessment and Plan: 69M s/p Whipple, revision, r/w anemia HCT 22 w/\n change in MS, resolved hypotension.\n Neurologic: AOx3. AMS with hypotension resolved. Fentanyl patch.\n Minimal dilaudid PRN.\n Cardiovascular: Hypotension responsive to fluid. SVT to 170s-180s, r/o\n MI with CE.\n Pulmonary: No active issues, R plueral effusion on CXR.\n Gastrointestinal / Abdomen: ECF w/ostomy appliace surrounding, On\n Cipro, linezolid, clinda for hepatic abscesses. Cefepime added due\n to continued spikes to double cover psuedomonas. Tender abdomen. CT\n w/o signs of intra-abdominal collection needing drainage.\n Worsening APhos, bili. Lactate 7 on . N/V ON ,\n zofran+compazine prn.\n Nutrition: TF on hold. NPO.\n Renal: Cr normal.\n Hematology: Stable anemia. Febrile and WBC 8.1-22, ?previously\n leukopenic. Suggestive of sepsis.\n Endocrine: Hypoglycemia, resolved getting D5 in IVF. SSI.\n Infectious Disease: Cipro,Cefepime, clinda, flagyl, linezolid (for\n VRE). Hx of Enterococci bacteremia tx w/ V/G/C/F (). Tender\n abdomen. +diarrhea, check CDiff w/BM. Isolation for VRE/MRSA. WBC\n normalized.\n Lines / Tubes / Drains: epigastric enterocutaneous fistula, RUQ former\n drain site, R PIV, J tube, Foley, R SCL (), L Aline ()\n Wounds:\n Imaging:\n Fluids:\n Consults: West2\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:27 PM 30 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n 18 Gauge - 08:26 PM\n Prophylaxis:\n DVT: (HSQ, SCDs, H2B)\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 487907,
"text": "HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula now with hypotension and change\n in MS.\n Nursing transfer summary\n Assessment:\n Admitted to SICU for mental status changes and hypotension\n Treated in SICU with fluid and additional antibiotics\n Neuro\n alert and oriented, very pleasant gentleman, No neuro deficits\n Endo\n Treating with sliding scale insulin\n GI\n Jube feeding distal to existing fistula\n Covered with stoma appliance\n Followed by ostomy service\n Jtube feedings slowly advancing w/banana flakes\n Diet changed to as tolerated today\n Tolerating well so far, no BM today\n GU foley, draining clear icteric uring\n ID On multiple antibiotics (clinda, cipro,\n defipime, linezolid and flagyl--?exactly what\ns growing out\n On contact precautions, ?. Stool\n sample sent today.\n Resp Good sats on room air\n CV Has been hemodynamically stable since .\n Social Wife and 3 sons, very supportive of patient\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n ANEMIA\n Code status:\n Full code\n Height:\n 71 Inch\n Admission weight:\n 58.2 kg\n Daily weight:\n 60.5 kg\n Allergies/Reactions:\n Azithromycin\n Rash;\n Zosyn (Intraven) (Piperacillin Sodium/Tazobactam)\n Rash;\n Meropenem\n Unknown;\n Precautions: Contact\n PMH: Anemia\n CV-PMH:\n Additional history: Whipple procedure for Ampullary carcinoma\n with subsequent complicated post op courseanastamotic leaks and failure\n to thrive, as well as a known EC fistula. recently discharged from the\n hospital of a long course of treatment for\n Klebsiella bacteremia from hepatic abscesses and obstructive\n cholangitis and issues with enteral feedings.\n Surgery / Procedure and date: PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple \n s/p . Drainage of intra-abdominal abscess through reopening of\n recent laparotomy; Repair of pancreaticojejunostomy through a\n bridge stent technique; Mass closure of the abdominal wall \n for pancreatic and biliary fistula, and intra-abdominal abscess\n s/p Tracheostomy \n s/p GJ-tube placed on .\n s/p PICC line placed on .\n s/p Hepatic drains placed on -- removed \n s/p Right-sided thoracentesis on .\n s/p J-tube placement via EC fistula and \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:115\n D:55\n Temperature:\n 96.3\n Arterial BP:\n S:155\n D:115\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 113 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 2,179 mL\n 24h total out:\n 1,570 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 02:34 AM\n Potassium:\n 3.8 mEq/L\n 02:34 AM\n Chloride:\n 105 mEq/L\n 02:34 AM\n CO2:\n 24 mEq/L\n 02:34 AM\n BUN:\n 16 mg/dL\n 02:34 AM\n Creatinine:\n 1.0 mg/dL\n 02:34 AM\n Glucose:\n 70 mg/dL\n 02:34 AM\n Hematocrit:\n 27.3 %\n 02:34 AM\n Finger Stick Glucose:\n 181\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: 9\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2173-10-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 487735,
"text": "HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula now with hypotension and change\n in MS.\n Chief complaint:\n Hypotension, change in MS\n :\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy\n Sepsis without organ dysfunction\n Assessment:\n Afebrile\n WBC 9\n Post transfusion Hct 28\n SBP 100s-120s\n Large brown loose stool x 1\n Action:\n Multi abx given per orders\n C-Diff sent \n Did not give pts banana flakes\n ? C-diff\n only 1 BM x few days per pt\n 0.5mg Dilaudid given IV for pain\n Response:\n Pt remained stable with no s/s sepsis overnight\n Pt slept overnight\n Plan:\n Cont multi abx\n ? Advance diet today\n Transfer to floor today\n"
},
{
"category": "Radiology",
"chartdate": "2173-10-17 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1100051,
"text": " 1:34 PM\n PORTABLE ABDOMEN Clip # \n Reason: upright eval for free air\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with tachycardia lactate 7\n REASON FOR THIS EXAMINATION:\n upright eval for free air\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN \n\n COMPARISON: .\n\n INDICATION: Assess for free air.\n\n Only a supine portable view of the abdomen is submitted for interpretation,\n precluding assessment for free intraperitoneal air. Considering the clinical\n concern, either a fully upright or left lateral decubitus view would be\n recommended. A percutaneous feeding tube is present terminating in the\n expected location of the jejunum. A non-obstructive bowel gas pattern is\n visualized.\n\n\n"
},
{
"category": "Nutrition",
"chartdate": "2173-10-18 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 487551,
"text": "Subjective: RN, tube feeds are to restart today.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 180 cm\n 58.2 kg\n 58.2 kg ()\n 17.9\n Pertinent medications: Dextrose 5% Lactated Ringers @125mL/hr, Abx,\n RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 82 mg/dL\n 02:47 AM\n Glucose Finger Stick\n 99\n 10:00 AM\n BUN\n 17 mg/dL\n 02:47 AM\n Creatinine\n 1.3 mg/dL\n 02:47 AM\n Sodium\n 134 mEq/L\n 02:47 AM\n Potassium\n 3.9 mEq/L\n 02:47 AM\n Chloride\n 105 mEq/L\n 02:47 AM\n TCO2\n 20 mEq/L\n 02:47 AM\n PO2 (arterial)\n 104 mm Hg\n 03:02 AM\n PCO2 (arterial)\n 37 mm Hg\n 03:02 AM\n pH (arterial)\n 7.39 units\n 03:02 AM\n pH (urine)\n 7.0 units\n 08:15 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 03:02 AM\n Calcium non-ionized\n 7.3 mg/dL\n 02:47 AM\n Phosphorus\n 3.8 mg/dL\n 02:47 AM\n Magnesium\n 1.4 mg/dL\n 02:47 AM\n ALT\n 15 IU/L\n 02:47 AM\n Alkaline Phosphate\n 526 IU/L\n 02:47 AM\n AST\n 21 IU/L\n 02:47 AM\n Amylase\n 139 IU/L\n 12:56 PM\n Total Bilirubin\n 3.5 mg/dL\n 02:47 AM\n WBC\n 22.1 K/uL\n 02:47 AM\n Hgb\n 8.1 g/dL\n 02:47 AM\n Hematocrit\n 24.0 %\n 02:47 AM\n Current diet order / nutrition support: Tube Feeds: Replete with Fiber\n @ 90mL/hr (2160kcals, 134g protein)\n Diet: NPO\n GI: J-tube via fistula\n Assessment of Nutritional Status\n 69 y.o.Male s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and J-tube\n placed through enterocutaneous fistula now with hypotension and change\n in MS. \ns tube feeds have been off/on since (and when\n running, only running at 10mL/hr) due to nausea, wretching, and foul\n smelling drainage via fistula. Plan is to restart tube feeds today at\n trophic rate to test tolerance. Patient is no longer allowed to take\n po\ns for pleasure at this time; is now NPO. Current tube feed order\n likely provides excessive protein (2.3g/kg), thus recommend changing\n formula to better meet needs. If patient is unable to tolerate enteral\n feeds, he may need TPN. Noted Mag repletions.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend tube feeding goal of Fibersource @ 90mL/hr\n x18hrs. Start at 10mL/hr and advance slowly as tolerated.\n Banana flakes TID once tube feeding is tolerated and\n advancing toward goal.\n Montior lytes, continue to replete as needed.\n Following - #\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 487421,
"text": "Sepsis without organ dysfunction\n Assessment:\n Pt with ?septic shower episode earlier today \n Low grade febrile at start of shift, slight ST low 100s, SBP\n range 89-120s\n AM labs showing WBC grossly elevated to 22 from 8\n AM labs also showing drop in hct from 30 to 24, however pt\n did receive multiple fld boluses in between lab draws\n likely pt\n dehydration falsely elevating hct, and later draw dilutional\n Lactate trending downward ~2 from 7\n Action:\n Cont abx as ordered\n Response:\n Pt with stable night, mostly sleeping\n Plan:\n Cont to monitor for worsening symptoms sepsis\n Cont to monitor hemodynamics\n .H/O cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Abd soft, tender, +BS\n Jtube cont clamped\n Fistula bag/appliance around Jtube collecting bilious/cloudy\n fld\n Abd pain reported few times through out shift, pain\n Action:\n Cont on IV clindamycin, cipro, Linezolid, flagyl\n Compazine x1\n IVP 0.5mg x2 dilaudid for pain, fentanyl patch cont\n Response:\n Plan:\n Cont abx\n Cont pain control\n Malnutrition\n Assessment:\n TF off\n Strict NPO\n Sudden onset of nausea/wretching x1\n Action:\n IVF with dextrose continues\n Response:\n N/V controlled with zofran, compezine\n Plan:\n Cont to treat N/V\n ?Nutrition consult/ recommendations\n ?Need to restart TPN if pt cannot tolerate adequate TF\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 487699,
"text": "HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula now with hypotension and change\n in MS.\n .\n Chief complaint:\n Hypotension, change in MS\n :\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n .\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy\n Sepsis without organ dysfunction\n Assessment:\n Afebrile\n WBC 9\n Post transfusion Hct 28\n SBP 100s-120s\n Large brown loose stool x 1\n Action:\n Multi abx given per orders\n C-Diff sent \n Did not give pts banana flakes d/t ? C-diff and only 1 BM x few days\n Response:\n Pt remained stable wit no s/s sepsis overnight\n Plan:\n Cont multi \n Transfer to floor if pt remains stable\n"
},
{
"category": "Physician ",
"chartdate": "2173-10-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 487806,
"text": "SICU\n HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula now with hypotension and change\n in MS.\n Chief complaint:\n PMHx:\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n .\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy\n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:42 PM\n STOOL CULTURE - At 12:44 AM\n CALLED OUT\n Wants to take PO.\n Allergies:\n Azithromycin\n Rash;\n Zosyn (Intraven) (Piperacillin Sodium/Tazobactam)\n Rash;\n Meropenem\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 08:00 PM\n Ciprofloxacin - 08:32 PM\n Linezolid - 10:23 PM\n Metronidazole - 12:21 AM\n Clindamycin - 02:06 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 04:42 PM\n Hydromorphone (Dilaudid) - 12:00 AM\n Other medications:\n :\n Ursodiol 600 mg po bid\n Metoprolol 50mg po BID\n Metoclopramide 5mg po QID\n Hydromorphine hcl 2mg po Q4H prn pain\n Iron\n Albuterol\n Ipratropium\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36\nC (96.8\n T current: 35.8\nC (96.4\n HR: 79 (63 - 87) bpm\n BP: 117/57(72) {95/45(57) - 117/67(78)} mmHg\n RR: 12 (11 - 20) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 60.5 kg (admission): 58.2 kg\n Height: 71 Inch\n CVP: 5 (-1 - 7) mmHg\n Total In:\n 4,994 mL\n 747 mL\n PO:\n Tube feeding:\n 171 mL\n 168 mL\n IV Fluid:\n 4,448 mL\n 579 mL\n Blood products:\n 375 mL\n Total out:\n 2,290 mL\n 1,070 mL\n Urine:\n 2,285 mL\n 970 mL\n NG:\n Stool:\n Drains:\n 5 mL\n 100 mL\n Balance:\n 2,704 mL\n -323 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Soft, Tender: , G tube\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3)\n Labs / Radiology\n 236 K/uL\n 9.0 g/dL\n 70 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 105 mEq/L\n 135 mEq/L\n 27.3 %\n 9.3 K/uL\n [image002.jpg]\n 03:19 AM\n 02:38 AM\n 05:57 AM\n 12:20 PM\n 12:56 PM\n 02:47 AM\n 03:02 AM\n 08:36 PM\n 02:34 AM\n WBC\n 18.3\n 9.7\n 5.3\n 8.1\n 22.1\n 11.2\n 9.3\n Hct\n 29.2\n 28.0\n 28.9\n 30.7\n 24.0\n 27.9\n 27.3\n Plt\n 233\n 221\n 250\n \n 236\n Creatinine\n 1.1\n 0.9\n 1.0\n 1.2\n 1.3\n 1.0\n Troponin T\n 0.01\n 0.02\n TCO2\n 17\n 23\n Glucose\n 167\n 87\n 80\n 61\n 82\n 70\n Other labs: PT / PTT / INR:12.6/26.5/1.1, CK / CK-MB / Troponin\n T:11//0.02, ALT / AST:14/16, Alk-Phos / T bili:447/2.7, Amylase /\n Lipase:139/61, Differential-Neuts:91.8 %, Band:15.0 %, Lymph:4.8 %,\n Mono:2.6 %, Eos:0.5 %, Lactic Acid:2.7 mmol/L, Albumin:2.0 g/dL,\n LDH:108 IU/L, Ca:7.8 mg/dL, Mg:2.2 mg/dL, PO4:3.5 mg/dL\n Imaging: CXR moderate R pleural effusion increased, rightward\n mediastinal shift ?opacification in R lower lobe is atelectasis.\n CT abd/pelv = Interval decrease in size of collections. New\n ill-defined hypodense lesions @ lateral right hepatic lobe. Tiny new\n fluid collection in the right lateral abdominal wall @ prior drain.\n Microbiology: SWAB No PMN, No Micro prelim NG\n Blood Culture P\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, MALNUTRITION, .H/O CANCER (MALIGNANT\n NEOPLASM), PANCREAS\n Assessment and Plan: 69M s/p Whipple, revision, r/w anemia HCT 22 w/\n change in MS, resolved hypotension.\n Neurologic: AOx3. AMS with hypotension resolved. Fentanyl patch.\n Minimal dilaudid PRN.\n Cardiovascular: Hypotension responsive to fluid. SVT to 170s-180s, r/o\n MI with CE.\n Pulmonary: No active issues, R plueral effusion on CXR.\n Gastrointestinal / Abdomen: ECF w/ostomy appliace surrounding, On\n Cipro, linezolid, clinda for hepatic abscesses. Cefepime added due\n to continued spikes to double cover psuedomonas. Tender abdomen. CT\n w/o signs of intra-abdominal collection needing drainage.\n Worsening APhos, bili. Lactate 7 on . N/V ON ,\n zofran+compazine prn.\n Nutrition: TF on hold. NPO.\n Renal: Cr normal.\n Hematology: Stable anemia. Febrile and WBC 8.1-22, ?previously\n leukopenic. Suggestive of sepsis.\n Endocrine: Hypoglycemia, resolved getting D5 in IVF. SSI.\n Infectious Disease: Cipro,Cefepime, clinda, flagyl, linezolid (for\n VRE). Hx of Enterococci bacteremia tx w/ V/G/C/F (). Tender\n abdomen. +diarrhea, check CDiff w/BM. Isolation for VRE/MRSA. WBC\n normalized.\n Lines / Tubes / Drains: epigastric enterocutaneous fistula, RUQ former\n drain site, R PIV, J tube, Foley, R SCL (), L Aline ()\n Wounds:\n Imaging:\n Fluids:\n Consults: West2\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:27 PM 30 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n 18 Gauge - 08:26 PM\n Prophylaxis:\n DVT: (HSQ, SCDs, H2B)\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: floor\n Total time spent: 31 min\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 486456,
"text": "TITLE:\n Hypotension (not Shock)\n Assessment:\n Received from 9 for hypotension, low grade fever and changes in\n mental status-Temp98.8 orally Initial sbp 104/50 100 no ectopics\n sbp trending down 70\ns to 90 sbp shortly after adm. Alert , oriented\n self and vaguely oriented to time/place, FS glucose 77 upon adm. O2 sat\n 96-93% on rm air. Bilat brth snds clear upper lobes, crackles lt base,\n diminish rt base, no cough. Neuro exam otherwise unremarkable. Abd\n jtube w ostomy bag (enterocutaneous fistula)golden bilious drainage\n moderate amts thin drainage. Abd soft nontender, not distended, active\n bowel sounds audible. Periph iv x 2 ,no iv fluids infusing on adm.\n Action:\n D50\n amp given,\n Ivf- NS started at 100cc/hr and fld bolus ns 1 liter hung\n for hypotension.\n Foley cath placed and initial drained 260cc icteric urine.\n Labs sent after d50 given\n Response:\n Plan:\n .H/O cancer (Malignant Neoplasm), duodenal\n Assessment:\n Jtube w ostomy bag around site draining bilious drainage.\n Action:\n Npo, drainage bag emptied for\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2173-10-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 486563,
"text": "SICU\n HPI:\n 69 yo M s/p whipple c/b biliary enteric and enterocutaneous fistulas\n now with fevers/ FTT, likely cholangitis\n HPI: PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p whipple\n complicated by biliary enteric and\n enterocutaneous fistula. Pt is s/p redo of jejeunal-hepatic anastamosis\n x 2 and j tube placed through enterocutaneous fistula, with recurrent\n cholangitis thought secondary to reflux of enteric contents into\n biliary tree, now s/p biliary drain, with fevers, elevated WBC, rising\n Tbili, all suggestive of cholangitis. Hypotensive requiring fluid\n boluses, now on aztreonam, cipro, and flagyl\n Chief complaint:\n Change in ms, anemia\n PMHx:\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy, as above\n Current medications:\n Active Medications ,\n 1. IV access: Peripheral line Order date: @ 0314 9. Heparin 5000\n UNIT SC BID Order date: @ 0314\n 2. IV access: Peripheral line Order date: @ 0314 10. Linezolid\n 600 mg PO Q12H\n to end Order date: @ 0314\n 3. 1000 mL NS\n Continuous at 100 ml/hr Order date: @ 0319 11. Metoprolol\n Tartrate 5 mg IV Q6H prn hr >100\n hold for sbp<100 or Hr>60 Order date: @ 0339\n 4. Ciprofloxacin 400 mg IV Q12H Order date: @ 0339 12.\n Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 0314\n 5. Clindamycin 600 mg IV Q8H Order date: @ 0339 13. 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: @ 0314\n 6. Famotidine 20 mg IV Q24H Order date: @ 0339 14. 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: @ 0314\n 7. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0314 15.\n Triamcinolone Acetonide 0.1% Cream 1 Appl TP :PRN pruritus Order\n date: @ 0314\n 8. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H:PRN pain Order date: \n @ 0346 16. Ursodiol 600 mg PO BID Order date: @ 0314\n 24 Hour Events:\n Admitted to sicu for change in ms, unresponsive, hypotension\n 80s, bolused 1L. Given amp for hypoglycemia, aline\n Allergies:\n Azithromycin\n Rash;\n Zosyn (Intraven) (Piperacillin Sodium/Tazobactam)\n Rash;\n Meropenem\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.2\nC (98.9\n HR: 104 (104 - 104) bpm\n BP: 104/60(71) {104/60(71) - 104/60(71)} mmHg\n RR: 19 (19 - 20) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 42 mL\n PO:\n Tube feeding:\n IV Fluid:\n 42 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 42 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Non-distended, Bowel sounds present, Tender: Throughout with\n palpation, no r/g, + BS. ECF with yellowing tf material. Former PTC\n drain wound c/d/i.\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n [image002.jpg]\n Imaging: CT abd: Unchanged position of two right lobe percutaneous\n drainage catheters within hepatic abscesses. three new collections up\n to 2 cm in diameterare present in the right lobe at the hepatic dome.\n Rigtt-sided pleural effusion with pleural enhancement; bilateral renal\n hypodensities.\n Microbiology: Blood Culture P\n Blood Culture P\n SWAB No PMN, No Micro\n Urine Cx P\n Blood Culture P\n Blood Culture P\n Blood Culture P\n Assessment and Plan\n Assessment and Plan: 69M s/p Whipple, revision, r/w anemia Hct 22. with\n change in ms hypotension.\n Neuro: fentanyl patch, dilaudid PRN\n CVS: Hypotension, s/p IVF bolus 500cc x2 with resolution into the igh\n 90s low 100s systolic bps.\n Pulm: No active issues, R plueral effusion on cxr\n GI: Ecf with ostomy appliace surrounding, On Cipro, linazolid, clinda\n for hepatic abscesses will d/w primary team RE CT in am, possible\n drainage procedure . Tender abdomen with hx of recurrent cholangitis\n Not tolerating TF Increased bili\n FEN: Tube feeds on hold, NPO , NS 100/hr Change to D5\n NS @100\n Renal: Cr 1.2 ~baseline , hyperkalemia will monitor.\n Heme: HCT 22.8--> transfuse 2u PRBC , f/u post transfusion hct now\n 31.5 stable/\n Endo: Hypoglycemia to 70s given amp d50.\n ID: Pancultured. History of Enterococci bacteremia s/p rx\n with Vanc/gent/cipro/flagyl. Slight leukocytosis with left shift.\n Tender abdomen. Hx of diarrhea- will check c.diff. Probable CT today\n Wounds: enterocutaneous fistula\n Consults: West2\n Billing Diagnosis:\n ICU Care\n Nutrition: NPO\n Glycemic Control: none\n Lines:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 min\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 486547,
"text": "TITLE:\n Hypotension (not Shock)\n Assessment:\n Received from 9 for hypotension, low grade fever and changes in\n mental status-Temp98.8 orally Initial sbp 104/50 100 no ectopics\n sbp trending down 70\ns to 90 sbp shortly after adm. Alert , oriented\n self and vaguely oriented to time/place, FS glucose 77 upon adm. O2 sat\n 96-93% on rm air. Bilat brth snds clear upper lobes, crackles lt base,\n diminish rt base, no cough. Neuro exam otherwise unremarkable. Abd\n jtube w ostomy bag (enterocutaneous fistula)golden bilious drainage\n moderate amts thin drainage. Abd soft nontender, not distended, active\n bowel sounds audible. Periph iv x 2 ,no iv fluids infusing on adm.\n Action:\n D50\n amp given,\n Ivf- NS started at 100cc/hr and fld bolus ns 1 liter hung\n for hypotension.\n Foley cath placed and initial drained 260cc icteric\n urine.U/A and cult sent.\n Labs sent after d50 given\n Antibiotic coverage changed to IV route. 1^st dose IV\n Clindamycin given\n Rt radial art line placed by Dr \n Response:\n Glucose 167 post rx for hypoglycemia. Sbp > 90 subsequent to fld bolus.\n Uop 30cc/hr\n Plan:\n Cont IVF as ordered, ,monitor bp and uop\n .H/O cancer (Malignant Neoplasm), duodenal\n Assessment:\n Jtube w fistula w ostomy bag to rt lateral abd- site w foul bilious\n drainage. Denies nausea, pain or tenderness.Afebrile\n Action:\n Npo, jtube clamped. Ostomy drainage bag emptied for 50cc foul smelling\n drng.\n Response:\n fistula drainage continues small amts.\n Plan:\n Abd CT scan today per primary team.\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 486551,
"text": "TITLE:\n 69 yo M s/p whipple c/b biliary enteric and enterocutaneous fistulas\n now with fevers/ FTT, likely cholangitis\n HPI: PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p whipple\n complicated by biliary enteric and\n enterocutaneous fistula. Pt is s/p redo of jejeunal-hepatic anastamosis\n x 2 and j tube placed through enterocutaneous fistula, with recurrent\n cholangitis thought secondary to reflux of enteric contents into\n biliary tree, now s/p biliary drain, with fevers, elevated WBC, rising\n Tbili, all suggestive of cholangitis. Hypotensive requiring fluid\n boluses on linezolid, clindamycin and cipro.\n Chief complaint:\n Change in ms, anemia\n PMHx:\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy, as above\n Hypotension (not Shock)\n Assessment:\n Received from 9 for hypotension, low grade fever and changes in\n mental status-Temp98.8 orally Initial sbp 104/50 100 no ectopics\n sbp trending down 70\ns to 90 sbp shortly after adm. Alert , oriented\n self and vaguely oriented to time/place, FS glucose 77 upon adm. O2 sat\n 96-93% on rm air. Bilat brth snds clear upper lobes, crackles lt base,\n diminish rt base, no cough. Neuro exam otherwise unremarkable. Abd\n jtube w ostomy bag (enterocutaneous fistula)golden bilious drainage\n moderate amts thin drainage. Abd soft nontender, not distended, active\n bowel sounds audible. Periph iv x 2 ,no iv fluids infusing on adm.\n Action:\n D50\n amp given,\n Ivf- NS started at 100cc/hr and fld bolus ns 1 liter hung\n for hypotension.\n Foley cath placed and initial drained 260cc icteric\n urine.U/A and cult sent.\n Labs sent after d50 given\n Antibiotic coverage changed to IV route. 1^st dose IV\n Clindamycin given\n Rt radial art line placed by Dr \n Response:\n Glucose 167 post rx for hypoglycemia. Sbp > 90 subsequent to fld bolus.\n Uop 30cc/hr\n Plan:\n Cont IVF as ordered, ,monitor bp and uop. ?Central line placemnt to\n follow fld status/ access.\n .H/O cancer (Malignant Neoplasm), duodenal\n Assessment:\n Jtube w fistula w ostomy bag to rt lateral abd- site w foul bilious\n drainage. Denies nausea, pain or tenderness.Afebrile\n Action:\n Npo, jtube clamped. Ostomy drainage bag emptied for 50cc foul smelling\n drng.\n Response:\n fistula drainage continues small amts.\n Plan:\n Abd CT scan today per primary team.\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 486745,
"text": "H/O cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Abd soft, tender, +BS\n Jtube cont clamped\n Fistula bag/appliance around Jtube collecting bilious/cloudy\n fld, ~100cc output this shift\n Abd pain reported few times through out shift\n Based on elevated WBC, elevated temp overnoc, abd\n sensitivity/diarrhea, h/o of CDIFF and tx of multiple abx, suspected\n infection is CDIFF vs. other infectious abd collection\n Action:\n Pt started on Linezolid, flagyl\n Cont on IV clindamycin, cipro\n Appliance ostomy bag changed by wound RN, supplies left in\n pt room\n Pt taken for CT scan for ?abscess/possible necessity for\n drain placement down in CT\n IVP 0.5mg dilaudid for pain, fentanyl patch applied as\n ordered q 72h\n Response:\n Pt afebrile, NSR, normotensive\n Plan:\n Cont abx\n Cont pain control\n ?trans back to 9 tomorrow\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 486802,
"text": "H/O cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Abd soft, tender, +BS\n Jtube cont clamped for pt comfort (pt refuses TF\ns after\n discussion with Dr. yesterday)\n Fistula bag/appliance around Jtube draining dark yellow foul\n smelling drainage\n Pt reports abdominal pain \n Action:\n Continues on Linezolid, flagyl, cipro, clindamycin\n Dilaudid prn and fentanyl patch\n Response:\n Pt afebrile\n Hemodynamically stable\n Pain resolved with Dilaudid\n Plan:\n Cont antibiotic regimen\n Cont monitor and control pain\n ?restart TF\ns today. Pt will discuss with team\n Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 486924,
"text": "SICU\n HPI:\n 69 yo M s/p whipple c/b biliary enteric and enterocutaneous fistulas\n now with fevers/ FTT, likely cholangitis\n HPI: PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p whipple\n complicated by biliary enteric and\n enterocutaneous fistula. Pt is s/p redo of jejeunal-hepatic anastamosis\n x 2 and j tube placed through enterocutaneous fistula, with recurrent\n cholangitis thought secondary to reflux of enteric contents into\n biliary tree, now s/p biliary drain, with fevers, elevated WBC, rising\n Tbili, all suggestive of cholangitis. Hypotensive requiring fluid\n boluses, now on aztreonam, cipro, and flagyl\n Chief complaint:\n Change in ms, anemia\n PMHx:\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy, as above\n .H/O cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Abd. Soft,nontender,+ bowelsounds. No flatus,no stool. Banana flakes\n held pending stool specimen for c. fii.tolerating fibersource hn at 10\n ml/hr via j tube. occasional nausea,retching. Tol. Small amounts of\n food supplied by family. Iv hydration continues.leaking foul smelling\n bilious drainage from ec fistula site where j tube enters. Skin\n intact,appliance changed with continued leakage.\n Action:\n Multiple antibiotics continue,zofran & dilaudid continue prn,iv\n rehydration,\n Response:\n Afebrile,hemodynamically stable,tolerating low rate tube\n feedings,appetite improved\n Plan:\n Send stool for c. diff ,continue antibiotic therapy,monitor & control\n pain,nausea\n Malnutrition\n Assessment:\n Tube feeds resumed at low dose,poor po intake,transient nausea\n especially with moving,turning\n Action:\n Zofran prn,advance tube feedings per team,? Tpn if unable to tolerate\n enteral nutrition\n Response:\n Tolerating small amounts of food brought in by family,nausea controlled\n woth zofran\n Plan:\n As above\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 487721,
"text": "HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula now with hypotension and change\n in MS.\n Chief complaint:\n Hypotension, change in MS\n :\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy\n Sepsis without organ dysfunction\n Assessment:\n Afebrile\n WBC 9\n Post transfusion Hct 28\n SBP 100s-120s\n Large brown loose stool x 1\n Action:\n Multi abx given per orders\n C-Diff sent \n Did not give pts banana flakes\n ? C-diff\n only 1 BM x few days\n 0.5mg Dilaudid given IV for pain\n Response:\n Pt remained stable with no s/s sepsis overnight\n Pt slept overnight\n Plan:\n Cont multi abx\n ? Advance diet today\n Transfer to floor today\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 486713,
"text": "Malnutrition\n Assessment:\n Pt with h/o extremely poor PO intake\n H/o TPN use\n Pt had been on TF @90cc/hr, NOT tolerating\n Action:\n Pt started back on PO\ns per pt comfort allowed by Dr.\n in afternoon\n Response:\n Pt tolerating small amts PO\n Plan:\n Plan to restart TF tomorrow per Dr.\n Allowing clears overnoc per pt comfort\n F/u on nutritional status, reccomendations\n .H/O cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Abd soft, tender, +BS\n Jtube cont clamped\n Fistula bag/appliance around Jtube collecting bilious/cloudy\n fld, ~100cc output this shift\n Abd pain reported few times through out shift\n Based on elevated WBC, elevated temp overnoc, abd\n sensitivity/diarrhea, h/o of CDIFF and tx of multiple abx, suspected\n infection is CDIFF vs. other infectious abd collection\n Action:\n Pt started on Linezolid, flagyl\n Cont on IV clindamycin, cipro\n Appliance ostomy bag changed by wound RN, supplies left in\n pt room\n Pt taken for CT scan for ?abscess/possible necessity for\n drain placement down in CT\n IVP 0.5mg dilaudid for pain, fentanyl patch applied as\n ordered q 72h\n Response:\n Pt afebrile, NSR, normotensive\n Plan:\n Cont abx\n Cont pain control\n ?trans back to 9 tomorrow\n Hypotension (not Shock)\n Assessment:\n Earlier in shift pt more hypotensive 80s-90s SBP\n For large majority of shift, pt normotensive, SBP ~100-140\n Action:\n IVF continues at 100cc/hr, fld changed to 1/2NSD5\n Response:\n Suspected dehydration 2/t recent h/o diarrhea\n Pt now normotensive\n Plan:\n Hypotension resolved\n Cont to monitor hemodynamics\n"
},
{
"category": "Physician ",
"chartdate": "2173-10-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 486872,
"text": "SICU\n HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula, with recurrent cholangitis\n thought secondary to reflux of enteric contents into biliary tree, now\n s/p biliary drain, with fevers, elevated WBC, rising Tbili, all\n suggestive of cholangitis. Hypotensive requiring fluid boluses, now on\n aztreonam, cipro, and flagyl\n Chief complaint:\n PMHx:\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n .\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy\n Current medications:\n 24 Hour Events:\n SICU for change in MS, unresponsive, SBP 80s, bolused 1L.\n aline. CT abd, no drainage required. TF resumed 10mL/hr.\n Allergies:\n Azithromycin\n Rash;\n Zosyn (Intraven) (Piperacillin Sodium/Tazobactam)\n Rash;\n Meropenem\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Linezolid - 10:15 PM\n Metronidazole - 12:08 AM\n Clindamycin - 03:01 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Hydromorphone (Dilaudid) - 08:05 PM\n Famotidine (Pepcid) - 06:01 AM\n Other medications:\n :\n Ursodiol 600 mg po bid\n Metoprolol 50mg po BID\n Metoclopramide 5mg po QID\n Hydromorphine hcl 2mg po Q4H prn pain\n Iron\n Albuterol\n Ipratropium\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.1\nC (97\n T current: 35.9\nC (96.6\n HR: 75 (65 - 96) bpm\n BP: 140/57(87) {104/24(54) - 140/59(88)} mmHg\n RR: 17 (10 - 22) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 58.2 kg (admission): 58.2 kg\n Height: 71 Inch\n Total In:\n 5,362 mL\n 932 mL\n PO:\n 60 mL\n Tube feeding:\n 5 mL\n IV Fluid:\n 5,182 mL\n 927 mL\n Blood products:\n Total out:\n 1,905 mL\n 1,120 mL\n Urine:\n 1,750 mL\n 1,060 mL\n NG:\n Stool:\n Drains:\n 155 mL\n 60 mL\n Balance:\n 3,457 mL\n -188 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: (Expansion: Symmetric)\n Abdominal: Soft, Non-distended, Tender: , G tube\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3)\n Labs / Radiology\n 221 K/uL\n 9.1 g/dL\n 87 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 102 mEq/L\n 134 mEq/L\n 28.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:19 AM\n 02:38 AM\n WBC\n 18.3\n 9.7\n Hct\n 29.2\n 28.0\n Plt\n 233\n 221\n Creatinine\n 1.1\n 0.9\n Troponin T\n 0.01\n Glucose\n 167\n 87\n Other labs: PT / PTT / INR:12.6/26.5/1.1, CK / CK-MB / Troponin\n T:8//0.01, ALT / AST:22/26, Alk-Phos / T bili:554/2.8, Amylase /\n Lipase:92/62, Ca:7.8 mg/dL, Mg:1.6 mg/dL, PO4:3.4 mg/dL\n Imaging: CT abd Unchanged position of 2 R lobe percutaneous\n drainage catheters w/in hepatic abscesses. 3 new collections up to 2cm\n in diameter are present in R lobe at hepatic dome. R pleural effusion\n w/ pleural enhancement; B renal hypodensities.\n CXR moderate R pleural effusion increased, rightward\n mediastinal shift ?opacification in R lower lobe is atelectasis.\n CT abd/pelv P\n Microbiology: Blood Culture P\n Blood Culture P\n Urine Cx P\n Blood Culture P\n Blood Culture P\n SWAB No PMN, No Micro\n Blood Culture P\n Assessment and Plan\n MALNUTRITION, .H/O CANCER (MALIGNANT NEOPLASM), PANCREAS\n Assessment and Plan: 69M s/p Whipple, revision, r/w anemia HCT 22 w/\n change in MS, resolved hypotension.\n Neurologic: AOx3. Fentanyl patch. Minimal dilaudid PRN.\n Cardiovascular: Hypotension, s/p IVF bolus 500mL x2 w/resolution.\n Pulmonary: No active issues, R plueral effusion.\n Gastrointestinal / Abdomen: ECF w/ostomy appliace surrounding, On\n Cipro, linezolid, clinda for hepatic abscesses. Tender abdomen w/ hx\n recurrent cholangitis. CT w/o signs of intra-abdominal collection\n needing drainage. Improving APhos, bili.\n Nutrition: TF held s/p resumed at 10mL/hr w/ subsequent n/v. Clear\n liquids for pleasure. NS 100/hr\n Renal: Cr normal.\n Hematology: HCT 32>28 S/p transfusion 2U PRBC .\n Endocrine: Hypoglycemia to 70s tx w/ amp d50.\n Infectious Disease: Cipro, clinda, flagyl, linezolid (for VRE). Hx of\n Enterococci bacteremia tx w/ V/G/C/F (). Tender abdomen. Hx of\n diarrhea, check CDiff w/BM. Isolation for VRE/MRSA. WBC normalized.\n Lines / Tubes / Drains: G-tube, R PIV,\n Wounds: epigastric enterocutaneous fistula, RUQ\n Imaging:\n Fluids:\n Consults: West2\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:47 AM 10 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 04:08 AM\n Arterial Line - 05:07 AM\n 22 Gauge - 12:57 PM\n Prophylaxis:\n DVT: ( HSQ, SCDs, H2B)\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2173-10-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 486896,
"text": "SICU\n HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula, with recurrent cholangitis\n thought secondary to reflux of enteric contents into biliary tree, now\n s/p biliary drain, with fevers, elevated WBC, rising Tbili, all\n suggestive of cholangitis. Hypotensive requiring fluid boluses, now on\n aztreonam, cipro, and flagyl\n Chief complaint:\n PMHx:\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n .\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy\n Current medications:\n 24 Hour Events:\n SICU for change in MS, unresponsive, SBP 80s, bolused 1L.\n aline. CT abd, no drainage required. TF resumed 10mL/hr.\n Allergies:\n Azithromycin\n Rash;\n Zosyn (Intraven) (Piperacillin Sodium/Tazobactam)\n Rash;\n Meropenem\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Linezolid - 10:15 PM\n Metronidazole - 12:08 AM\n Clindamycin - 03:01 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Hydromorphone (Dilaudid) - 08:05 PM\n Famotidine (Pepcid) - 06:01 AM\n Other medications:\n :\n Ursodiol 600 mg po bid\n Metoprolol 50mg po BID\n Metoclopramide 5mg po QID\n Hydromorphine hcl 2mg po Q4H prn pain\n Iron\n Albuterol\n Ipratropium\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.1\nC (97\n T current: 35.9\nC (96.6\n HR: 75 (65 - 96) bpm\n BP: 140/57(87) {104/24(54) - 140/59(88)} mmHg\n RR: 17 (10 - 22) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 58.2 kg (admission): 58.2 kg\n Height: 71 Inch\n Total In:\n 5,362 mL\n 932 mL\n PO:\n 60 mL\n Tube feeding:\n 5 mL\n IV Fluid:\n 5,182 mL\n 927 mL\n Blood products:\n Total out:\n 1,905 mL\n 1,120 mL\n Urine:\n 1,750 mL\n 1,060 mL\n NG:\n Stool:\n Drains:\n 155 mL\n 60 mL\n Balance:\n 3,457 mL\n -188 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: (Expansion: Symmetric)\n Abdominal: Soft, Non-distended, Tender: , G tube\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3)\n Labs / Radiology\n 221 K/uL\n 9.1 g/dL\n 87 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 102 mEq/L\n 134 mEq/L\n 28.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:19 AM\n 02:38 AM\n WBC\n 18.3\n 9.7\n Hct\n 29.2\n 28.0\n Plt\n 233\n 221\n Creatinine\n 1.1\n 0.9\n Troponin T\n 0.01\n Glucose\n 167\n 87\n Other labs: PT / PTT / INR:12.6/26.5/1.1, CK / CK-MB / Troponin\n T:8//0.01, ALT / AST:22/26, Alk-Phos / T bili:554/2.8, Amylase /\n Lipase:92/62, Ca:7.8 mg/dL, Mg:1.6 mg/dL, PO4:3.4 mg/dL\n Imaging: CT abd Unchanged position of 2 R lobe percutaneous\n drainage catheters w/in hepatic abscesses. 3 new collections up to 2cm\n in diameter are present in R lobe at hepatic dome. R pleural effusion\n w/ pleural enhancement; B renal hypodensities.\n CXR moderate R pleural effusion increased, rightward\n mediastinal shift ?opacification in R lower lobe is atelectasis.\n CT abd/pelv P\n Microbiology: Blood Culture P\n Blood Culture P\n Urine Cx P\n Blood Culture P\n Blood Culture P\n SWAB No PMN, No Micro\n Blood Culture P\n Assessment and Plan\n MALNUTRITION, .H/O CANCER (MALIGNANT NEOPLASM), PANCREAS\n Assessment and Plan: 69M s/p Whipple, revision, r/w anemia HCT 22 w/\n change in MS, resolved hypotension. No evidence of abscess on imaiging.\n Neurologic: AOx3. Fentanyl patch. Minimal dilaudid PRN.\n Cardiovascular: Hypotension, s/p IVF bolus 500mL x2 w/resolution.\n Pulmonary: No active issues, R plueral effusion.\n Gastrointestinal / Abdomen: ECF w/ostomy appliace surrounding, On\n Cipro, linezolid, clinda for hepatic abscesses. Tender abdomen w/ hx\n recurrent cholangitis. CT w/o signs of intra-abdominal collection\n needing drainage. Improving APhos, bili.\n Nutrition: TF held s/p resumed at 10mL/hr w/ subsequent n/v. Clear\n liquids for pleasure. NS 100/hr\n Renal: Cr normal.\n Hematology: HCT 32>28 S/p transfusion 2U PRBC .\n Endocrine: Hypoglycemia to 70s tx w/ amp d50.\n Infectious Disease: Cipro, clinda, flagyl, linezolid (for VRE). Hx of\n Enterococci bacteremia tx w/ V/G/C/F (). Tender abdomen. Hx of\n diarrhea, check CDiff w/BM. Isolation for VRE/MRSA. WBC normalized.\n Lines / Tubes / Drains: G-tube, R PIV,\n Wounds: epigastric enterocutaneous fistula, RUQ\n Imaging:\n Fluids:\n Consults: West2\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:47 AM 10 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 04:08 AM\n Arterial Line - 05:07 AM\n 22 Gauge - 12:57 PM\n Prophylaxis:\n DVT: ( HSQ, SCDs, H2B)\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 487664,
"text": "Sepsis without organ dysfunction\n Assessment:\n Afebrile\n WBC 11\n SBP 100s-120s\n Large brown loose stool x 1\n Action:\n Multi abx given per orders\n C-Diff sent\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 487665,
"text": "HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula now with hypotension and change\n in MS.\n .\n Chief complaint:\n Hypotension, change in MS\n :\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n .\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy\n Sepsis without organ dysfunction\n Assessment:\n Afebrile\n WBC 11\n Post transfusion Hct 28\n SBP 100s-120s\n Large brown loose stool x 1\n Action:\n Multi abx given per orders\n C-Diff sent \n Response:\n Pt remained stable and s/s sepsis overnight\n Plan:\n Cont multi \n Transfer to floor if pt remains stable\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 486847,
"text": "H/O cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Abd soft, tender, +BS\n Jtube cont clamped for pt comfort (pt refuses TF\ns after\n discussion with Dr. yesterday)\n Fistula bag/appliance around Jtube draining dark yellow foul\n smelling drainage\n Pt reports abdominal pain \n Action:\n Continues on Linezolid, flagyl, cipro, clindamycin\n Dilaudid prn and fentanyl patch\n Response:\n Pt afebrile\n Hemodynamically stable\n Pain resolved with Dilaudid\n Plan:\n Cont antibiotic regimen\n Cont monitor and control pain\n ?restart TF\ns today. Pt will discuss with team\n Transfer to floor\n ------ Protected Section ------\n Pt agreed to restart TF\ns after speaking with Chief resident of primary\n team. TF\ns started at 10cc/hr.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:47 ------\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 487009,
"text": "SICU\n HPI:\n 69 yo M s/p whipple c/b biliary enteric and enterocutaneous fistulas\n now with fevers/ FTT, likely cholangitis\n HPI: PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p whipple\n complicated by biliary enteric and\n enterocutaneous fistula. Pt is s/p redo of jejeunal-hepatic anastamosis\n x 2 and j tube placed through enterocutaneous fistula, with recurrent\n cholangitis thought secondary to reflux of enteric contents into\n biliary tree, now s/p biliary drain, with fevers, elevated WBC, rising\n Tbili, all suggestive of cholangitis. Hypotensive requiring fluid\n boluses, now on aztreonam, cipro, and flagyl\n Chief complaint:\n Change in ms, anemia\n PMHx:\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy, as above\n .H/O cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Abd. Soft,nontender,+ bowelsounds. No flatus,no stool. Banana flakes\n held pending stool specimen for c. fii.tolerating fibersource hn at 10\n ml/hr via j tube. occasional nausea,retching. Tol. Small amounts of\n food supplied by family. Iv hydration continues.leaking foul smelling\n bilious drainage from ec fistula site where j tube enters. Skin\n intact,appliance changed with continued leakage.\n Action:\n Multiple antibiotics continue,zofran & dilaudid continue prn,iv\n rehydration,\n Response:\n Afebrile,hemodynamically stable,tolerating low rate tube\n feedings,appetite improved\n Plan:\n Send stool for c. diff ,continue antibiotic therapy,monitor & control\n pain,nausea\n Malnutrition\n Assessment:\n Tube feeds resumed at low dose,poor po intake,transient nausea\n especially with moving,turning\n Action:\n Zofran prn,advance tube feedings per team,? Tpn if unable to tolerate\n enteral nutrition\n Response:\n Tolerating small amounts of food brought in by family,nausea controlled\n woth zofran\n Plan:\n As above\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 487068,
"text": ".H/O cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Abd. Soft,nontender,+ bowelsounds. No flatus,no stool. Banana flakes\n held pending stool specimen for c. fii.tolerating fibersource hn at 10\n ml/hr via j tube. occasional nausea,retching. Tol. Small amounts of\n food supplied by family. Iv hydration continues.leaking foul smelling\n bilious drainage from ec fistula site where j tube enters. Skin\n intact,appliance changed with continued leakage.\n Action:\n Multiple antibiotics continue,zofran & dilaudid continue prn,iv\n rehydration,\n Response:\n Afebrile,hemodynamically stable,tolerating low rate tube\n feedings,appetite improved\n Plan:\n Send stool for c. diff ,continue antibiotic therapy,monitor & control\n pain,nausea\n Malnutrition\n Assessment:\n Tube feeds resumed at low dose,poor po intake,transient nausea\n especially with moving,turning\n Action:\n Zofran prn,advance tube feedings per team,? Tpn if unable to tolerate\n enteral nutrition\n Response:\n Tolerating small amounts of food brought in by family,nausea controlled\n woth zofran\n Plan:\n As above\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 487707,
"text": "HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula now with hypotension and change\n in MS.\n .\n Chief complaint:\n Hypotension, change in MS\n :\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n .\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy\n Sepsis without organ dysfunction\n Assessment:\n Afebrile\n WBC 9\n Post transfusion Hct 28\n SBP 100s-120s\n Large brown loose stool x 1\n Action:\n Multi abx given per orders\n C-Diff sent \n Did not give pts banana flakes\n ? C-diff\n only 1 BM x few days\n Response:\n Pt remained stable with no s/s sepsis overnight\n Pt slept overnight\n Plan:\n Cont multi abx\n ? start \n Transfer to floor today\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 487110,
"text": ".H/O cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Abd soft, tender, +BS\n Jtube cont clamped\n Fistula bag/appliance around Jtube collecting bilious/cloudy\n fld\n Abd pain reported few times through out shift, pain\n Action:\n Cont on IV clindamycin, cipro, Linezolid, flagyl\n IVP 0.5mg x2 dilaudid for pain, fentanyl patch cont\n Response:\n Pt low grade febrile ~99.5, NSR-low ST with exursion,\n normotensive\n Plan:\n Cont abx\n Cont pain control\n ?trans back to 9 tomorrow\n Malnutrition\n Assessment:\n TF cont at 10cc/h\n Pt with very poor PO intake\n Sudden onset of nausea/wretching recurrent, especially with\n moving, turning\n Action:\n Zofran prn\n Compezine x1 started\n Talked with pt at length re:lack of appetite and his growing\n concern that he will die if he does not start eating again\n Pt expressing wishes to eat and desire to regain appetite,\n but simply cannot eat without extreme discomfort\n Response:\n Tolerating small amounts of food brought in by family,nausea\n N/V controlled woth zofran, compezine\n Plan:\n Cont to treat N/V\n Cont to encourage POs as tolerated\n Cont trophic TF as pt can tolerate, adv per primary team/as\n pt can tolerate\n ?Nutrition consult/ recommendations\n ?Need to restart TPN if pt cannot tolerate adequate TF\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 486747,
"text": "H/O cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Abd soft, tender, +BS\n Jtube cont clamped\n Fistula bag/appliance around Jtube draining dark yellow foul\n smelling drainage\n Pt reports abdominal pain \n Action:\n Continues on Linezolid, flagyl, cipro, clindamycin\n Dilaudid prn and fentanyl patch\n Response:\n Pt afebrile\n Hemodynamically stable\n Pain resolved with Dilaudid\n Plan:\n Cont antibiotic regimen\n Cont monitor and control pain\n Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2173-10-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 487336,
"text": "SICU\n HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula now with hypotension and change\n in MS.\n .\n Chief complaint:\n Hypotension, change in MS\n :\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n .\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy\n .\n Current medications:\n Insulin SC (per Insulin Flowsheet)\n Linezolid 600 mg IV Q12H\n Metoprolol Tartrate 5 mg IV Q6H prn hr >100\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n CefePIME 2 g IV Q24H\n Midazolam 0.5 mg IV ONCE\n Ciprofloxacin 400 mg IV Q12H . Ondansetron 8 mg IV Q8H:PRN nausea\n Clindamycin 600 mg IV Q8H\n Prochlorperazine 10 mg PO/IV Q6H:PRN nausea/vomiting\n Famotidine 20 mg IV Q24H\n Fentanyl Patch 50 mcg/hr TP Q72H\n HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H:PRN pain\n Triamcinolone Acetonide 0.1% Cream\n Heparin 5000 UNIT SC BID\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:36 AM\n CALLED OUT\n Allergies:\n Azithromycin\n Rash;\n Zosyn (Intraven) (Piperacillin Sodium/Tazobactam)\n Rash;\n Meropenem\n Unknown;\n Last dose of Antibiotics:\n Clindamycin - 06:02 PM\n Ciprofloxacin - 08:02 PM\n Cefipime - 08:23 PM\n Linezolid - 10:46 PM\n Metronidazole - 11:57 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 02:09 PM\n Famotidine (Pepcid) - 05:58 PM\n Heparin Sodium (Prophylaxis) - 08:23 PM\n Hydromorphone (Dilaudid) - 10:46 PM\n Other medications:\n Flowsheet Data as of 01:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.3\nC (102.7\n T current: 36.6\nC (97.9\n HR: 84 (74 - 175) bpm\n BP: 95/36(53) {85/30(53) - 139/56(77)} mmHg\n RR: 15 (13 - 39) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 58.2 kg (admission): 58.2 kg\n Height: 71 Inch\n CVP: -1 (-1 - 6) mmHg\n Total In:\n 3,224 mL\n 189 mL\n PO:\n Tube feeding:\n 163 mL\n IV Fluid:\n 3,060 mL\n 189 mL\n Blood products:\n Total out:\n 2,106 mL\n 80 mL\n Urine:\n 2,056 mL\n 80 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 1,118 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: 7.44/24/72/16/-5\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: No(t) Regular), tachcardic but regular without\n M/R/G\n Respiratory / Chest: (Breath Sounds: CTA bilateral : slightly decreased\n L base)\n Abdominal: Soft, Non-distended, No(t) Non-tender, Tender: Thoughout and\n especially RUQ no r/ no g\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Cool)\n Skin: Jaundice, J tube in place in ECF, TF without pouch\n Neurologic: (Awake / Alert / Oriented: No(t) x 3, x 2), Follows simple\n commands, (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 219 K/uL\n 10.1 g/dL\n 61 mg/dL\n 1.2 mg/dL\n 16 mEq/L\n 4.1 mEq/L\n 15 mg/dL\n 103 mEq/L\n 133 mEq/L\n 30.7 %\n 8.1 K/uL\n [image002.jpg]\n 03:19 AM\n 02:38 AM\n 05:57 AM\n 12:20 PM\n 12:56 PM\n WBC\n 18.3\n 9.7\n 5.3\n 8.1\n Hct\n 29.2\n 28.0\n 28.9\n 30.7\n Plt\n 233\n 221\n 250\n 219\n Creatinine\n 1.1\n 0.9\n 1.0\n 1.2\n Troponin T\n 0.01\n 0.02\n TCO2\n 17\n Glucose\n 167\n 87\n 80\n 61\n Other labs: PT / PTT / INR:12.6/26.5/1.1, CK / CK-MB / Troponin\n T:11//0.02, ALT / AST:21/28, Alk-Phos / T bili:759/4.6, Amylase /\n Lipase:139/61, Differential-Neuts:82.0 %, Band:15.0 %, Lymph:1.0 %,\n Mono:0.0 %, Eos:1.0 %, Lactic Acid:7.0 mmol/L, Ca:8.2 mg/dL, Mg:1.6\n mg/dL, PO4:3.9 mg/dL\n Imaging: CT abd/pelv = Interval decrease in size of\n collections. New ill-defined hypodense lesions @ lateral right hepatic\n lobe. Tiny new fluid collection in the right lateral abdominal wall @\n prior drain\n Microbiology: Urine Cx P\n Blood Culture P\n Blood Culture P\n SWAB No PMN, No Micro prelim NG\n Blood Culture P\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, MALNUTRITION, .H/O CANCER (MALIGNANT\n NEOPLASM), PANCREAS\n Assessment and Plan: 69M s/p Whipple, revision, r/w anemia HCT 22 w/\n change in MS, resolved hypotension.\n .\n PLAN:\n Neuro: AOx3. Fentanyl patch. Minimal dilaudid PRN.\n CVS: Hypotension responsive to fluid. SVT to 170s-180s, r/o MI with\n CE.\n Pulm: No active issues, R plueral effusion on CXR.\n GI: ECF w/ostomy appliace surrounding, On Cipro, linezolid, clinda for\n hepatic abscesses. Cefepime added due to continued spikes to\n double cover psuedomonas. Tender abdomen. CT w/o signs of\n intra-abdominal collection needing drainage. Worsening APhos, bili.\n Lactate 7 on . N/V ON , zofran+compazine prn.\n FEN: TF on hold. NPO.\n Renal: Cr normal.\n Heme: HCT 32>28 S/p transfusion 2U PRBC . Stable.\n Endo: Hypoglycemia, resolved getting D5 in IVF. SSI.\n ID: Cipro,Cefepime, clinda, flagyl, linezolid (for VRE). Hx of\n Enterococci bacteremia tx w/ V/G/C/F (). Tender abdomen. +diarrhea,\n check CDiff w/BM. Isolation for VRE/MRSA. WBC normalized.\n Wounds: epigastric enterocutaneous fistula, RUQ former drain site\n Consults: West2\n Billing Diagnosis:\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 22 Gauge - 12:57 PM\n Arterial Line - 03:00 PM\n Multi Lumen - 05:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2173-10-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 487103,
"text": "SICU\n HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula, with recurrent cholangitis\n thought secondary to reflux of enteric contents into biliary tree, now\n s/p biliary drain, with fevers, elevated WBC, rising Tbili, all\n suggestive of cholangitis. Hypotensive requiring fluid boluses, now on\n aztreonam, cipro, and flagyl\n Chief complaint:\n Hypotension\n PMHx:\n duodenal adenocarcinoma, HTN, PUD, ECF\n .\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy\n Current medications:\n 10. Linezolid 600 mg IV Q12H\n To End Order date: @ 0910\n 11. Metoprolol Tartrate 5 mg IV Q6H prn hr >100\n hold for sbp<100 or Hr>60 Order date: @ 0339\n 3. Ciprofloxacin 400 mg IV Q12H Order date: @ 0339\n 12. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 0950\n 4. Clindamycin 600 mg IV Q8H Order date: @ 0339\n 13. Ondansetron 8 mg IV Q8H:PRN nausea Order date: @ 2249\n 5. Famotidine 20 mg IV Q24H Order date: @ 0339\n 14. Prochlorperazine 10 mg PO/IV Q6H:PRN nausea/vomiting Order date:\n @ 2329\n 6. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0314\n 7. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H:PRN pain Order date: \n @ 0346\n 8. Heparin 5000 UNIT SC BID Order date: @ 0314\n 17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP :PRN pruritus\n Order date: @ 0314\n 9. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1728 18. Ursodiol 600 mg PO\n BID Order date: @ 0314\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:36 AM\n CALLED OUT\n : Reg diet for pleasure eating. Resumed TFs. ?to floor.\n Nausea ON, zofran->compazine. Comfortable/slept.\n Allergies:\n Azithromycin\n Rash;\n Zosyn (Intraven) (Piperacillin Sodium/Tazobactam)\n Rash;\n Meropenem\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 07:37 PM\n Linezolid - 10:23 PM\n Metronidazole - 12:00 AM\n Clindamycin - 01:51 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 05:22 PM\n Heparin Sodium (Prophylaxis) - 07:37 PM\n Hydromorphone (Dilaudid) - 11:44 PM\n Other medications:\n Flowsheet Data as of 05:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.3\nC (99.2\n HR: 77 (67 - 122) bpm\n BP: 104/58(69) {96/52(62) - 141/80(85)} mmHg\n RR: 15 (11 - 22) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 58.2 kg (admission): 58.2 kg\n Height: 71 Inch\n Total In:\n 3,939 mL\n 223 mL\n PO:\n 240 mL\n Tube feeding:\n 172 mL\n 49 mL\n IV Fluid:\n 3,526 mL\n 174 mL\n Blood products:\n Total out:\n 3,055 mL\n 1,120 mL\n Urine:\n 2,775 mL\n 1,120 mL\n NG:\n Stool:\n Drains:\n 280 mL\n Balance:\n 884 mL\n -897 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Pleasant, alert/conversational.\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), No M/R/G.\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n Mild intermittent wheezing bilat.)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Labs / Radiology\n 221 K/uL\n 9.1 g/dL\n 87 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 102 mEq/L\n 134 mEq/L\n 28.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:19 AM\n 02:38 AM\n WBC\n 18.3\n 9.7\n Hct\n 29.2\n 28.0\n Plt\n 233\n 221\n Creatinine\n 1.1\n 0.9\n Troponin T\n 0.01\n Glucose\n 167\n 87\n Other labs: PT / PTT / INR:12.6/26.5/1.1, CK / CK-MB / Troponin\n T:8//0.01, ALT / AST:22/26, Alk-Phos / T bili:554/2.8, Amylase /\n Lipase:92/62, Ca:7.8 mg/dL, Mg:1.6 mg/dL, PO4:3.4 mg/dL\n Imaging: Abd CT: Interval decrease in size of multiple gas\n containing hepatic fluid\n collections. There are new ill-defined hypodense lesions within the\n lateral\n right hepatic lobe, which are suspicious for new foci of infection\n given the\n short interval time course. There is a tiny new fluid collection in the\n right\n lateral abdominal wall in the area of prior drain, measuring\n approximately 1.8\n cm maximally.\n Assessment and Plan\n MALNUTRITION, .H/O CANCER (MALIGNANT NEOPLASM), PANCREAS\n Assessment and Plan: 69M s/p Whipple, revision, r/w anemia HCT 22 w/\n change in MS, resolved hypotension. Resolved nausea.\n Neurologic: Pain controlled, AOx3. Fentanyl patch. Minimal dilaudid\n PRN.\n Cardiovascular: Hypotension, resolved.\n Pulmonary: No active issues, R plueral effusion.\n Gastrointestinal / Abdomen: ECF w/ostomy appliace surrounding, On\n Cipro, linezolid, clinda for hepatic abscesses. Tender abdomen w/ hx\n recurrent cholangitis. CT w/o signs of intra-abdominal collection\n needing drainage. Improving APhos, bili. N/V ON , zofran+compazine\n prn.\n Nutrition: TF held s/p resumed at 10mL/hr w/ subsequent n/v. Team wants\n to advance to goal . Reg diet for pleasure. KVO with PO hydration\n and TFs.\n Renal: Foley, Cr normal.\n Hematology: HCT 32>28 S/p transfusion 2U PRBC . Stable.\n Endocrine: Hypoglycemia, resolved. SSI.\n Infectious Disease: Cipro, clinda, flagyl, linezolid (for VRE). Hx of\n Enterococci bacteremia tx w/ V/G/C/F (). Tender abdomen. Hx of\n diarrhea, check CDiff w/BM. Isolation for VRE/MRSA. WBC normalized.\n Lines / Tubes / Drains: Foley, J-Tube, PIV\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: West2\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:47 AM 10 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:08 AM\n 22 Gauge - 12:57 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: Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2173-10-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 487184,
"text": "SICU\n HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula, with recurrent cholangitis\n thought secondary to reflux of enteric contents into biliary tree, now\n s/p biliary drain, with fevers, elevated WBC, rising Tbili, all\n suggestive of cholangitis. Hypotensive requiring fluid boluses, now on\n aztreonam, cipro, and flagyl\n Chief complaint:\n Hypotension\n PMHx:\n duodenal adenocarcinoma, HTN, PUD, ECF\n .\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy\n Current medications:\n 10. Linezolid 600 mg IV Q12H\n To End Order date: @ 0910\n 11. Metoprolol Tartrate 5 mg IV Q6H prn hr >100\n hold for sbp<100 or Hr>60 Order date: @ 0339\n 3. Ciprofloxacin 400 mg IV Q12H Order date: @ 0339\n 12. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 0950\n 4. Clindamycin 600 mg IV Q8H Order date: @ 0339\n 13. Ondansetron 8 mg IV Q8H:PRN nausea Order date: @ 2249\n 5. Famotidine 20 mg IV Q24H Order date: @ 0339\n 14. Prochlorperazine 10 mg PO/IV Q6H:PRN nausea/vomiting Order date:\n @ 2329\n 6. Fentanyl Patch 50 mcg/hr TP Q72H Order date: @ 0314\n 7. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H:PRN pain Order date: \n @ 0346\n 8. Heparin 5000 UNIT SC BID Order date: @ 0314\n 17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP :PRN pruritus\n Order date: @ 0314\n 9. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1728 18. Ursodiol 600 mg PO\n BID Order date: @ 0314\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:36 AM\n CALLED OUT\n : Reg diet for pleasure eating. Resumed TFs. ?to floor.\n Nausea ON, zofran->compazine. Comfortable/slept.\n Allergies:\n Azithromycin\n Rash;\n Zosyn (Intraven) (Piperacillin Sodium/Tazobactam)\n Rash;\n Meropenem\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 07:37 PM\n Linezolid - 10:23 PM\n Metronidazole - 12:00 AM\n Clindamycin - 01:51 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 05:22 PM\n Heparin Sodium (Prophylaxis) - 07:37 PM\n Hydromorphone (Dilaudid) - 11:44 PM\n Other medications:\n Flowsheet Data as of 05:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.3\nC (99.2\n HR: 77 (67 - 122) bpm\n BP: 104/58(69) {96/52(62) - 141/80(85)} mmHg\n RR: 15 (11 - 22) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 58.2 kg (admission): 58.2 kg\n Height: 71 Inch\n Total In:\n 3,939 mL\n 223 mL\n PO:\n 240 mL\n Tube feeding:\n 172 mL\n 49 mL\n IV Fluid:\n 3,526 mL\n 174 mL\n Blood products:\n Total out:\n 3,055 mL\n 1,120 mL\n Urine:\n 2,775 mL\n 1,120 mL\n NG:\n Stool:\n Drains:\n 280 mL\n Balance:\n 884 mL\n -897 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Pleasant, alert/conversational.\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), No M/R/G.\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n Mild intermittent wheezing bilat.)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Labs / Radiology\n 221 K/uL\n 9.1 g/dL\n 87 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 102 mEq/L\n 134 mEq/L\n 28.0 %\n 9.7 K/uL\n [image002.jpg]\n 03:19 AM\n 02:38 AM\n WBC\n 18.3\n 9.7\n Hct\n 29.2\n 28.0\n Plt\n 233\n 221\n Creatinine\n 1.1\n 0.9\n Troponin T\n 0.01\n Glucose\n 167\n 87\n Other labs: PT / PTT / INR:12.6/26.5/1.1, CK / CK-MB / Troponin\n T:8//0.01, ALT / AST:22/26, Alk-Phos / T bili:554/2.8, Amylase /\n Lipase:92/62, Ca:7.8 mg/dL, Mg:1.6 mg/dL, PO4:3.4 mg/dL\n Imaging: Abd CT: Interval decrease in size of multiple gas\n containing hepatic fluid\n collections. There are new ill-defined hypodense lesions within the\n lateral\n right hepatic lobe, which are suspicious for new foci of infection\n given the\n short interval time course. There is a tiny new fluid collection in the\n right\n lateral abdominal wall in the area of prior drain, measuring\n approximately 1.8\n cm maximally.\n Assessment and Plan\n MALNUTRITION, .H/O CANCER (MALIGNANT NEOPLASM), PANCREAS\n Assessment and Plan: 69M s/p Whipple, revision, r/w anemia HCT 22 w/\n change in MS, resolved hypotension. Resolved nausea.\n Neurologic: Pain controlled, AOx3. Fentanyl patch. Minimal dilaudid\n PRN.\n Cardiovascular: Hypotension, resolved.\n Pulmonary: No active issues, R plueral effusion.\n Gastrointestinal / Abdomen: ECF w/ostomy appliace surrounding, On\n Cipro, linezolid, clinda for hepatic abscesses. Tender abdomen w/ hx\n recurrent cholangitis. CT w/o signs of intra-abdominal collection\n needing drainage. Improving APhos, bili. N/V ON , zofran+compazine\n prn.\n Nutrition: TF held s/p resumed at 10mL/hr w/ subsequent n/v. Team wants\n to advance to goal . Reg diet for pleasure. KVO with PO hydration\n and TFs.\n Renal: Foley, Cr normal.\n Hematology: HCT 32>28 S/p transfusion 2U PRBC . Stable.\n Endocrine: Hypoglycemia, resolved. SSI.\n Infectious Disease: Cipro, clinda, flagyl, linezolid (for VRE). Hx of\n Enterococci bacteremia tx w/ V/G/C/F (). Tender abdomen. Hx of\n diarrhea, check CDiff w/BM. Isolation for VRE/MRSA. WBC normalized.\n Lines / Tubes / Drains: Foley, J-Tube, PIV\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: West2\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 06:47 AM 10 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 04:08 AM\n 22 Gauge - 12:57 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: Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 487327,
"text": "Sepsis without organ dysfunction\n Assessment:\n ? septic episode shaking chills followed by temp spike within 1 hr. (\n chills occurred 1 hr after eating mod amt eggs with bacon and cereal.\n Fistula leakage was very active at this time).\n Hr increased >150 and bp initially stable. Pt appeared very anxious\n prior to temp spike.( fistula bag had leaked and patient thought he was\n cold because he was wet). Pt was medicated with Lorazopam.\n Despite pt being calmer, Hr remained elevated.\n Action:\n Tylenol given,pan cultured Lopressor given followed by fluid for low\n bp. Central line was inserted along with a-line\n Response:\n Pt stable by 1700\n Plan:\n Strict NPO. TF d/c\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 487094,
"text": "Malnutrition\n Assessment:\n Tube feeds resumed at low dose,poor po intake,transient nausea\n especially with moving,turning\n Action:\n Zofran prn,advance tube feedings per team,? Tpn if unable to tolerate\n enteral nutrition\n Response:\n Tolerating small amounts of food brought in by family,nausea controlled\n woth zofran\n Plan:\n As above\n"
},
{
"category": "Physician ",
"chartdate": "2173-10-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 487495,
"text": "SICU\n HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula now with hypotension and change\n in MS.\n .\n Chief complaint:\n Hypotension, change in MS\n :\n PMH: duodenal adenocarcinoma, HTN, PUD, ECF\n .\n PSH:\n s/p gastric resection for PUD\n s/p revision with Roux-en-Y and partial gastrectomy in \n s/p whipple, as above \n s/p takeback for repair of pancreaticojejunostomy\n .\n Current medications:\n Insulin SC (per Insulin Flowsheet)\n Linezolid 600 mg IV Q12H\n Metoprolol Tartrate 5 mg IV Q6H prn hr >100\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n CefePIME 2 g IV Q24H\n Midazolam 0.5 mg IV ONCE\n Ciprofloxacin 400 mg IV Q12H . Ondansetron 8 mg IV Q8H:PRN nausea\n Clindamycin 600 mg IV Q8H\n Prochlorperazine 10 mg PO/IV Q6H:PRN nausea/vomiting\n Famotidine 20 mg IV Q24H\n Fentanyl Patch 50 mcg/hr TP Q72H\n HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H:PRN pain\n Triamcinolone Acetonide 0.1% Cream\n Heparin 5000 UNIT SC BID\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:36 AM\n CALLED OUT\n Allergies:\n Azithromycin\n Rash;\n Zosyn (Intraven) (Piperacillin Sodium/Tazobactam)\n Rash;\n Meropenem\n Unknown;\n Last dose of Antibiotics:\n Clindamycin - 06:02 PM\n Ciprofloxacin - 08:02 PM\n Cefipime - 08:23 PM\n Linezolid - 10:46 PM\n Metronidazole - 11:57 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 02:09 PM\n Famotidine (Pepcid) - 05:58 PM\n Heparin Sodium (Prophylaxis) - 08:23 PM\n Hydromorphone (Dilaudid) - 10:46 PM\n Other medications:\n Flowsheet Data as of 01:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.3\nC (102.7\n T current: 36.6\nC (97.9\n HR: 84 (74 - 175) bpm\n BP: 95/36(53) {85/30(53) - 139/56(77)} mmHg\n RR: 15 (13 - 39) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 58.2 kg (admission): 58.2 kg\n Height: 71 Inch\n CVP: -1 (-1 - 6) mmHg\n Total In:\n 3,224 mL\n 189 mL\n PO:\n Tube feeding:\n 163 mL\n IV Fluid:\n 3,060 mL\n 189 mL\n Blood products:\n Total out:\n 2,106 mL\n 80 mL\n Urine:\n 2,056 mL\n 80 mL\n NG:\n Stool:\n Drains:\n 50 mL\n Balance:\n 1,118 mL\n 109 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: 7.44/24/72/16/-5\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: No(t) Regular), tachcardic but regular without\n M/R/G\n Respiratory / Chest: (Breath Sounds: CTA bilateral : slightly decreased\n L base)\n Abdominal: Soft, Non-distended, No(t) Non-tender, Tender: Thoughout and\n especially RUQ no r/ no g\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Cool)\n Skin: Jaundice, J tube in place in ECF, TF without pouch\n Neurologic: (Awake / Alert / Oriented: No(t) x 3, x 2), Follows simple\n commands, (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 219 K/uL\n 10.1 g/dL\n 61 mg/dL\n 1.2 mg/dL\n 16 mEq/L\n 4.1 mEq/L\n 15 mg/dL\n 103 mEq/L\n 133 mEq/L\n 30.7 %\n 8.1 K/uL\n [image002.jpg]\n 03:19 AM\n 02:38 AM\n 05:57 AM\n 12:20 PM\n 12:56 PM\n WBC\n 18.3\n 9.7\n 5.3\n 8.1\n Hct\n 29.2\n 28.0\n 28.9\n 30.7\n Plt\n 233\n 221\n 250\n 219\n Creatinine\n 1.1\n 0.9\n 1.0\n 1.2\n Troponin T\n 0.01\n 0.02\n TCO2\n 17\n Glucose\n 167\n 87\n 80\n 61\n Other labs: PT / PTT / INR:12.6/26.5/1.1, CK / CK-MB / Troponin\n T:11//0.02, ALT / AST:21/28, Alk-Phos / T bili:759/4.6, Amylase /\n Lipase:139/61, Differential-Neuts:82.0 %, Band:15.0 %, Lymph:1.0 %,\n Mono:0.0 %, Eos:1.0 %, Lactic Acid:7.0 mmol/L, Ca:8.2 mg/dL, Mg:1.6\n mg/dL, PO4:3.9 mg/dL\n Imaging: CT abd/pelv = Interval decrease in size of\n collections. New ill-defined hypodense lesions @ lateral right hepatic\n lobe. Tiny new fluid collection in the right lateral abdominal wall @\n prior drain\n Microbiology: Urine Cx P\n Blood Culture P\n Blood Culture P\n SWAB No PMN, No Micro prelim NG\n Blood Culture P\n Assessment and Plan\n SEPSIS WITHOUT ORGAN DYSFUNCTION, MALNUTRITION, .H/O CANCER (MALIGNANT\n NEOPLASM), PANCREAS\n Assessment and Plan: 69M s/p Whipple, revision, r/w anemia HCT 22 w/\n change in MS, resolved hypotension.\n .\n PLAN:\n Neuro: AOx3. Fentanyl patch. Minimal dilaudid PRN.\n CVS: Hypotension responsive to fluid. SVT to 170s-180s, r/o MI with\n CE.\n Pulm: No active issues, R plueral effusion on CXR.\n GI: ECF w/ostomy appliace surrounding, On Cipro, linezolid, clinda for\n hepatic abscesses. Cefepime added due to continued spikes to\n double cover psuedomonas. Tender abdomen. CT w/o signs of\n intra-abdominal collection needing drainage. Worsening APhos, bili.\n Lactate 7 on . N/V ON , zofran+compazine prn.\n FEN: TF on hold. NPO.\n Renal: Cr normal. Check urine for hemoglobin and myoglobin.\n Heme: HCT 32>28 S/p transfusion 2U PRBC . Likely heme repressed in\n part d/t Linezolid.\n Endo: Hypoglycemia, resolved getting D5 in IVF. SSI.\n ID: Septic picture responsive to IVF. Cefepime added to prior broad\n regimen of Cipro, clinda, flagyl, linezolid (for VRE), for pseudomonas\n double coverage. Hx of Enterococci bacteremia tx w/ V/G/C/F ().\n Tender abdomen. +diarrhea, check CDiff w/BM. Isolation for VRE/MRSA.\n WBC 5>22.\n Wounds: epigastric enterocutaneous fistula, RUQ former drain site\n Consults: West2\n Billing Diagnosis:\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 22 Gauge - 12:57 PM\n Arterial Line - 03:00 PM\n Multi Lumen - 05:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 487572,
"text": "HPI:\n 69yoM w/PUD s/p roux-en-y/gastric bypass and duodenal adenoCA s/p\n whipple complicated by biliary enteric and enterocutaneous\n fistula. Pt is s/p redo of jejeunal-hepatic anastamosis x 2 and j tube\n placed through enterocutaneous fistula now with hypotension and change\n in MS.\n .\n Malnutrition\n Assessment:\n Patient NPO for oral nutrition\n Feeds begun via j tube this afternoon\n Action:\n Will add banana flakes this pm when advancing rate\n Will monitor fistula site for increased drainage\n Appliance remains intact at this point\n Response:\n Tolerating feeds so far\n Patient verbalizing desire to eat\n Plan:\n Advance feeds as ordered\n Ask primary team if patient can eat.\n Sepsis without organ dysfunction\n Assessment:\n Patient\ns vss today\n No evidence of sepsis clinically except for elevated white count\n Action:\n Central line /aline remain in\n OOB to chair\n Response:\n Tolerating above well\n Plan:\n Continue to monitor for clinical signs of sepsis\n"
},
{
"category": "Nursing",
"chartdate": "2173-10-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 486703,
"text": "Malnutrition\n Assessment:\n Pt with h/o extremely poor PO intake\n H/o TPN use\n Pt had been on TF @90cc/hr, NOT tolerating\n Action:\n Pt started back on PO\ns per pt comfort allowed by Dr.\n in afternoon\n Response:\n Plan:\n .H/O cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Abd soft, tender, +BS\n Jtube cont clamped\n Fistula bag/appliance around Jtube collecting bilious/cloudy\n fld, ~100cc output this shift\n Abd pain reported few times through out shift\n Based on elevated WBC, elevated temp overnoc, abd\n sensitivity/diarrhea, h/o of CDIFF and tx of multiple abx, suspected\n infection is CDIFF vs. other infectious abd collection\n Action:\n Pt started on Linezolid, flagyl\n Cont on IV clindamycin, cipro\n Appliance ostomy bag changed by wound RN, supplies left in\n pt room\n Pt taken for CT scan for ?abscess/possible necessity for\n drain placement down in CT\n IVP 0.5mg dilaudid for pain, fentanyl patch applied as\n ordered q 72h\n Response:\n Pt afebrile, NSR, normotensive\n Plan:\n Cont abx\n Cont pain control\n ?trans back to 9 tomorrow\n Hypotension (not Shock)\n Assessment:\n Earlier in shift pt more hypotensive 80s-90s SBP\n For large majority of shift, pt normotensive, SBP ~100-140\n Action:\n IVF continues at 100cc/hr, fld changed to 1/2NSD5\n Response:\n Suspected dehydration 2/t recent h/o diarrhea\n Pt now normotensive\n Plan:\n Hypotension resolved\n Cont to monitor hemodynamics\n"
},
{
"category": "Radiology",
"chartdate": "2173-10-15 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1099789,
"text": " 12:52 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: evaluate for pre-hepatic, peri-pancreatic fluid collections.\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with fevers, s/p multiple abdominal operations, whipple and\n revisions now with possible sepsis\n REASON FOR THIS EXAMINATION:\n evaluate for pre-hepatic, peri-pancreatic fluid collections. Cholangitis, Liver\n abscess.PO, feeding tube, and IV contrast please\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of Whipple procedure, multiple abdominal\n surgeries, and hepatic abscesses, with fever and hypotension.\n\n TECHNIQUE: MDCT of the abdomen and pelvis was performed following the\n uneventful administration of nonionic intravenous contrast.\n\n Comparison exams are dated and .\n\n FINDINGS:\n\n Limited images of the lung bases again demonstrate right basilar\n consolidation, likely representing atelectasis, not significantly changed.\n There is a small right pleural effusion, not significantly changed and trace\n left pleural fluid.\n\n ABDOMEN: Again noted are postsurgical changes from a Whipple procedure, and\n left-sided pneumobilia is noted. There has been interval removal of hepatic\n drains, and previously seen fluid collections containing gas within the right\n hepatic lobe have decreased in size. There are new ill- defined hypodense\n lesions within the lateral right hepatic lobe. For example, a lesion seen\n within segment VIII measures 1.2 cm, and a lesion seen within segment VII\n measures 1.7 cm. In the region of prior drain, there is a new 1.8 x 1.1 cm\n fluid collection in the lateral right abdominal wall, which contains a small\n focus of gas. There are stable postoperative changes in the mesentery. No new\n mesenteric fluid collections are identified.\n\n Again noted are bilateral renal hypodensities, too small to characterize. The\n adrenal glands are unremarkable. There are no grossly enlarged lymph nodes.\n\n Again noted is a percutaneous jejunostomy tube terminating in the left lower\n quadrant. The abdominal bowel loops are nondilated. There is no bowel wall\n thickening. There is no ascites.\n\n PELVIS: The bladder is decompressed with a Foley catheter and contains a\n small focus of gas. The pelvic bowel loops are unremarkable. There is no\n free fluid. There are no pathologically enlarged lymph nodes.\n\n Bone windows demonstrate degenerative changes of the spine. There are no\n focal suspicious osseous lesions.\n (Over)\n\n 12:52 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: evaluate for pre-hepatic, peri-pancreatic fluid collections.\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n 1. Interval decrease in size of multiple gas containing hepatic fluid\n collections. There are new ill-defined hypodense lesions within the lateral\n right hepatic lobe, which are suspicious for new foci of infection given the\n short interval time course. There is a tiny new fluid collection in the right\n lateral abdominal wall in the area of prior drain, measuring approximately 1.8\n cm maximally. Otherwise, no new fluid collections are identified.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-10-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1099692,
"text": " 12:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: any pneumonia or other fluid collections in chest, specially\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with leaking chest wound\n REASON FOR THIS EXAMINATION:\n any pneumonia or other fluid collections in chest, specially right side\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:47 A.M.\n\n HISTORY: Leaking chest wound, question pneumonia or fluid collection in the\n chest.\n\n IMPRESSION: AP chest compared to :\n\n Right pleural drain no longer present. Moderate right pleural effusion has\n increased. No pneumothorax. Rightward mediastinal shift suggests\n opacification in the right lower lobe is atelectasis. Left lung is clear.\n Heart size is normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-10-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1100041,
"text": " 2:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: tachycardia to 170 with chest pain and tachypnea\n Admitting Diagnosis: ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69M s/p Whipple, revision, r/w anemia HCT 22 w/ change in MS, resolved\n hypotension.\n REASON FOR THIS EXAMINATION:\n tachycardia to 170 with chest pain and tachypnea\n ______________________________________________________________________________\n WET READ: PXDb SUN 3:41 PM\n Tip of the right subclavian terminating at the cavoatrial junction.\n Chronically elevated hemidiaphragm obscures part of the lower mediastinum, and\n may explain apparent deep positioning of the catheter tip. DW Dr.\n . ( )\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: Radiograph of two days earlier.\n\n INDICATION: Change in mental status. Chest pain.\n\n Interval placement of right subclavian catheter terminating in the lower SVC\n with no evidence of pneumothorax. Examination is otherwise unchanged since\n the recent study except for development of linear atelectasis at the left lung\n base.\n\n\n"
}
] |
9,877 | 172,081 | After cath, she came to the CCU on a balloon pump and intubated. She was alert and her vitals were all adequate. 1.CAD: Her LAD lesion was stented. Further review of the cath films showed diffuse disease in her RCA and OM-1. She had no more cardiac chest pain while here, and daily ECGs did not show any new ischemia/infarction. It was determined that she should have a stress test in approx 1 month as an outpatient to determine the need for further catheterization/stenting in the future. Her cardiac enzymes were followed until they began to trend downward. She was initially on ASA, plavix, and a statin. Her beta-blocker and ACE-I were held due to BP issues. Once she recovered from this, and her vitals were improving, she was slowly started back on her ACE and B-blocker without issue. She was initially on heparin due to akinetic apex. A repeat echo several days post-cath showed improvement and her heparin was stopped. No additional anticoagulation will be needed. On D/C, she was feeling well. 2.Pump: She was initally on a balloon pump, but this was removed in the morning after admission, as she was holding her own BP without issue, and tolerated weaning trials. She was initially on dopamine as well. She had received lasix in ED, and had a large diuresis. We believe she was hypovolemic at that point, and her BP responded well to a 1L fluid bolus. Echo was done several days later as above, and showed an EF of 45-50%. All walls are mobile enough for her to not require chronic anticoagulation. 3.Rhythm: She stayed in NSR for the admission. She had one episode of non-sustained VT, but it was asymptomatic. 4.Pulmonary: She was intubated on arrival. She was quickly weaned from the vent in the morning without trouble and extubated. Her initial pulm edema was improving on CXR. It was likely acute CHF due to her anterior MI. Her O2 sats remained adequate throughout. She did have some blood tinged sputum, but this was likely the result of ET tube trauma, and gradually faded. 5.Anemia: She had a decrease in hematocrit during the stay. Retroperitoneal bleed was a question, so she had an abdominal CT which was negative for this. She continued to have a low Hct, but it was stable. It is likely due to combination of dilution by fluids and bleeding from procedures. If this persists as an outpt, she can have her anemia worked up further. It was trending up on discharge. 6.DMII: She was initially maintained on sliding scale insulin. When she began eating, her home oral meds were added back. We waited >48 hrs until restarting her metformin. She had good glycemic control on day of discharge. 7.FEN:She was given maintenance fluids initially, then began eating and drinking on her own. Her electrolytes were monitored and repleted as needed. 8.PT was consulted and she walked with them several times, including up and down stairs. They recommended that she is safe to go home alone, but that she may benefit from outpt cardiac rehab if she does not recover quickly onher own. 9. She was discharged home with stable vitals and several family members to help her at home. She will follow-up with her PCP and with Drs and in 1 month to arrange for a stress test. 10. Her Lasix was stopped, but her other home BP meds were kept at their original doses. She was also put on Plavix and understands the need to keep taking this for 6 months no matter what. | Overall left ventricular systolic functionis mildly depressed.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: anterior apex - hypokinetic; septal apex -hypokinetic; apex - hypokinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion.MITRAL VALVE: The mitral valve leaflets are structurally normal.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Image quality was suboptimal.Conclusions:Suboptimal images.1. Restingregional wall motion abnormalities include apical, mid and apical anteroseptaland apical anterior hypokinesis.3.Right ventricular chamber size is normal. Overall left ventricular systolic function is mildlydepressed.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: mid anteroseptal - hypokinetic; anterior apex -hypokinetic; septal apex - hypokinetic; apex - hypokinetic;RIGHT VENTRICLE: The right ventricular wall thickness is normal. Myocardial infarction.Height: (in) 65Weight (lb): 190BSA (m2): 1.94 m2BP (mm Hg): 152/72HR (bpm): 80Status: InpatientDate/Time: at 09:41Test: TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size. A tiny left mid lung zone granuloma is again identified. ?VSD.Height: (in) 68Weight (lb): 200BSA (m2): 2.05 m2BP (mm Hg): 110/68HR (bpm): 101Status: InpatientDate/Time: at 10:30Test: Portable TTE (Focused views)Doppler: Focused pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. Right ventricular systolic function isnormal.AORTA: The aortic root is mildly dilated. Resting regional wall motion abnormalities include distal septal,apical and distal anterior severe hyokinesis/akinesis..3.Right ventricular chamber size and free wall motion are normal.4.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion. arrived to CCU intubated on dopa,integrillin and versed drip.Cardiac: HR 70's NSR no VEA. Mild (1+) mitralregurgitation is seen.PERICARDIUM: There is no pericardial effusion.Conclusions:1. SINGLE VIEW CHEST, AP UPRIGHT: There has been interval development of diffuse, bilateral interstitial and alveolar opacities, predominantly in a perihilar distribution. Right ventricular systolicfunction is normal.4.The aortic root is mildly dilated.5.The aortic valve leaflets (3) are mildly thickened. There is mild regional left ventricularsystolic dysfunction. Overall left ventricular systolic function is mildlydepressed. The left atrium is elongated.2.Left ventricular wall thicknesses are normal. The left atrium is elongated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. No aortic regurgitationis seen.6.The mitral valve leaflets are mildly thickened. The cardiac silhouette and mediastinum are within normal limits. ccu nsg progress note.o:sedated w fent/versed gtts-doses decreased in am for ?extubation. CT ABDOMEN WITHOUT IV CONTRAST: There are small bilateral pleural effusions and bibasilar atelectasis. The diffuse, bilateral interstitial and alveolar opacities, predominantly within the right lobe vs. the left are essentially unchanged. The left ventricular cavitysize is normal. The left ventricular cavitysize is normal. The ascending aorta is normal indiameter.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. She had sputum and urine culture sent.CV: Pt remains painfree on heparin at 1150u/hr. Sinus rhythmanteroseptal myocardial infarction with ST-T wave configuration suggestsacute/recent/in evolution precessDiffuse ST-T wave abnormalitiesSince previous tracing of , further lateral ST-T wave changespresent and less suugestive of prior inferior myocardial infarction Sinus rhythmBorderline low voltageAnteroseptal myocardial infarction with ST-T wave configuration suggestsacute/recent/in evolution processClinical correlation is suggestedSince previous tracing of , lateral ST-T wave changes less prominent There is left atrial enlargement and further evolution of acuteanteroseptal myocardial infarction and evidence of interim inferior myocardialinfarction as well with new Q waves in leads III and aVF. ST segment elevation in V1-V5 withQS deflections in leads V1-V4 consistent with acute anteroseptal myocardialinfarction compared to the previous tracing of . Further evolution anterolateral and apical myocardial infarction.Clinical correlation is suggested.TRACING #3 Sinus rhythmAnteroseptal myocardial infarction with ST-T wave configuration suggestsacute/recent/in evolution processConsider inferior infarct, age indeterminateDiffuse ST-T wave abnormalitiesClinical correlation is suggestedSince previous tracing of , no significant change Sinus rhythmAnteroseptal myocardial infarction with ST-T wave configuration suggestsacute/recent in evolution processConsider inferior infarct, age indeterminateDiffuse ST-T wave abnormalitiesClinical correlation is suggestedSince previous tracing of same date, no significant change Sinus rhythm with slowing of the rate as compared to the previous tracingof . Sinus rhythm with slowing of the rate as compared to the previous tracingof . There is loss ofinferior forces with more prominent Q waves in leads III and aVF representinginferior injury as well. These changes may represent pseudonormalizationand new or extension of acute anterolateral myocardial injury. Left atrial enlargement. Clinical correlation issuggested.TRACING #1 Rule out myocardial infarction. The T waves are less inverted in the precordial leads and there iscontinued ST segment elevation. There is some return of the T wave inversion previously recorded.The prior recording may have represented pseudonormalization. Sinus tachycardia with increase in rate as compared to the previous tracingof . Sinus tachycardia. Clinical correlationis suggested.TRACING #2 Followup andclinical correlation are suggested.TRACING #4 Sinus rhythm. There is continued lowlimb lead voltage. heparin increased to 1150u for subtheraputic ptt- reck ptt pending. Clinical correlation is suggested.TRACING #5 episode of substernal discomfort-ekg wo acute chges- resident aware-resolved wo intervention.a:stable throughout night.p:contin present management. ccu nsg progress note.o:captopril increased to 75mgx3 & lopressor increased to 50mgx2- tolerating weel. | 21 | [
{
"category": "Radiology",
"chartdate": "2122-07-12 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 832268,
"text": " 9:44 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: S/P CATH, BACK PAIN, DECREASING HCT, ? RP BLEED\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with acute MI, s/p cath w/ decr. HCT and c/o Back pain\n REASON FOR THIS EXAMINATION:\n r/o RP bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Back pain, status post catheterization, evaluate for\n retroperitoneal hemorrhage.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung bases through the pubic symphysis, without IV contrast administration.\n\n CT ABDOMEN WITHOUT IV CONTRAST: There are small bilateral pleural effusions\n and bibasilar atelectasis. The liver, gallbladder, pancreas, spleen, adrenal\n glands, kidneys, bowel loops are unremarkable in this unenhanced study. There\n are extensive vascular calcifications along the aorta, which is not dilated.\n There is no free fluid or pneumoperitoneum. No lymphadenopathy.\n\n CT PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, uterus, and bladder\n are unremarkable. No free pelvic fluid or lymphadenopathy. Stranding is\n noted within the right groin region, consistent with recent catheterization.\n No hematomas are identified.\n\n The osseous structures are grossly unremarkable.\n\n IMPRESSION: No evidence of retroperitoneal hematoma. Small bilateral pleural\n effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 832083,
"text": " 8:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evalfor ett placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with\n\n REASON FOR THIS EXAMINATION:\n evalfor ett placement\n ______________________________________________________________________________\n FINAL REPORT\n Shortness of breath, s/p intubation.\n\n COMPARISON: 20 minutes earlier.\n\n SINGLE VIEW CHEST, AP SUPINE: The ETT is appropriately placed within the\n trachea at the level of thoracic inlet. NG tube is seen coursing below the\n diaphragm into the stomach. The diffuse, bilateral interstitial and alveolar\n opacities, predominantly within the right lobe vs. the left are essentially\n unchanged.\n\n IMPRESSION: Appropriate placement of ETT and NG tube.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 832266,
"text": " 8:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF vs. infectious etiology\n Admitting Diagnosis: MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman anterior STEMI c/b pulmonary edema\n\n REASON FOR THIS EXAMINATION:\n CHF vs. infectious etiology\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 66 year old woman with pulmonary infiltrates, question\n infection vs. CHF.\n\n TECHNIQUE: A single AP view of the chest is provided.\n\n FINDINGS: There are faint patchy areas of increased density in both lung\n fields. Blunting of the right and left lateral costophrenic recesses is also\n noted consistent with small pleural effusions. The cardiac silhouette and\n mediastinum are within normal limits. The ETT and NGT have been removed.\n There is no evidence for pneumothorax. The bones and soft tissues are\n unremarkable.\n\n IMPRESSION: Significant improvement in the aeration of both lungs with almost\n complete resolution of diffuse alveolar opacities seen seen on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 832080,
"text": " 8:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval forchf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with\n REASON FOR THIS EXAMINATION:\n eval forchf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: .\n\n SINGLE VIEW CHEST, AP UPRIGHT: There has been interval development of diffuse,\n bilateral interstitial and alveolar opacities, predominantly in a perihilar\n distribution. These findings are most marked within the right mid and lower\n lung zones. There are likely small bilateral pleural effusions. There is left\n ventricular enlargement of cardiac size. There is no pneumothorax. A tiny left\n mid lung zone granuloma is again identified.\n\n IMPRESSION: Diffuse, bilateral interstitial and alveolar opacities consistent\n with pulmonary edema.\n\n"
},
{
"category": "Echo",
"chartdate": "2122-07-13 00:00:00.000",
"description": "Report",
"row_id": 101831,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 65\nWeight (lb): 190\nBSA (m2): 1.94 m2\nBP (mm Hg): 152/72\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 09:41\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. The left atrium is elongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. There is mild regional left ventricular\nsystolic dysfunction. Overall left ventricular systolic function is mildly\ndepressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: mid anteroseptal - hypokinetic; anterior apex -\nhypokinetic; septal apex - hypokinetic; apex - hypokinetic;\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function is\nnormal.\n\nAORTA: The aortic root is mildly dilated. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. The left atrium is normal in size. The left atrium is elongated.\n2.Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. There is mild regional left ventricular systolic dysfunction.\nOverall left ventricular systolic function is mildly depressed. Resting\nregional wall motion abnormalities include apical, mid and apical anteroseptal\nand apical anterior hypokinesis.\n3.Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic root is mildly dilated.\n5.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation\nis seen.\n6.The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n7.There is no pericardial effusion.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof , no signicant change.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2122-07-10 00:00:00.000",
"description": "Report",
"row_id": 101832,
"text": "PATIENT/TEST INFORMATION:\nIndication: Acute MI. ?evidence of pericardial effusion.?VSD.\nHeight: (in) 68\nWeight (lb): 200\nBSA (m2): 2.05 m2\nBP (mm Hg): 110/68\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 10:30\nTest: Portable TTE (Focused views)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis mildly depressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: anterior apex - hypokinetic; septal apex -\nhypokinetic; apex - hypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal.\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: Image quality was suboptimal.\n\nConclusions:\nSuboptimal images.\n1. The left atrium is normal in size.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Overall left ventricular systolic function is mildly\ndepressed. Resting regional wall motion abnormalities include distal septal,\napical and distal anterior severe hyokinesis/akinesis..\n3.Right ventricular chamber size and free wall motion are normal.\n4.The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. No AR seen but the views are limited.\n5.The mitral valve leaflets are structurally normal. No NR seen but the views\nare limited.\n6.There is an anterior space which most likely represents a fat pad, though a\nloculated anterior pericardial effusion cannot be excluded.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-12 00:00:00.000",
"description": "Report",
"row_id": 1392483,
"text": "CCU NSG NOTE: ALT IN CV: RI MI\nS: \"I feel much better this afternoon\"\nO: For complete VS see CCu flow sheet.\nID: Tm 100.2 at 8am. Pt has received tylenol and is afebrile in afternoon. She had sputum and urine culture sent.\nCV: Pt remains painfree on heparin at 1150u/hr. HR was in low 100s with low grade fever, down to 80s. Lopressor was increased to 75mg . Captopril was held at 2pm as bp was in 90s. It was given at 4pm. She was K+ replaced in am. Groin is dry with some eccymosis. PUlses on the R are dopplerable, they are palpable on the left. Her feet are warm, CSM nl.\nRESP: Pt coughing up bloody sputum. Sample was sent. No sputum by the afternoon. She is sating 96-98% on RA. She initially had rales but is now clear.\nGI: Pt eating and drinking without problem.\nGU: FOley out in am, now voiding on commode.\nCOMFORT: pt very achy, c/o of significant back pain when moving. As crit had dropped from 37 on admit to 30 this am she went to CT which r/o bleeding. Crit at noon was 32. He received percocette at 8 and noon and pain was greatly decreased and she required only tylenol at 4pm.\nACT: Pt OOB to chair with on strong assist. As she moves more she becomes stronger, but she feels very weak. She has PT consult.\nENDO: Finger stick 250 at 10a and she received 10u reg insulin. Sugar down to low 100s by 4pm.Not yet restarted on oral agents.\nMS: Pt in good spirits this afternoon. Oriented x 3, asking questions about rehab and future activity.\nA: Pain free/crit stable/CT neg/activity increasing/C/O\nP: To floor when bed available. Team to consult with Dr tomorrow about intervention on other vessels. Monitor for pain. GAS. Keep careful I & O.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-10 00:00:00.000",
"description": "Report",
"row_id": 1392478,
"text": "CCU NPN: please see flowsheet for objective data\n\n67 yr old female acutely SOB this am,called EMS. EW sats 70's,EKG ST elevations V1-4,intubated,heparin and integrillin started in EW,also received 80mg lasix and aspirin. in cath lab LAD stented,RCA 80% and OM1 90% stenosis.issues with hypotension started on dopa and end of case IABP placed. arrived to CCU intubated on dopa,integrillin and versed drip.\n\nCardiac: HR 70's NSR no VEA. initially MAPS 55-57 with PAD's and CVP 6. had diuresed 2600 from lasix,given NS fluid bolus 500cc x2 then able to wean off dopa. PA 24-27/13-16 CVP 6-9 numbers on IABP 1:1 CO/CI/SVR 4.2/1.99 1162 by fick,also thermodilution 3.99/1.89/1604. IABP weaned to 1:2 repeat numbers 4.2/1.99/1410 systolic unloading and diastolic unloading integrillin continues at 2mcg/kg/min until 2am. heparin at 500u/hr. pulses palpable rt DP dopplerable. IABP site has slight ooze,resident and fellow are aware. K 3.8 repleted with 20KCL IV\n\nResp: vented on 40% 550 X18 5 of peep,ABG 7.47/33/68 suctioned once for thin yellow blood tinged secretions. rate decreased to 15 no A-line\n\nNeuro: mildly sedated on versed and fentanyl. opens eyes spont and to name,nods head appropriately, mouthes words. moves all ext.\n\nGI: OGT in place,+BS,NPO except meds\n\nGU: UO initially put out 800c then 220cc/hr now 40-100. IV fluid at 1/2 NS at 100/hr for 1liter. -540cc\n\nHeme: HCT 37,plts 330\n\nID: afebrile\n\nSocial: three children,two out of the country,one daughter,, on the way .sig other in is spokesperson for now. home phone ,cell phone .\n\nA:67 yo s/p AMI with stenting to LAD,initially hypotensive after diuresis responded well to fluid boluses.IABP now on 1:2 to stay on 1:1 overnight\n\nP:cont to follow hemodynamics closely\n check PTT,plts and Hct\n monitor uo\n titrate fent and versed for comfort\n check ABG on new vent settings\n emotional support pt and family\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-11 00:00:00.000",
"description": "Report",
"row_id": 1392479,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned sml amts thick white secretions.IABP 1:1. Awakwe and alert,temp 99.1 on Midaz. RSBI done on 0 peep /5 IPS 40.8. Will cont to monitor resp status for further weaning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-11 00:00:00.000",
"description": "Report",
"row_id": 1392480,
"text": "ccu nsg progress note.\no:sedated w fent/versed gtts-doses decreased in am for ?extubation. easily arousable/cooperative/oriented. soft restraints to upper extrem. intubated/vented w present settings-ac/550x13/40/+5 w gd abg/sats. breath sounds=clear. sx-minimal thick white secretons. hemody stable throughout night-iabp placed 1:2 w #'s-6.4/2.80/800 w pads , cvp 5-6, & iabp maps upper 70's. integrillin dced @ 0200. heparin @ 500u. ivf @ kvo. k replaced w 40meq for 3.5. pulses all present-r fem c&d. npo-ogt to sx-bilious. adeq uo. low grade t. daughter arrived-spent x w mom. am sent.\n\na:stable throughout the night. iabp weaned to 1:2 w goal dc when able. sedation decreased to lighten for extubation.\n\np:?extubate. ?dc iabp. contin present management. support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-11 00:00:00.000",
"description": "Report",
"row_id": 1392481,
"text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 74-,BP 97-129/56-62 IABP weaned off and d/ced 10am. has small hematoma, 1\" by 3\" soft. with a little ecchymosis. had started captoptril last night now increased so that dose at 8pm 50mg.lopressor now 25mg . heparin restarted at 5:30 at 800u/hr. last K 3.7 had just taken 40meq po.\n\nResp: extubated at 8:30am,now on RA with sats 92-97,does have productive cough thick bloody\n\nGU: UO 30-150/hr +160 for day even length of stay.urine was cloudy UA/culture sent.\n\nGI: +BS,good appetite\n\nEndocrine: FS 139-174 covered at 6pm with 2u reg insulin.does take oral at home\n\nHeme: repeat Hct 36.7 PTT 22.4 off heparin\n\nNeuro: alert and oriented x3,has c/o back pain received two tylenol at 6pm\n\nSocial: daughter and boyfriend in visiting\n\nA: stable off IABP and vent post AMI\n\nP:monitor BP & HR as captopril and lopressor increased\n follow PTT's on heparin\n cont to check FS q6\n emotional support pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-07-12 00:00:00.000",
"description": "Report",
"row_id": 1392482,
"text": "ccu nsg progress note.\no:captopril increased to 75mgx3 & lopressor increased to 50mgx2- tolerating weel. heparin increased to 1150u for subtheraputic ptt- reck ptt pending. episode of substernal discomfort-ekg wo acute chges- resident aware-resolved wo intervention.\n\na:stable throughout night.\n\np:contin present management. support as indicated.\n"
},
{
"category": "ECG",
"chartdate": "2122-07-15 00:00:00.000",
"description": "Report",
"row_id": 290442,
"text": "Sinus rhythm\nBorderline low voltage\nAnteroseptal myocardial infarction with ST-T wave configuration suggests\nacute/recent/in evolution process\nClinical correlation is suggested\nSince previous tracing of , lateral ST-T wave changes less prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2122-07-14 00:00:00.000",
"description": "Report",
"row_id": 290443,
"text": "Sinus rhythm\nanteroseptal myocardial infarction with ST-T wave configuration suggests\nacute/recent/in evolution precess\nDiffuse ST-T wave abnormalities\nSince previous tracing of , further lateral ST-T wave changes\npresent and less suugestive of prior inferior myocardial infarction\n\n"
},
{
"category": "ECG",
"chartdate": "2122-07-13 00:00:00.000",
"description": "Report",
"row_id": 290444,
"text": "Sinus rhythm\nAnteroseptal myocardial infarction with ST-T wave configuration suggests\nacute/recent in evolution process\nConsider inferior infarct, age indeterminate\nDiffuse ST-T wave abnormalities\nClinical correlation is suggested\nSince previous tracing of same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2122-07-13 00:00:00.000",
"description": "Report",
"row_id": 290445,
"text": "Sinus rhythm\nAnteroseptal myocardial infarction with ST-T wave configuration suggests\nacute/recent/in evolution process\nConsider inferior infarct, age indeterminate\nDiffuse ST-T wave abnormalities\nClinical correlation is suggested\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2122-07-11 00:00:00.000",
"description": "Report",
"row_id": 290447,
"text": "Sinus tachycardia with increase in rate as compared to the previous tracing\nof . The T waves are less inverted in the precordial leads and there is\ncontinued ST segment elevation. These changes may represent pseudonormalization\nand new or extension of acute anterolateral myocardial injury. Followup and\nclinical correlation are suggested.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2122-07-11 00:00:00.000",
"description": "Report",
"row_id": 290448,
"text": "Sinus rhythm. Further evolution anterolateral and apical myocardial infarction.\nClinical correlation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2122-07-10 00:00:00.000",
"description": "Report",
"row_id": 290449,
"text": "Sinus rhythm with slowing of the rate as compared to the previous tracing\nof . There is left atrial enlargement and further evolution of acute\nanteroseptal myocardial infarction and evidence of interim inferior myocardial\ninfarction as well with new Q waves in leads III and aVF. Clinical correlation\nis suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2122-07-10 00:00:00.000",
"description": "Report",
"row_id": 290450,
"text": "Sinus tachycardia. Left atrial enlargement. ST segment elevation in V1-V5 with\nQS deflections in leads V1-V4 consistent with acute anteroseptal myocardial\ninfarction compared to the previous tracing of . There is continued low\nlimb lead voltage. Rule out myocardial infarction. Clinical correlation is\nsuggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2122-07-12 00:00:00.000",
"description": "Report",
"row_id": 290446,
"text": "Sinus rhythm with slowing of the rate as compared to the previous tracing\nof . There is some return of the T wave inversion previously recorded.\nThe prior recording may have represented pseudonormalization. There is loss of\ninferior forces with more prominent Q waves in leads III and aVF representing\ninferior injury as well. Clinical correlation is suggested.\nTRACING #5\n\n"
}
] |
25,770 | 142,833 | Pt returned to the ED s/p esophageal dilatation with chest pain and SOB. CT showed evidence of esophageal perforation. He was paleced on broad spectrum emperic antibiotics -vanco, levo, fluc, flagyl /07. He was intubated and taken to the OR where a 1 cm tear was found approx 33 cm down the esophagus. At this time there was a family meeting where they decided to not go ahead with definitive repair and to make him DNR. He was taken to the SICU intubated and on pressors. Pressors were weaned off and he extubated without difficulty. On he had R sided u/s guided R pleural drainage yielding 900 cc of fluid. The next day he had the same done on the L side with 850 of drainage. On he had a laparotomy with G and J tube placement. He also had respiratory difficulties on the floor which may been due to narcotic pain med administered which warranted a transfer to the CSRU. Pt recovered w/ narcan and non invasive resp support. On the R pigtail was d/c'd and on the L pigtail was d/c'd without complications. On he was in good condition for transfered back to the floor. He completed his antibiotic course and has remianed afebrile. He is working w/PT but remains deconditioned and requires ongoing rehab. His tube feeds were advanced to goal. | Right-sided central venous catheter remains in appropriate position and nasogastric tube is again identified with its sideport likely within the esophagus. REASON FOR THIS EXAMINATION: r/o effusion FINAL REPORT EXAMINATION: One view chest, . Again seen is a nasogastric tube with distal tip at the gastroesophageal junction and side port at the level of the lower esophagus unchanged in position. Fluid bolus x1 for hypotension prior to gtt w/short acting results. +PP, mild LE edema. Pboots in place.RESP: Intubated. There is a right subclavian line and bilateral chest tubes, which are unchanged in position. +BS, abdomen softly distended. Ascending thoracic aorta is dilated or tortuous and unchanged. Right femoral CVL placed by SICU HO. A right subclavian line and left chest tube remain in place. Status post endotracheal intubation. A nasogastric tube has been withdrawn. IMPRESSION: Unchanged malpositioning of the NG tube. Sedated w/PPF and Fent gtts. FINDINGS: Compared with 2/6, the right subclavian line has been removed. Left basal pleural catheter unchanged in position. A small air fluid level is again identified over the right hemithorax representing a loculated pleural effusion and pleural thickening. FINDINGS: Compared with , the bilateral pleural catheters are unchanged in position. FINDINGS: Single frontal radiograph of the chest labeled supine again demonstrates an endotracheal tube at a high position at the level of the clavicles, unchanged. IMPRESSION: No significant change post-extubation and removal of right chest tube. Right-sided subclavian central venous catheter is unchanged in position with tip in mid SVC and nasogastric tube likely has tip within stomach, however, side port is likely within the esophagus. IMPRESSION: AP chest compared to through . Bibasilar airspace opacities, bilateral calcified pleural plaques and blunting of the costophrenic sulci are unchanged. A small right lateral basilar pneumothorax persists, essentially unchanged compared with the prior study of . UPDATED: PT WEANED AND EXTUBATED THIS AM WITHOUTINCIDENT. Pboots in place.RESP: CPAP+PS. NGT in place w/minimal amt drg. remaines intubated and vented, weaned to PSV tol ok at this time. Vent weaned from CMV to CPAP tol well. care note - Pt. FOLEY PATENT, ABDOMEN SOFT, +BS. AFEBRILE.PT STILL NPO, TPN INFUSING. CVP 10-12.GI: Abd soft +BS. Cont with 1+ pit edema. Frequent oral care per protocol.GI: NPO. BS clear & diminished throughout. THEY ARE OK W/OTHER PORTS.GI: SOFT DISTENTED ABDOMEN, +BS, NG ON LIS W/BILIOUS DRAINAGE. Tolerating PS at this time. +BS, abdomen softly distended. Respiratory Care Note:Pt received from OR. pt tol tf -no residual- j tube clogged x 2- flushed Q 4hr. NPO, TPN infusing. c&r bilios colored sputum- dr. aware. CVP 0 after lasix admin. Resp. PPI CONT. SBP IN NORMAL LIMITS. See CareVue for RSBI and details.Plan: Wean as tolerated. HR Sinus rhythm with rare PVC's. Denies c/o pain. Continue current plan, OOB, pulm hygeine, ? BLS CTA. Skin W/D/I. updateD: pt more comfortable today on percocet down j-tube. Suctioning for minimal thick clear secretions. Sxn for scant amt. IV anitbx. RUE erythematous and warm @brachial site where access attempted by anesthesia. NG TUBE ON LIS/BILIOUS DRAINAGE. g tube drianing inc amt of bilious fluid. Occas. CHANGE TO CRUSHED DOSE VIA J-TUBE.EXTREMTIES WARM AND DRY.RESP; BS CLEAR, DIM LEFT SIDE- L AND R PIGTAILS REMAIN PT WEANED AND EXTUBATED, C&R LARGE AMT THIN CLEAR SECRETIONS- ADDITIONAL LR FLUID D/ PT SAT REMAINED >95% ON 4L NP. denied pain throughout shift.CV: SR w/PVC's. Nursing Note--A ShiftPlease see Carevue for complete assessment and specifics:NEURO: Propofol weaned off. BS+. Report (P). No BM this shift.ENDO: Stable BG. pupils equal and rx to light.cardiac: hr 80-90 sr-sbp 114-130/50-lopressor changed to po via j-tube. , RRT Afebrile. Pt. Pt. Abd soft&distended. NPNPlease see CareVue for full assessments.NEURO: Alert. PT APPEARED MORE DISTENDED AS DAY PROGRESSED, BS HYPOACTIVE- DR AWARE.GU: FOLEY INTACT DRAINING LG AMT CL YELLOW URINE.SKIN; INTACT-NO OBVIOUS SKIN BREAKDOWN NOTED. BEDSIDE SEMI-UPRIGHT CHEST: ET tube, right subclavian central venous line, and NG tube are again noted (NG tube tip is not visible due to technique and possibly position). Small area of pneumomediastinum superior to the aortic knob is unchanged. IMPRESSION: Single chest view demonstrating extensive pleural plaquing apparently stable in comparison with the previous examination. There is at least a small volume of pneumomediastinum above the aortic arch and perhaps a larger component inferiorly just above the diaphragm. Interval resolution of pneumomediastinum. Interval decrease in right pleural effusion and improved aeration at the right base. A right subclavian central venous catheter terminates in the upper SVC. Endotracheal tube is unchanged in standard position. A right-sided pleural drain is in unchanged position. Moderate right pleural effusion has a linear layering pattern and may herald a hydropneumothorax. Unchanged pneumomediastinum. There is mild perinephric stranding of uncertain significance. Bilateral pleural effusions, calcified pleural plaques, and lucency in the left upper lung are unchanged. Assess for pleural effusion or collection. IMPRESSION: Pneumomediastinum. Compared to the previous examination, the pneumomediastinum has resolved. Multiple thoracic wedge compression fractures, stable compared to prior plain radiographs. Right pleural tube placement. Right-sided subclavian catheter and nasogastric tube are unchanged in position. Calcified coronary arteries and circumflex stent are unchanged. Bilateral effusions are again seen. Small bilateral pleural effusions. Status post left pleural drain placement as described above. Associated small bilateral pleural effusions. A small pneumomediastinum is seen adjacent to the aortic knob and is not significantly changed. Improved aeration and decreased atelectasis at right lung base with pleural drain in place. Pleural calcifications are unchanged. Pt asymptomatic. Right pleural effusion has decreased and there is improved aeration of the right base. CHEST: The tip of the right subclavian line lies in the mid-to-lower SVC. x1 brief (<5sec) episode ST to 140's self resolved. The heart is normal in size, and there is a very small pericardial effusion. Significant interval decrease in size of the left pleural effusion. | 42 | [
{
"category": "Radiology",
"chartdate": "2126-12-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 947020,
"text": " 9:22 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx, s/p removal of R pigtail catheter\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esophageal rupture, managing conservatively- s/p\n bilateral pleural catheter placement.\n REASON FOR THIS EXAMINATION:\n r/o ptx, s/p removal of R pigtail catheter\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE AP VIEW. Comparison with .\n\n Study submitted for dictation .\n\n The patient has been extubated and a right chest tube has been removed. A\n right subclavian line and left chest tube remain in place. A nasogastric tube\n has been withdrawn. Bibasilar airspace opacities, bilateral calcified pleural\n plaques and blunting of the costophrenic sulci are unchanged.\n\n IMPRESSION: No significant change post-extubation and removal of right chest\n tube.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 947367,
"text": " 9:55 AM\n CHEST (PA & LAT) Clip # \n Reason: pigtail d/c on \n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p g/j tubes\n\n REASON FOR THIS EXAMINATION:\n pigtail d/c on \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Surveillance after esophageal rupture, drainage of left pleural\n empyema, and now status post removal of the pigtail catheter.\n\n COMPARISON: Prior chest radiographs from , 4 and 5, .\n\n TECHNIQUE AND FINDINGS: Frontal and lateral chest radiographs were obtained\n in upright position.\n\n There has been interval reaccumulation of pleural fluid at both bases since\n the last chest radiograph from yesterday, now with obscuring of the cardiac\n apex. No new pneumothorax is seen. Bilateral pleural calcification, heart\n size enlargement, unfolding of the aorta and the position of the right\n subclavian central venous line (tip in superior vena cava) remain unchanged.\n\n CONCLUSION: Interval reaccumulation of pleural fluid at both lung bases since\n yesterday.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 946681,
"text": " 5:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esophageal rupture, managing conservatively- s/p\n bilateral pleural catheter placement.\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old male with conservative management of esophageal rupture\n status post bilateral pleural catheter placement.\n\n Comparison is made to prior film dated .\n\n SINGLE UPRIGHT PORTABLE AP CHEST RADIOGRAPH:\n\n Chronic pleural scarring and calcification is again identified with no\n definite pneumothorax visualized. A small air fluid level is again identified\n over the right hemithorax representing a loculated pleural effusion and\n pleural thickening. There is unchanged appearance to left-sided atelectasis\n and effusion. Right-sided subclavian central venous catheter is unchanged in\n position with tip in mid SVC and nasogastric tube likely has tip within\n stomach, however, side port is likely within the esophagus.\n\n IMPRESSION:\n\n 1) No definite pneumothorax identified with unchanged appearance to pleural\n thickening/calcification and probable loculated right-sided pleural effusion.\n\n 2) Side port of nasogastric tube likely within esophagus. Advancement\n recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 946870,
"text": " 7:04 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: stat for intubation\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esophageal rupture, managing conservatively- s/p\n bilateral pleural catheter placement.\n REASON FOR THIS EXAMINATION:\n stat for intubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 78-year-old man with esophageal rupture with conservative\n management, status post bilateral pleural catheter placements and intubation.\n\n CHEST, PORTABLE SUPINE: Comparison is made to earlier in the same day. The\n patient is now intubated, with the tip of the endotracheal tube lying 5 cm\n above the carina. Bilateral pleural catheters and a right subclavian central\n venous catheter are unchanged. There is no pneumothorax. Bilateral\n parenchymal densities, predominantly at the bases, and bilateral effusions are\n not significantly changed. A nasogastric tube terminates in the distal\n esophagus.\n\n IMPRESSION:\n 1. Malpositioning of a nasogastric tube, which terminates in the distal\n esophagus.\n\n 2. Status post endotracheal intubation.\n\n 3. Otherwise, no significant interval change.\n\n Findings discussed with Dr. from Surgery on the same evening.\n\n s\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 947532,
"text": " 8:49 AM\n CHEST (PA & LAT) Clip # \n Reason: assess lung expansion\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p g/j tubes, esophageal perf\n\n REASON FOR THIS EXAMINATION:\n assess lung expansion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST 8:29 A.M. \n\n INDICATION: Assess lung expansion.\n\n FINDINGS: Compared with 2/6, the right subclavian line has been removed. No\n pneumothorax.\n\n Otherwise, no significant interval changes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 947062,
"text": " 8:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esophageal rupture, managing conservatively- with left\n pleural catheter placement.\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:19 A.M. \n\n HISTORY: Esophageal rupture managed conservatively with left pleural\n catheter.\n\n IMPRESSION: AP chest compared to through .\n\n There has been little change in the chest radiographic appearance since\n following removal of the right pleural drain. There is no\n pneumothorax on either side of the chest. Small residual bilateral pleural\n effusions are probably present as well as pleural thickening on the left and\n bilateral pleural calcification. Heart is top normal size, unchanged.\n Ascending thoracic aorta is dilated or tortuous and unchanged. Tip of the\n right subclavian line projects over the junction of the brachiocephalic veins.\n Left basal pleural catheter unchanged in position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 947226,
"text": " 10:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess lung expansion\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p L. pigtail catheter removal\n REASON FOR THIS EXAMINATION:\n assess lung expansion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Left empyema drained pigtail catheter removed.\n\n CHEST:\n\n Pigtail catheter has been removed as no evidence of pneumothorax. Extensive\n pleural calcification is again noted.\n\n IMPRESSION: No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 946745,
"text": " 7:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusions; please do x-ray at 7 AM.\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esophageal rupture, managing conservatively- s/p\n bilateral pleural catheter placement.\n REASON FOR THIS EXAMINATION:\n evaluate effusions; please do x-ray at 7 AM.\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Followup evaluation status post pleural catheter placement.\n\n Comparison is made to prior films dated and .\n\n SINGLE UPRIGHT AP PORTABLE CHEST RADIOGRAPH\n\n No significant change since prior film with stable appearance to loculated\n right-sided pleural effusion and left-sided atelectasis with small pleural\n effusion. Right-sided central venous catheter remains in appropriate position\n and nasogastric tube is again identified with its sideport likely within the\n esophagus. No pneumothorax.\n\n IMPRESSION:\n 1. No significant interval change.\n 2. Sideport of nasogastric tube likely within the esophagus.\n\n Findings discussed with caring physician, . on date of exam at\n approximately 11:40 a.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 946874,
"text": " 7:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o cva\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with\n REASON FOR THIS EXAMINATION:\n r/o cva\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old man, evaluate for CVA.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage, shift of\n normally midline structures, or hydrocephalus. -white matter\n differentiation appears grossly preserved. Mild mucosal thickening noted\n within the ethmoid, maxillary and sphenoid sinuses.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage. MRI with\n diffusion-weighted images is more sensitive in evaluation for acute\n ischemia/infarct and for vascular detail. This was discussed with the\n clinical team following completion of study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 946397,
"text": " 7:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esophageal rupture, managing conservatively- s/p bilateral\n pleural catheter placement.\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, 8:34 A.M. ON .\n\n INDICATION: Status post esophageal rupture and bilateral pleural catheters.\n Evaluate effusion.\n\n FINDINGS: Compared with , the bilateral pleural catheters are\n unchanged in position. No obvious change in the atelectasis/effusion at the\n left base.\n\n There has been interval decrease in the right pleural effusion with\n re-expansion of portions of the right lower lobe. A small right lateral\n basilar pneumothorax persists, essentially unchanged compared with the prior\n study of .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 946932,
"text": " 7:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esophageal rupture, managing conservatively- s/p\n bilateral pleural catheter placement.\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: One view chest, .\n\n COMPARISON: Chest x-ray .\n\n INDICATION: Rule out effusion. 78-year-old male with esophageal rupture.\n\n FINDINGS: Single frontal radiograph of the chest labeled supine again\n demonstrates an endotracheal tube at a high position at the level of the\n clavicles, unchanged. There is a right subclavian line and bilateral chest\n tubes, which are unchanged in position. Again seen is a nasogastric tube with\n distal tip at the gastroesophageal junction and side port at the level of the\n lower esophagus unchanged in position. There are bibasilar airspace\n opacities, which are not significantly changed. There is unchanged mild\n pulmonary edema. There is no evidence of pneumothorax.\n\n IMPRESSION: Unchanged malpositioning of the NG tube. No significant interval\n change, otherwise.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-13 00:00:00.000",
"description": "Report",
"row_id": 1597906,
"text": "NPN\nPlease see CareVue for full assessments\nPt. to SICU from OR ~2200. Pt had presented to ED with c/o severe CP, SOB, tacypnea and tachycardia. Had an EGD/Dilation 1/25AM without complications per report. CXR showed mediastinal air. Also seen on CT. Likely MD note. Pt. intubated in ED, pressors started for episodes of hypotension, and pt. taken to OR. Family spoke w/MD and decided against surgery and pt was made DNR. Pt. to SICU intubated, paralyzed, and on pressors.\nNEURO: Paralyzed on arrival. Sedated w/PPF and Fent gtts. PERRL 3mm and briskly reactive. Occassional movement of extremities on bed. Withdraws to nailbed stimuli. Noted to have periodic episodes of BLE tremors. SICU HO notified. Restraints on per protocol.\n\nCV: ST on arrival to SR w/PVC's presently. On Levophed gtt. Fluid bolus x1 for hypotension prior to gtt w/short acting results. Maintaining goal SBP grtr 100 on gtt. Gtt rate presently 0.14mcg/kg/min. Left brachial Aline dampening at times. Right femoral CVL placed by SICU HO. Tender to palpate. Ecchymotic around insertion site. No hematoma noted. SICU HO notified and in to eval. Transfused 1Unit Platelets. Multiple lyte repletions(Mag Sulfate, Potassium, Calcium gluconate, Sodium Phosphate)Please see carevue for specifics. Extremites cool to touch but pedal pulses palp. Pboots in place.\n\nRESP: Intubated. CMV650, RR12 5PEEP. FiO2 50% since arrival. RSBI this AM per protocol. BLS CTA. O2Sats 98-100%. Sxn for dk red/brown thick secretions. Oral suction freq for blood. SICO and Primary teams aware.\n\nGI: NPO. NGT placed and advanced by SICU HO after placement confirmed by CXR. NGT to intermittnet sxn w/bloody output. Output noted to decrease after platelet administration. BS+. Abd S/NT. Slightly distented. No BM.\n\nGU: Foley patent draining adequate amounts CYU.\n\nINTEG: Intact.\nPLAN: Monitor neuro status/sedation, Monitor CV, Maintain Levo gtt, titrate to goal, monitor for s/s bleeding, monitor resp status, sxn PRN, pain management, BG management, provide emotional support to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-14 00:00:00.000",
"description": "Report",
"row_id": 1597912,
"text": "Nursing Note--A shift\nPlease see Carevue for complete assessment and specifics:\n\nRESP: Extubated 8AM. Sat 95% on 3L NC. Productive cough for thick blood tinged sputum. Expectorates every few minutes--patient states that this is his baseline.\n\nCARDIAC: Tmax 99.2. Maintaining SBP >100, able to wean Levophed off. HR 80-105 SR with occ pvc's. +PP P-boots off.\n\nGI: NPO. Abd soft +BS. TPN to start this afternoon. +flatus. NGT to intermittent suction draining small amts of yellowish blood tinged fluid.\n\nGU: Foley intact draining qs clear yellow urine.\n\nNEURO: A&Ox3. Answers questions appropriately. Follows commands consistently. MAE in bed. +gag, +cough. OOB to chair 2 min assist. Sat-up for 2 hours.\n\nINTEG: Skin slightly dry-lotion applied. Small erethematous area around mouth. Mouth care q 2-4hours.\n\nPSYCH/SOCIAL: Very pleasant and cooperative. Motivated to be independent. Very supportive family at bedside.\n\nPLAN: Continue to monitor, NGT to intermittent suction, Maintain SBP >100, Ambulate as tolerated, Encourage independence with ADL's, Provide extra comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-15 00:00:00.000",
"description": "Report",
"row_id": 1597913,
"text": "Nursing note:\n A/Ox3, moving all extremities on bed. Pleasant and cooperative w/care. Denies pain. Lung sounds clear. +Strong cough productive for thick white sputum, self-suctioning w/Yankauer. Tmax 99.9. SR-ST, no ectopy. +PP, mild LE edema. +BS, abdomen softly distended. TPN infusing. NGT patent to LIS for small amount old dark blood. No increase in output or frank bleeding noted. Foley patent adequate amount amber urine. Glucose levels elevated, insulin per sliding scale.\nA/P: Stable s/p esophageal after esophageal dilation. To have CT scan and ? drainage of collection today. Continue current plan of care, IV abx, increase activity level, pulm hygeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-15 00:00:00.000",
"description": "Report",
"row_id": 1597914,
"text": "Condition Update A:\nPlease refer to careview and remarks for details.\n\nPt A&O x3, follows commands. Denies c/o pain. Tmax 100 PO. NSR 80's. SBP 140-150's. CVP 0 after lasix admin. Cont with 1+ pit edema. K=3.7, repleted with potassium 20mEq IV. NGT with 30cc bilious output. No bleeding from mouth. Expectorating thick tan secretions. Chest CT with IV contrast admin. Report (P). Glucose levels <165. OOB to chair with mod (A) x2. Emotional support provided to pt and family.\n\nPLAN: Possibly to IR Mon for drainage of fluid collection. Monitor labs. Pulmonary toilet. IV anitbx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-16 00:00:00.000",
"description": "Report",
"row_id": 1597915,
"text": "Nursing note:\n A/Ox3, denies pain. SR in 80s, no ectopy. SBP 140s-150s, Lopressor increased w/effect. Afebrile. Lung sounds clear, dim to bases. Expectorating thick white secretions, using Yankauer to self-suction. Sats 100%. +BS, abdomen softly distended. NPO, TPN infusing. Foley patent amber urine, good diuresis from Lasix during day. No bleeding from NGT or mouth.\nA/P: Stable, ? IR for drain today for pleural effusion. Continue current plan, OOB, pulm hygeine, ? to floor soon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-13 00:00:00.000",
"description": "Report",
"row_id": 1597907,
"text": "Respiratory Care Note:\n\nPt received from OR. orally intubated & sedated. No vent change made o/n, since adm vent settings. ABG ok this morning. We are sxtn for mod amt of thick yellowish this morning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-13 00:00:00.000",
"description": "Report",
"row_id": 1597908,
"text": "Resp. care note - Pt. remaines intubated and vented, weaned to PSV tol ok at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-13 00:00:00.000",
"description": "Report",
"row_id": 1597909,
"text": "Nursing Note--A Shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: Propofol weaned off. PERRLA 3 and brisk. Nods and shakes head appropriately to questions asked. Mouths words around ETT. MAE in bed. Follows commands consistently. Weak gag, weak cough.\n\nRESP: LSCTA. Vent weaned from CMV to CPAP tol well. Sat 94-98%. Deep ETT sxn for small amts of thin white secretions. Mouth sxn for moderate to copious amts of bloody secretions. Bronchoscopy in the AM sxn copious amt of thick white secretion and small amt of blood tinged.\n\nCARDIAC: Tmax 101.2. HR 80-105 SR with rare PVC's. >90 with Propofol off and vent change to CPAP. Maintaining MAP of >60 with Levo gtt. Levo gtt weaned off but needed to be restarted. +PP P-boots on. CVP 10-12.\n\nGI: Abd soft +BS. NGT to intermittent sxn draining small amts of dark red bloody fluid.\n\nGU: Foley intact draining qs clear yellow urine.\n\nINTEG: Skin dry in areas lotion applied. Scant amt of blood from meatus.\n\nPSYCH/Social: Very cooperative. Family at bedside for most of the day. Patient is very calm and interactive with their presence. SICU and MD's spoke with family re: plan of care.\n\nOTHER: Right Quad subclavian placed.\n\nPLAN: Wean Levo gtt as tolerated, Possible extubation in the am, Closely monitor for signs of bleeding, Provide extra comfort and support to patient and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-21 00:00:00.000",
"description": "Report",
"row_id": 1597921,
"text": "UPDATE\nD: PT WEANED AND EXTUBATED THIS AM WITHOUTINCIDENT. C/O GENERALIZED BODY ACHE THROUGHOUT DAY- C/O BACK AND ABD PAIN- REQUIRED FENTANYL 12.5 MG IVP Q 1HR FOR RELIEF OF PAIN. PT AWAKE ALL DAY. POST EXTUBATION PT WITH \"HORSE WEAK VOICE\"-\nG TUBE TO INTERMITTENT SX- MIN BILIOUS MATERIAL-J TUBE INTIALLY TO GRAVITY- CHANGED TO FEEDINGS AT 10CC/HR.\nNEURO: PT AWAKE, ANXIOUS AT TIMES-\"FREQ ON THE LIGHT\"-MAE, PUPILS 4MM EQUAL RX TO LIGHT.\nCARDIAC: PT IN 90-108 , NO ECTOPY NOTED, SBP 130-160/60- LOPRESSOR GIVEN IVP--? CHANGE TO CRUSHED DOSE VIA J-TUBE.\nEXTREMTIES WARM AND DRY.\nRESP; BS CLEAR, DIM LEFT SIDE- L AND R PIGTAILS REMAIN PT WEANED AND EXTUBATED, C&R LARGE AMT THIN CLEAR SECRETIONS- ADDITIONAL LR FLUID D/ PT SAT REMAINED >95% ON 4L NP. PT APPEARED TO BE SOB AT TIMES-SEEMED TO SUBSIDE WITH RELAXATION.\nGI: G TUBE TO INTERMITTENT SX- SMALL AMT BILIOUS DRIANAGE-J TUBE TO GRAVITY THEN FEEDINGS STARTED. PPI CONT. PT APPEARED MORE DISTENDED AS DAY PROGRESSED, BS HYPOACTIVE- DR AWARE.\nGU: FOLEY INTACT DRAINING LG AMT CL YELLOW URINE.\nSKIN; INTACT-NO OBVIOUS SKIN BREAKDOWN NOTED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-22 00:00:00.000",
"description": "Report",
"row_id": 1597922,
"text": "Neuro: pt alert oriented following commands. Slept in short naps through night, \"I just can't get comfortable\"\nResp: o2 sats 98% on 4l np breath sounds with wheezes last evening placed back on regular inhalers since extubated. Coughing and raising small amounts of thick green tinged sputum Ho aware. Right side pigtail cath removed by ho and chest x ray done post removal.\nLeft side continues to drain serous fluid 100cc/shift.\nC/V: vss afebile.\nGI: Jtube with tube feeds at 10cc/hr tolerating well. G tube to low intermittent suction draining bilious fluid small amount.\nEndo: blood sugars treated with sliding scale insulin\nGU: good urine out.\nPain: fair to good relief with fentanyl 25mcq lasting 2hours before pt states he is uncomfortable all over.\nActivity: oob to chair this am with 2 assists 2nd to very uncomfortable in bed.\nPlan: Increase activity. Monitor GI drainage and tube feeds ? increase if tolerating. Possible transfer back to floor. today or tomorrow. Needs better control\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-22 00:00:00.000",
"description": "Report",
"row_id": 1597923,
"text": "update\nD: pt more comfortable today on percocet down j-tube. c&r bilios colored sputum- dr. aware. g tube drianing inc amt of bilious fluid. pt tol fedding-inc to 30cc-tube did clog x2- required irrigation with slight force- to open.\nplan: pulm toiletry- pt states he brings up a fair amt of sputum at home-monitor charecter of sputum .\nneuro: pt awake, alert oriented x 3, mae. pupils equal and rx to light.\ncardiac: hr 80-90 sr-sbp 114-130/50-lopressor changed to po via j-tube. extremities warm and dry-palp pedal pules easily.\nresp: pt bs coarse at times-mainly secretions noted in back of throat-pt able to c&r sputum easily- sputum- dk green in color- similar to drainage from g tube. spirocare with tv to 750cc.\ngi: abd sl distended, bs hypoactive. g tube draining bilious material. pt tol tf -no residual- j tube clogged x 2- flushed Q 4hr. no bm today- pt cont on colace--? need for dulcolax.\ngu: foley draining cl yellow urine in good amts.\nskin; intact, midline abd inc slightly pink.\nfamily: spoke with pt and family considering rehab.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-14 00:00:00.000",
"description": "Report",
"row_id": 1597910,
"text": "NPN\nPlease see CareVue for full assessments.\n\nNEURO: Alert. Opens eyes spont. PERRL 3mm and brisk. Nods heads and mouths words appropriately to questions. MAE and follows all commands. Restraints removed while RN in room-no attempts at ETT. Fent gtt remains @30mcg. PPF gtt remains off. Pt. denied pain throughout shift.\n\nCV: SR w/PVC's. 2x episodes 8beat run vtach. AM labs pending. Levo gtt infusing to maintain goal MAP >60. Right subclavian CVL with scant bleeding from insertion site. DSD to Right femoral site intact. Skin W/D/I. PPP. Pboots in place.\n\nRESP: CPAP+PS. BLS CTA. Sxn for scant amt. secretions. Occas. bloody secretion from mouth. Frequent oral care per protocol.\n\nGI: NPO. NGT in place w/minimal amt drg. BS+. Abd soft&distended. No BM this shift.\nENDO: Stable BG. No coverage required per RISS.\nGU: Foley patent draining dk yellow concentrated urine. Dried blood noted at tip of meatus.\n\nINTEG: Intact. RUE erythematous and warm @brachial site where access attempted by anesthesia. Improving since yesterday. Pt. denies pain at site. Otherwise skin intact.\nPLAN: Monitor CV, titrate/wean levo gtt, monitor for bleeding/Hct, monitor resp status, pain management, provide emotional support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-14 00:00:00.000",
"description": "Report",
"row_id": 1597911,
"text": "Resp Care\nPT remains intubated on PSV. No vent changes made this shift. BS clear & diminished throughout. Suctioning for minimal thick clear secretions. ABG while pt asleep shows slight respiratory acidosis, however pt minute volume increased from 7 to 12 when awake. No changes made to vent at this time. See CareVue for RSBI and details.\nPlan: Wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-17 00:00:00.000",
"description": "Report",
"row_id": 1597918,
"text": "PLEASE SEE CAREVUE FOR SPECIFICS.\nPT ALERT. OERIENTEDx3. DILAUDID 0.5MG IV GIVEN FOR PAIN. LUNG SOUNDS MOSTLY CLEAR, DIMINISHED AT BASES.SELF-SUCT FOR WHITE/THICK SECRETIONS, PT NEED PULMONARY TOUILET.THORACENTESIS DONE ON LEFT SIDE, SAMPLES SENT FOR CX AND PIGTAIL DRAIN PLACEMENT DONE.RIGHT SIDE PIGTAIL DRAIN NOT PUTTING ANY FLUID, LEFT SIDE ~15CC SEROSANG FLUID.\nHR IN NSR W/OCCA PVC'S. SBP IN NORMAL LIMITS. AFEBRILE.\nPT STILL NPO, TPN INFUSING. NG TUBE ON LIS/BILIOUS DRAINAGE. FOLEY PATENT, ABDOMEN SOFT, +BS. NO BM DURING DAY SHIFT.\nPT IS GOING TO BE TRANSFERED TO 2 TODAY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-21 00:00:00.000",
"description": "Report",
"row_id": 1597919,
"text": "RESPIRATORY CARE NOTE\n\nPatient received from 2 s/p respiratory arrest. Originally very acidotic and required high Ve to normalize. 0500 pt awake and placed on CPAP/PS 15/5. RSBI completed on PS 5=85. Tolerating PS at this time. Vt-400-500, RR 25-30. Will decrease PS as tolerated.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-21 00:00:00.000",
"description": "Report",
"row_id": 1597920,
"text": "Pt admitted from 2 after Respiratory Arrest and intubation. Pt had undergone a J/G tube placement earlier in day had returned to floor awake alert. Received 2mg iv Dilaudid at 1730 and Lopressor at 1800 and was found unresponsive with 02 sat in the 90's RR 24 pt was given Nacrcan but continued to get worse turned blue dropped O2 Sats requiring intubation. Was taking for a head CT and transfered to CSRU.\nNeuro: pt initially difficult to arouse but as night progressed but awake alert and following commands attempting to mouth questions. Moves all extremities well.\nResp: pt intubated on CMV rate increased to several time to rate of 24 for Respiratory acidosis. ONce awake this am placed on Cpap with ips of 15 ABG's pending. Pigtail drain not draining anything, Left side drainingserous fluid moderate amounts.\nC/V: pt received a total of 3L of NS for hypotension. Aline placed on arrival. HR Sinus rhythm with rare PVC's. BP has improved this am after fluid boluses.\nGI: NPO No drainage from NGT, Gtube or Jtube. Pt is to have nothing down tubes.\nEndo: blood sugars treated with sliding scale.\nGU: Urine outputs dipped several times with low BP but improved after volume.\nSkin: Intact no breakdown.\nPain: pt complaining of back pain HO notified and Fentanyl 12.5-25mcg ordered.\nSocial: Family updated several times through night by phone.\nPlan: Wean to extubate this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-16 00:00:00.000",
"description": "Report",
"row_id": 1597916,
"text": "PLEASE SEE CAREVUE FOR SPECIFICS.\n\nNEURO: ALERT, ORIENTEDx3,EXT IN NORMAL STRENGHTS, SIT IN CHAIR DURING DAY.DENIES PAIN.\nRESP: RIGHT LUNG SOUND IS COARSE, DIMINISHED AT BASES.EXPECTORATING THICK/WHITE SECRETIONS,USING YANKAUER TO SELF-SUCTION.SAT'S 100 W/4L NC.THORACENTESIS FOR PLEURAL EFFUSION DONE TODAY, 900CC FLUID DRAINED DURING PROCEDURE, PIGTAIL PLACEMENT ON RIGHT SIDE. SENT SAMPLES FOR CX AND CHEMISTRY. TOMORROW,? LEFT SIDE PIGTAIL PLACEMENT WILL BE DONE.\nCV: HR IN NSR W/RARE PVC'S, SBP 130-150, METOPROLOL 7.5MG Q6H GIVEN W/GOOD EFFECT.AFEBRILE.PT'S MULTILUMEN CENTRAL CATH WAS LEAKING IN THE MORNING, ALL LUMENS ARE CHECKED, PROXIMAL PORT WASN'NT WORKING, IT CLAMPED AND TEAM AWARE. THEY ARE OK W/OTHER PORTS.\nGI: SOFT DISTENTED ABDOMEN, +BS, NG ON LIS W/BILIOUS DRAINAGE. NO BLEEDING FROM NG OR MOUTH. REMAINED NPO, TPN INFUSING.\nGU: FOLEY PATENT W/GOOD AMOUNT OF YEL/CLEAR URINE O/P.\nENDO; BLOOD GLUCOSE WELL CONTROLLED W/ SLIDING SCALE.\nSKIN: INTACT.\nPLAN: CLOSELY MONITOR PT'S RIGHT PIGTAIL DRAINAGE AND RESP STATUS. TOMORROW ? LEFT SIDE PIGTAIL PLACEMENT, TPN WILL CONTINUE AT LEAST 3 WEEKS.FOLLOW CX RESULTS AND CONTINUE CURRENT PLAN.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-17 00:00:00.000",
"description": "Report",
"row_id": 1597917,
"text": "NPN\nPlease see CareVue for full assessments.\nNEURO: Intact. MAE and follows all commands. Minimal assist w/transfers OOB to commode/chair. Denied pain throughout shift but stated general discomfort due to prolonged bedrest.\n\nCV: SR w/occassional PVC's. HR 70's-80's. x1 brief (<5sec) episode ST to 140's self resolved. Pt asymptomatic. Pt stated attempting to reposition self at that time. SICU HO aware. NBP stable. Lopressor per schedule. CVL proximal port not in use as noted in shift RN assessment. SICU team aware. HCT stable 30.5. PPP. Pboots in place.\n\nRESP: BLS increasingly diminished throughout shift. DOE at baseline per pt due to history of COPD/emphysema. Pt states breathing improved since right side thoracentesis. Plan for left side today. O2Sats 96-100% on 4L nc. Frequently expectorating small amts tan secrtetions w/Yankaur.\n\nGI: NPO w/TPN infusing via R CVL. NGT to LIS w/75cc bilious output for shift. BS+. Abd S/NT/ND. Med hard stool guaiac neg. Pt. reports no BM x5days prior to this BM.\nENDO: BG well controlled w/RISS.\nGU: Patent foley draining clr yellow urine.\nINTEG: Intact.\nPLAN: Left side thoracentesis, Monitor CV, rep status, pain management, BG management, maintain NPO, assist OOB to chair, assist w/ADL's, provide emotional support to pt/family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-12-23 00:00:00.000",
"description": "Report",
"row_id": 1597924,
"text": "Neuro: pt in much better spirits last night feeling better. Slept well through night. awake alert and oriented this am.\nResp: O2 sats 94-98% on 3l np coughing and raising sm to mod amounts of thick greenish yellow secretions. Left pigtail draining serous fluid\nC/V: vss afebrile\nGI: GT passing moderate amounts of bilious fluid. J tube - Replete with Fiber at 30cc/hr tolerating well. NO stools so far. no residuals.\nEndo: Blood sugars treated by sliding scale\nGU: good urine outputs.\nSkin: Abd Incision slightly pink no drainage.\nPlan: Increase tube feeds stop hyperal, OOB to floor and transfer to floor\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 946111,
"text": " 2:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r-pigtal cath placement r/p ptx\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esophageal rupture, managing conservatively.\n\n REASON FOR THIS EXAMINATION:\n r-pigtal cath placement r/p ptx\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Esophageal rupture. Right pleural tube placement.\n\n A single AP view of the chest is obtained on at 1453 hours and is\n compared with the prior day's radiograph. A right-sided pigtail catheter has\n been inserted into the pleural space. Right-sided subclavian catheter and\n nasogastric tube are unchanged in position. The appearances of the lung\n fields are not significantly changed on the left side but there does appear to\n have been a decrease in the right-sided pleural effusion. A small\n pneumomediastinum is seen adjacent to the aortic knob and is not significantly\n changed. There is no evidence of pneumothorax.\n\n IMPRESSION:\n\n Decrease in size of right pleural effusion after insertion of a right-sided\n pigtail pleural catheter. No other major change since the prior day.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 945618,
"text": " 10:07 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess NGT placement (unable to visualize on previous CXR)\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with chest pain, shortness of breath, after endoscopy\n respiratory distress\n REASON FOR THIS EXAMINATION:\n assess NGT placement (unable to visualize on previous CXR)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain, shortness of breath. NG tube placement.\n\n COMPARISON: .\n\n CHEST AP: The tip of the NG tube is at the GE junction and needs to be\n advanced. The tip of the endotracheal tube is 3 cm above the carina. Moderate\n right pleural effusion has a linear layering pattern and may herald a\n hydropneumothorax. No obvious pneumopthorax is seen. Follow up chest x-ray\n recommended. Bibasilar consolidations are unchanged. Pleural calcification is\n seen in both lungs bilaterally.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 946227,
"text": " 8:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate cathter position and pleural fluid status.\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esophageal rupture, managing conservatively- s/p pleural\n cathter placement Left.\n REASON FOR THIS EXAMINATION:\n Evaluate cathter position and pleural fluid status.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old man with esophageal rupture being managed\n conservatively. Evaluate pleural catheter position and pleural fluid status.\n\n COMPARISON: AP upright portable chest x-ray dated , at 02:53.\n\n AP UPRIGHT PORTABLE CHEST X-RAY: There has been interval placement of a left\n inferior pleural drain with the tip in the medial aspect of the left lung\n base. A previously seen moderately large left pleural effusion has\n significantly decreased in size. There is persistent pleural thickening, and\n mild loculation of fluid along the left lateral pleural margin. A right\n subclavian central venous catheter terminates in the upper SVC. A right-sided\n pleural drain is in unchanged position. There is improved aeration at the\n right lung base, with persistent mild linear atelectasis and plueral\n calcifications. A nasogastric tube descends below the diaphragm with the tip\n in the area of the stomach fundus. There is no pneumothorax.\n\n IMPRESSION:\n 1. Status post left pleural drain placement as described above. Significant\n interval decrease in size of the left pleural effusion.\n 2. Improved aeration and decreased atelectasis at right lung base with\n pleural drain in place.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-15 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 945934,
"text": " 12:41 PM\n CT CHEST W/CONTRAST Clip # \n Reason: ESOPHAGEAL PERFORATION, EVALUATE FOR PLEURAL EFFUSION, COLLECTIONS\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esoph perforation\n REASON FOR THIS EXAMINATION:\n pleural effusions/collections\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Esophageal perforation. Assess for pleural effusion or\n collection.\n\n COMPARISON: CT of the chest .\n\n TECHNIQUE: Contrast-enhanced chest CT using 75 cc of Optiray nonionic\n contrast.\n\n CHEST CT WITH CONTRAST: There is no axillary, hilar, or mediastinal\n lymphadenopathy. A nasogastric tube is noted, tip within the stomach.\n\n Compared to the previous examination, the pneumomediastinum has resolved.\n There are some linear foci of gas within the hiatal hernia, uncertain whether\n the gas is located between rugal folds, or whether these may be within the\n gastric wall. Bilateral pleural effusions have increased in size, and there\n is persistent, slightly increased consolidation at the lung bases bilaterally.\n Calcified pleural plaques consistent with previous asbestos exposure are\n unchanged, as is focal linear scarring within the left upper lobe.\n Emphysematous changes are again noted bilaterally. Calcified coronary arteries\n and circumflex stent are unchanged.\n\n Limited images of the upper abdomen demonstrate a small low-density lesion\n within the posteroinferior aspect of the right kidney, too small to\n definitively characterize. Multiple healing right rib fractures are\n unchanged. No new osseous lesions are evident.\n\n IMPRESSION:\n 1. Interval resolution of pneumomediastinum. Some residual linear foci of\n gas within the hiatal hernia may be either intraluminal or intramural.\n 2. Interval increase in size of bilateral pleural effusions, now moderate in\n size . Slight interval increase in extent of bibasilar areas of consolidation.\n 3. Please see complete report from , for multiple additional\n incidental findings, all of which appear unchanged on the current exam.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2126-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 945612,
"text": " 9:12 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ett placement?\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with chest pain, shortness of breath, after endoscopy\n respiratory distress\n REASON FOR THIS EXAMINATION:\n ett placement?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:27 p.m. \n\n HISTORY: Chest pain and shortness of breath, rule respiratory distress.\n\n IMPRESSION: AP chest compared to through 25:\n\n Moderate right pleural effusion has increased in consolidation worsened in\n both the right middle and lower lobes since . Pleural calcification\n is seen on both sides of the chest could be due to asbestos exposure,\n bilateral pleural insults such as empyema. Heart size normal.\n\n Stomach is severely distended with gas, and the nasogastric tube ends in the\n lower esophagus and would need to be advanced 15 cm to move all the side ports\n beyond the GE junction. ET tube tip is between 3 and 4 cm from the carina in\n standard placement. There is at least a small volume of pneumomediastinum\n above the aortic arch and perhaps a larger component inferiorly just above the\n diaphragm. The superior component may have been present on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 945655,
"text": " 7:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess new NGT placement\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with chest pain, shortness of breath, after endoscopy\n respiratory distress\n REASON FOR THIS EXAMINATION:\n assess new NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-UPRIGHT CHEST RADIOGRAPH\n\n INDICATION: 78-year-old male with possible esophageal perforation after\n endoscopy, for assessment of new nasogastric tube placement.\n\n COMPARISON: .\n\n FINDINGS: Nasogastric tube courses below the diaphragm, with its tip in the\n stomach. Endotracheal tube is unchanged in standard position. Right pleural\n effusion has decreased and there is improved aeration of the right base. Small\n area of pneumomediastinum superior to the aortic knob is unchanged. There is\n no pneumothorax. Pleural calcifications are unchanged.\n\n IMPRESSION:\n 1. Nasogastric tube with tip in the stomach.\n 2. Unchanged pneumomediastinum. No evidence of pneumothorax.\n 3. Interval decrease in right pleural effusion and improved aeration at the\n right base.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 945907,
"text": " 6:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval \n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esophageal rupture, managing conservatively.\n\n REASON FOR THIS EXAMINATION:\n interval \n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 06:29\n\n INDICATION: Esophageal rupture - followup.\n\n COMPARISON: at 04:22.\n\n FINDINGS: The ETT has been removed. Other lines and tubes remain in place.\n There is no PTX and no significant interval change in the appearance of the\n heart, lungs, and mediastinum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 945780,
"text": " 4:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate effusion\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esophageal rupture, managing conservatively.\n\n REASON FOR THIS EXAMINATION:\n Evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Esophageal rupture. Evaluate effusion.\n\n COMPARISON: and .\n\n BEDSIDE SEMI-UPRIGHT CHEST: ET tube, right subclavian central venous line,\n and NG tube are again noted (NG tube tip is not visible due to technique and\n possibly position). The cardiac and mediastinal contours are unchanged.\n Bilateral pleural effusions, calcified pleural plaques, and lucency in the\n left upper lung are unchanged. No pneumothorax is appreciated.\n\n IMPRESSION: Essentially no change in the appearance of the chest compared to\n the prior day's examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-12 00:00:00.000",
"description": "CT CHEST W&W/O C",
"row_id": 945594,
"text": " 5:37 PM\n CT CHEST W&W/O C Clip # \n Reason: eval ptx, esoph injury\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esoph dilation, now c free air under diaphragm\n REASON FOR THIS EXAMINATION:\n eval ptx, esoph injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old man with esophageal dilatation of free air under\n diaphragms. Evaluate for pneumothorax or esophageal injury.\n\n TECHNIQUE: CT of the chest without contrast was followed by acquisition after\n administration of intravenous contrast and oral contrast material. Multiplanar\n reformations were performed.\n\n FINDINGS: There is mediastinal emphysema centered around the esophagus. There\n is no pneumothorax, and there is no free intra-abdominal air. Administration\n of oral contrast material does not reveal contrast extravasation. This\n however does not exclude an esophageal perforation, which likely is present\n here, as the contrast layers dependently and does not cause full distention of\n the esophageal lumen. The distal esophageal wall appears thickened. No\n discontinuity of the esophageal wall is seen at any location to pinpoint to a\n possible perforation.\n\n The heart is normal in size, and there is a very small pericardial effusion.\n Coronary artery calcifications and stents are seen. There are atherosclerotic\n calcifications of the aortic arch and the origin of great vessels. No air is\n seen in the anterior mediastinum. There is no mediastinal or hilar\n lymphadenopathy. A consolidative process in the right lower lobe, surrounded\n by tree-in- and small pleural effusion is concerning for\n pneumonia. There also is a nodular opacity measuring 8 x 7 mm in the superior\n segment of the left lower lobe (9:50). Emphysematous changes are most\n pronounced at the lung bases. There are calcified pleural plaques bilaterally\n along the chest walls and also along the diaphragmatic pleura, consistent with\n prior asbestos exposure.\n\n Calcified granulomas are seen in the liver. There is mild perinephric\n stranding of uncertain significance. A hypoattenuating lesion is seen in the\n right kidney in the upper pole measuring approximately 12 mm. Additional\n smaller subcentimeter hypoattenuating lesions are seen in the right kidney.\n Further evaluation with ultrasound is recommended. There are atherosclerotic\n calcifications of the abdominal aorta and the origin of its major tributaries.\n Several prominent lymph nodes are seen in the upper abdomen. There is no\n ascites.\n\n BONE WINDOWS: There are multiple thoracic wedge compression fractures which\n appear stable on chest x-rays dating back to . No suspicious lytic or\n blastic osseous lesions are seen.\n\n (Over)\n\n 5:37 PM\n CT CHEST W&W/O C Clip # \n Reason: eval ptx, esoph injury\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Posterior mediastinal emphysema centered around the esophagus after\n attempted dilatation of esophageal stricture, highly suggestive of esophageal\n perforation. No extravasation of orally instilled contrast material. No\n pneumothorax or free intra- abdominal air.\n 2. Right lower lobe consolidative process suspicious for pneumonia.\n Associated small bilateral pleural effusions.\n 3. Calcified pleural plaques bilaterally suggestive of prior asbestos\n exposure.\n 4. Left lower lobe nodule. A followup CT and 3-6 months is recommended to\n assess for resolution/stability.\n 5. Hypoattenuating lesions in the right kidney, most of which are too small\n to characterize. Ultrasound could be performed for further evaluation.\n 6. Cholelithiasis without evidence of cholecystitis.\n 7. Calcified granulomas in the liver indicating prior granulomatous disease.\n 8. Hypoenhancing lesion with peripheral contrast puddling in segment V of the\n liver most likely representing hemangioma. Additional hypoenhancing lesion in\n segment VIII of the liver, incompletely characterized. These lesions should\n be further assessed with ultrasound or MRI.\n 9. Multiple thoracic wedge compression fractures, stable compared to prior\n plain radiographs.\n 10. Small bilateral pleural effusions.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 945596,
"text": " 5:40 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: POST INTUBATION\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 78-year-old man status post intubation.\n\n Portable AP chest dated at 17:39 is compared to the same examination\n from 40 minutes earlier. The patient has been intubated. The endotracheal\n tube terminates 3.6 cm above the carina. The lung volumes are very low, which\n obscures optimal evaluation of the heart. The aorta is tortuous. There is\n air tracking along the aortic arch adn descending aorta consistent with\n pneumomediastinum. The lungs show bilateral calcified pleural plaques but are\n otherwise clear. There is no pleural effusion or pneumothorax.\n\n IMPRESSION: Pneumomediastinum. Endotracheal tube terminating 3.6 cm above\n the carina. Otherwise, unchanged appearance of the chest since minutes\n earlier. Chest CT already scheduled for suspected esophageal perforation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 945724,
"text": " 2:43 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: new Right subclav CVL placed, please eval placement, r/o ptx\n Admitting Diagnosis: ESOPHAGEAL PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with esophageal rupture, managing conservatively.\n REASON FOR THIS EXAMINATION:\n new Right subclav CVL placed, please eval placement, r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post esophageal rupture, managing conservatively,\n right subclavian line placed, check position.\n\n CHEST: The tip of the right subclavian line lies in the mid-to-lower SVC.\n The position of the endotracheal tube and nasogastric tube remains\n satisfactory. No pneumothorax is present. Bilateral effusions are again\n seen. There has been no significant change since the prior film of seven\n hours earlier.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 945590,
"text": " 4:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for perforation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with chest pain, shortness of breath, after endoscopy\n REASON FOR THIS EXAMINATION:\n eval for perforation\n ______________________________________________________________________________\n WET READ: SP 5:40 PM\n Extensive old asbestos exposure changes, stable in comparision with previous\n chest x-rays ofJuly and .No evidence of CHF or new parenchymal\n abnormalities. Generally widened and elongated aorta as before. No signs of\n viscous perforation. If pulm. detail required a CT is the only way to look\n beyond the extensive pleural plaquing.\n WET READ VERSION #1 SP 5:33 PM\n ______________________________________________________________________________\n FINAL REPORT\n\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Chest pain, shortness of breath, following endoscopy, evaluate\n for possible perforation.\n\n FINDINGS: AP single view of the chest obtained with the patient in sitting\n upright position is analyzed in direct comparison with the previous chest x-\n ray examinations dated and . Heart size is difficult\n to assess because of relatively high positioned diaphragms related to poor\n inspirational effort. Significant cardiac enlargement is unlikely. There\n exists, however, marked general widening of the entire thoracic aorta\n including the ascending aorta as well as the descending aorta, coinciding with\n significant elongation. No conclusive evidence for local abnormality of the\n aortic contour is identified. Pulmonary vasculature is not congested. There\n exist bilateral basal densities mostly related to extensive diaphragmatic as\n well as lateral pleural chest wall plaquing more marked on the left than on\n the right. There is no conclusive evidence for new pulmonary infiltrates and\n no evidence of pneumothorax is present.\n\n When comparison is made to the previous chest examinations there is extensive\n pleural plaquing existed already earlier and no significant interval change\n can be identified. Our records do not include a previous CT examination,\n which could be used to evaluate in detail the pulmonary parenchyma\n overshadowed by the pleural changes on plain chest examination.\n\n IMPRESSION: Single chest view demonstrating extensive pleural plaquing\n apparently stable in comparison with the previous examination. There is no\n evidence of pneumothorax or new acute infiltrates.\n\n"
}
] |
10,873 | 184,107 | On the day of admission, this 20-year-old female was medically stabilized and evaluated with CT and MR her L2 burst fracture. Despite significant canal compromise, she remained neurologically intact. Due to her unstable pattern and neurologic compromise, anterior and posterior spinal reconstructive surgery was performed. A left T12 thoracoabdominal approach was performed with corpectomy at L2 and L1-L3 anterior spinal fusion using a Harm's cage and screw and rod fixation from L1-L3. On postoperative day 1 from her anterior surgery, she underwent an uncomplicated posterior spinal fusion with instrumentation and iliac crest bone graft from levels T10-L4 with pedicle screws placed at L4 and hook and rod construct above. Her postoperative course was unremarkable. She received homologous blood transfusion postoperatively after intraoperative transfusion, and her hemoglobin stabilized, and she remained asymptomatic for her residual anemia. The wounds were sealed, and she is healing primarily, both wounds, the flank, and posterior wounds. She has resumed normal bowel and bladder function. Her pain is controlled with oral medications. She is immobilized in a TLSO brace. She is discharged for continued rehabilitative care including psychiatric rehabilitation and physical rehabilitation. She will follow-up with Dr. in days for examination of the wounds and assessment of the construct radiographically. Long-term plans are for brace wear for three months and physical therapy for up to six months for full recovery of function after her surgery. Her psychiatric care is deferred to the guidance of the consulting team. , Dictated By: MEDQUIST36 D: 09:02:23 T: 09:25:03 Job#: | Low thoracic and low lumbar intervertebral body disc space heights are preserved. TECHNIQUE: Noncontrast CT of the head was performed. Allowing for portable supine technique, the heart size, mediastinal and hilar contours are within normal limits. ivf decreased to 75ml/hr.skin:intact.id:afebrile.heme:heparin sq discontinued(for OR? Sagittal images show that the conus is located one vertebral body cephalad to this area. The conus appears to terminate one level cephalad. npn 0700-1900neuro:a&ox3.follows commands,mae's equally,strength wnl.sensation intact to all ext.denies tingling,numbness.solumedrol gtt continues until 2300.c/o lower back pain.given 1mg dilaudid ivp x 1 w/ relief.denies thoughts of harming herself. IV CONTRAST: Nonionic IV Optiray contrast is used for trauma situation. This fracture courses inferiorly and terminates within the right L2 superior facet. Right maxillary sinus retention cyst. CT PELVIS WITH CONTRAST: The bladder and distal ureters are normal. IVF.No oxygen, sats 99%, breath sounds clear.NPO. Saturations adequate on RA.GI - Tolerating clear liq. The remainder of the imaged vertebral bodies have normal alignment and are nonfractured. TECHNIQUE: Helically acquired images were obtained from L1 through the top of S1 and sagittal and coronal reformats were constructed. 10:07 PM CHEST (SINGLE VIEW) Clip # Reason: TRAUMA FINAL REPORT INDICATIONS: Status post trauma. Dilaudid 1mg x1 with good effect. Vertebral body height and disk space height are preserved. IMPRESSION: Status post spinal fusion as described. Vertebral body height and disc space height are preserved. It is causing mild kyphotic angulation and right convexity scoliosis. Using incentive spirometry.Hemodynamically:SR, SB when asleep. Solumedrol drip as ordered. evidence of hardware loosening. The base of the brain is unremarkable, and the lung apices are clear. Pt reported some decrease in sensation at 0400 exam. Nursing Progress Note:Please see also CareVue and the transfer note.Pt condition stable today.Neuro:Remains on logroll precautions. Mild retrolisthesis of L2 on L3 is also noted. CT ABDOMEN WITH CONTRAST: Lung bases are clear. There is a slight kyphotic angulation surrounding the level of injury. Apparent fractures of the left anterior 7th and right anterior 6th - 8th ribs are likely related to respiratory motion, as these are not identified on (Over) 9:15 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT RECONSTRUCTION Reason: r/o traumatic injury Field of view: 36 Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) plain film examination. There is a mild amount of signal abnormality within the L5-S1 intervertebral disc which likely represents early degenerative change. FINDINGS: Single AP view of the chest is limited in detail due to trauma board. Pelvic bowel loops are normal. The conus is seen to occur at the L1-2 level, just superior to the fracture. There is probably mild retrolisthesis of L1 relative to L3. FINDINGS: AP & lateral views of thoracic spine show no fracture or dislocation. Appropriate behavior, affect.CV - SPB 90s when asleep. Please page Trauma HO on call when scan is completeThank you FINAL REPORT INDICATION: L2 burst fracture. appropriately.gi:+bs.taking clear liquids well.gu:u/o adequate,>100ml/hr,but has slowed this afternoon.will monitor. Please note that the upper most lung apices are clipped from view. 8:59 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: MVA FINAL REPORT INDICATION: Trauma. Clip # Reason: INTRA-OP CK LEVEL Admitting Diagnosis: S/P FALL;L4 BURST FRACTURE;RIB FRACTURE FINAL REPORT INTRAOPERATIVE, CHECK LEVEL. Above and below this level, the vertebral bodies have normal signal, height, and alignment. SINGLE AP VIEW OF THE PELVIS is limited in detail due to trauma board. CT CERVICAL SPINE WITH SAGITTAL AND CORONAL RECONSTRUCTIONS: There is no fracture or malalignment. The ventricles and sucli are normal in size and symmetrical. FINAL REPORT INDICATION: Trauma. Pt currently denies pain. The SI joints, hip joints, and pubic symphysis are intact. SINGLE CHEST: Comparison is made to recent radiograph of earlier the same day obtained as part of a trauma series. AP and lateral radiographs of the L-spine demonstrate the patient to be status post left lateral spinal fusion with interbody cage at L1-L3 with posterior spinal fusion extending upward from L4 and off the imaged field of view. | 15 | [
{
"category": "Radiology",
"chartdate": "2192-09-06 00:00:00.000",
"description": "O L-SPINE (AP & LAT) IN O.R.",
"row_id": 837941,
"text": " 3:52 PM\n L-SPINE (AP & LAT) IN O.R. Clip # \n Reason: INTRA-OP CK LEVEL\n Admitting Diagnosis: S/P FALL;L4 BURST FRACTURE;RIB FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n INTRAOPERATIVE, CHECK LEVEL.\n\n Three intraoperative films demonstrate L1-2 and L2-3 interspace to be\n localized with subsequent placement of hardware with basket and screws placed\n at L1 and L3.\n\n CONCLUSION: Intraoperative films demonstrating localization of L1-2 and L2-3\n interspace with subsequent placement of hardware, as described above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-03 00:00:00.000",
"description": "CT L-SPINE W/O CONTRAST",
"row_id": 837636,
"text": " 9:50 PM\n CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: s/p fall with l2 burst fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p fall with l2 burst fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Fall.\n\n TECHNIQUE: Helically acquired images were obtained from L1 through the top of\n S1 and sagittal and coronal reformats were constructed.\n\n FINDINGS: There is a comminuted burst type fracture of the L2 vertebral body\n with retropulsion of fragments resulting in greater than 50% canal stenosis.\n Sagittal images show that the conus is located one vertebral body cephalad to\n this area. The lateral aspects of the neural foramen at this level remain\n open. Fracture seen to also extend through the left lamina of L2. This\n fracture courses inferiorly and terminates within the right L2 superior facet.\n The remainder of the imaged vertebral bodies have normal alignment and are\n nonfractured.\n\n There are limited views of the retroperitoneum but this area is assessed on CT\n of the abdomen and pelvis performed on the same day.\n\n IMPRESSION:\n\n 1. Comminuted burst fracture of the L2 vertebral body with extension to the\n posterior elements and retropulsion of fragments resulting in severe spinal\n canal compression. The conus appears to terminate one level cephalad.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-03 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 837637,
"text": " 10:07 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATIONS: Status post trauma.\n\n SINGLE CHEST: Comparison is made to recent radiograph of earlier the same day\n obtained as part of a trauma series.\n\n Allowing for portable supine technique, the heart size, mediastinal and hilar\n contours are within normal limits. The lungs appear grossly clear. No pleural\n effusions or pneumothoraces are identified. Skeletal structures reveal no\n gross acutely displaced fractures. Incidental note is made of IV contrast\n within the renal collecting systems, likely related to recent CT exam\n performed prior to the chest radiograph.\n\n IMPRESSION: No radiographic evidence of acute traumatic thoracic injury.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-11 00:00:00.000",
"description": "L-SPINE (AP & LAT)",
"row_id": 838497,
"text": " 1:29 PM\n L-SPINE (AP & LAT) Clip # \n Reason: alignment\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with\n REASON FOR THIS EXAMINATION:\n alignment\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Spinal fusion.\n\n AP and lateral radiographs of the L-spine demonstrate the patient to be status\n post left lateral spinal fusion with interbody cage at L1-L3 with posterior\n spinal fusion extending upward from L4 and off the imaged field of view. There\n is probably mild retrolisthesis of L1 relative to L3. evidence of hardware\n loosening. Bowel gas pattern unremarkable. Low thoracic and low lumbar\n intervertebral body disc space heights are preserved.\n\n IMPRESSION: Status post spinal fusion as described.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-07 00:00:00.000",
"description": "O L-SPINE (WITH OBLIQUE) IN O.R.",
"row_id": 838124,
"text": " 10:02 PM\n L-SPINE (WITH OBLIQUE) IN O.R. Clip # \n Reason: S/O SCREW AND ROD\n ______________________________________________________________________________\n FINAL REPORT\n Rods and screws stabilizing spine. Five interoperative portable films taken\n portably lacking detail show the sequence in placement of pedicle screws and\n rods stabilizing the lumbar spine with the inferior pedicle screws placed at\n L4.\n\n CONCLUSION: Pedicle screws and rods stabilizing lumbar spine as described\n above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-03 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 837631,
"text": " 8:59 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: MVA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Trauma. Motor vehicle accident.\n\n FINDINGS: Single AP view of the chest is limited in detail due to trauma\n board. Heart size and pulmonary vasculature are normal. Please note that the\n upper most lung apices are clipped from view. Allowing for this, no\n pneumothorax or apical cap seen. No pleural effusions or fractures are\n identified. Mediastinum is normal in appearance.\n\n SINGLE AP VIEW OF THE PELVIS is limited in detail due to trauma board. The SI\n joints, hip joints, and pubic symphysis are intact. No fracture or dislocation\n seen.\n\n IMPRESSION: No radiographic evidence of trauma related pathology to the chest\n or pelvis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-03 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 837632,
"text": " 9:15 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/o trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with 25 foot fall\n REASON FOR THIS EXAMINATION:\n r/o trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RKKR MON 10:56 PM\n No Fx or malalignment\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT cervical spine.\n\n INDICATION: Trauma. Twenty-five foot fall.\n\n TECHNIQUE: Multiple contiguous noncontrast axial images of the cervical spine\n were performed. Images were reconstructed in the sagittal and coronal planes.\n\n CT CERVICAL SPINE WITH SAGITTAL AND CORONAL RECONSTRUCTIONS: There is no\n fracture or malalignment. Vertebral body height and disk space height are\n preserved. There is no prevertebral or adjacent neck soft tissue swelling.\n The lateral masses of C1 are well aligned with C2.\n\n The base of the brain is unremarkable, and the lung apices are clear.\n\n IMPRESSION: No fracture or malalignment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-04 00:00:00.000",
"description": "MR L SPINE SCAN",
"row_id": 837671,
"text": " 8:50 AM\n MR L SPINE SCAN Clip # \n Reason: L2 burst fx- with retropulsion of fragments- eval for cord i\n Admitting Diagnosis: S/P FALL;L4 BURST FRACTURE;RIB FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with\n REASON FOR THIS EXAMINATION:\n L2 burst fx- with retropulsion of fragments- eval for cord injury. Please page\n Trauma HO on call when scan is completeThank you\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: L2 burst fracture.\n\n Sagittal and axial T1 and T2 weighted images were obtained through the lumbar\n spine including sagittal inversion recovery images. No contrast was\n administered.\n\n A comparison is made to CT from earlier this same day.\n\n FINDINGS: There is a comminuted burst type fracture of the L2 vertebral body\n with retropulsion of a large fracture fragment resulting in greater than 50%\n narrowing of the spinal canal. The conus is seen to occur at the L1-2 level,\n just superior to the fracture. The retropulsed fragment displaces and\n compresses the spinal nerve roots, which are not individually identified.\n There is low signal seen within the expected location of the left lateral\n recess at the L2-3 level, though individual nerve roots cannot be discerned at\n this level. There is no definite evidence of epidural hemorrhage, though this\n is difficult to assess due to the large amount of retropulsed fragments.\n\n There is a slight kyphotic angulation surrounding the level of injury. Above\n and below this level, the vertebral bodies have normal signal, height, and\n alignment. There is a mild amount of signal abnormality within the L5-S1\n intervertebral disc which likely represents early degenerative change.\n\n IMPRESSION:\n\n Comminuted burst type fracture of the L2 vertebral body with posterior\n retropulsion and near complete occlusion of the spinal canal at this level.\n The nerve roots are displaced posteriorly and clumped together. There is no\n definite evidence of an epidural hematoma but a small one is not excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 837633,
"text": " 9:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o trauma\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n Additional information has been obtained from CareWeb Clinical Lookup since\n the approval of the original report. Reason for exam should also state\n delusions.\n\n\n 9:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with 25 foot fall\n REASON FOR THIS EXAMINATION:\n r/o trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RKKR MON 9:24 PM\n No IC Bleed or mass effect. No Fx.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma. 25 foot fall.\n\n TECHNIQUE: Noncontrast CT of the head was performed.\n\n FINDINGS: There is no intraaxial or extraaxial hemorrhage identified. There\n is no mass effect or shift of the normally midline structures. /white\n matter differentiation is preserved. The ventricles and sucli are normal in\n size and symmetrical.\n\n Bone windows show no fracture or suspicious lesions. A mucus retention cyst\n is seen within the right maxillary sinus.\n\n IMPRESSION: No intracranial hemorrhage or mass effect. Right maxillary sinus\n retention cyst.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-03 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 837634,
"text": " 9:15 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: r/o traumatic injury\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with 25 foot fall\n REASON FOR THIS EXAMINATION:\n r/o traumatic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RKKR MON 11:02 PM\n Burst Fx L2 with retropulsion, severe central stenosis\n Probable rib Fxs - L 7th and R 6,7,8th anterior ribs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Trauma. 25 foot fall.\n\n TECHNIQUE: Contrast enhanced images of the abdomen and pelvis following the\n administration of 150 cc of IV Optiray were performed. Images are\n reconstructed in the sagittal and coronal plains.\n\n IV CONTRAST: Nonionic IV Optiray contrast is used for trauma situation.\n\n CT ABDOMEN WITH CONTRAST: Lung bases are clear. The liver, gallbladder,\n pancreas, spleen, adrenal glands, stomach, kidneys, and bowel loops are normal\n without evidence of injury. The arterial vascular structures are intact, and\n no hematoma is identified. There is no free fluid or free air.\n\n CT PELVIS WITH CONTRAST: The bladder and distal ureters are normal. No free\n fluid. Pelvic bowel loops are normal. The uterus and adnexa are unremarkable.\n\n CORONAL AND SAGITTAL RECONSTRUCTIONS: Images reconstructed in the sagittal\n and coronal planes demonstrate a burst fracture of the L2 vertebral body with\n 50% loss in vertebral body height and mild kyphotic angulation at this level.\n There is retropulsion of a large fracture fragment causing severe central\n canal stenosis. Mild retrolisthesis of L2 on L3 is also noted. The fracture\n is noted to involve the L lamina and R inferior articular facet, and there is\n widening of the right joint articulation.\n\n Apparent fractures at the left 7th and right 6-8th ribs are likely secondary\n to respiratory motion.\n\n IMPRESSION:\n\n\n 1. Burst fracture of the L2 vertebral body with 50% loss in height and\n retropulsion, causing severe central canal stenosis. Please see CT lumbar\n spine study of the same day for further details.\n\n 2. Apparent fractures of the left anterior 7th and right anterior 6th - 8th\n ribs are likely related to respiratory motion, as these are not identified on\n (Over)\n\n 9:15 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: r/o traumatic injury\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n plain film examination.\n\n 3. No solid organ injury seen.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-03 00:00:00.000",
"description": "T-SPINE",
"row_id": 837635,
"text": " 9:28 PM\n T-SPINE; L-SPINE (AP & LAT) Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma. Fall from height.\n\n FINDINGS: AP & lateral views of thoracic spine show no fracture or\n dislocation. Vertebral body height and disc space height are preserved.\n\n AP & LATERAL VIEWS OF THE LUMBAR SPINE demonstrate burst fracture of the L2\n vertebral body with 50% loss in height and retropulsion of fracture fragments\n into the central canal as well as mild posterior listhesis with respect to L3.\n It is causing mild kyphotic angulation and right convexity scoliosis. Note is\n made of contrast material within the renal collecting systems and bladder from\n CT examination the same day.\n\n IMPRESSION: L2 vertebral body burst fracture with 50% loss of height,\n retropulsion of fracture fragments, and mild posterolisthesis on L3. Please\n see CT studies of the same day for further details.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-05 00:00:00.000",
"description": "Report",
"row_id": 1405403,
"text": "TSICU Nursing Progress Note\nNeuro - AAOx3. Sleeping between exams. Extremities equal and strong bilaterally. Pt reported some decrease in sensation at 0400 exam. Dr. examined. Sensation returned to at 0500 exam. Dilaudid 1mg x1 with good effect. Pt currently denies pain. Appropriate behavior, affect.\n\nCV - SPB 90s when asleep. HR 50s when asleep, occasional sinus arrhythmia. Strong peripheral pulses, warm extremities.\n\nResp - lungs clear bilaterally. Saturations adequate on RA.\n\nGI - Tolerating clear liq. + bowel sounds.\n\nGU - Clear yellow urine via foley.\n\nSkin - intact\n\nHeme - pneumoboots on\n\nEndo - covered with insulin sliding scale\n\nSocial - Primary MD in to visit.\n\nA - Intact neurologically s/p fall. Emotionally appropriate.\n\nP - Monitor until planned surgery on Thursday. Provide emotional support to patient and family. Maintain logroll precautions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-05 00:00:00.000",
"description": "Report",
"row_id": 1405404,
"text": "Nursing Progress Note:\nPlease see also CareVue and the transfer note.\n\nPt condition stable today.\n\nNeuro:\nRemains on logroll precautions. Denying tingling or numbness. Moving all 4 to commands with good strength. Flat affect, drowsy in between assessments, startles easily. Hydromorphone for pain. Denying hallucinations. For OR tomorrow.\n\nResp:\nOxygenating well on room air. Using incentive spirometry.\n\nHemodynamically:\nSR, SB when asleep. Becomes tachycardic when startled. Normotensive. Drops SBP to 90s when asleep. Peripherally warm and well perfused.\n\nGI:\nFOr clear fluids until midnight but refusing at this time.\nReceived LR bolus for declining urine output.\n\nSocial:\nVisited by family.\n\nPlan:\nFor OR tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-04 00:00:00.000",
"description": "Report",
"row_id": 1405401,
"text": "T/SICU Nursing Admission Note\n\nPt is 20 year old admitted at 12am from EW after jumping out of second story window of her parent's home (about 25ft). Pt says voices told her to do it. She sustained an L2 burst fracture and rib fractures. No neuro deficits.\n\nPMHx: Depression, Raynaud's, panniculitis.\n\nNo known allergies.\n\nNo meds.\n\nPt was given Morphine for back pain in EW and remains sleepy. Arouses easily and oriented. No neuro deficits. Solumedrol drip as ordered. Cervical collar on.\n\nNSR-ST, no ectopy. BP 100/50. Afebrile. Pneumboots and Heparin. IVF.\n\nNo oxygen, sats 99%, breath sounds clear.\n\nNPO. Abd. soft.\n\nUrine output brisk via Foley.\n\nSkin intact, remains on logroll precautions. Sliding scale Insulin.\n\n mother and sister spoke with staff about pt's erratic behavior over past few days. They are very concerned. They state that pt is a perfectionist, an architecture student at RISD who was supposed to start her second year today. They will return tomorrow and hope to speak with attending surgeon and psychiatrist.\n\nPlan: MRI, possible OR today, psych to follow, support family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-04 00:00:00.000",
"description": "Report",
"row_id": 1405402,
"text": "npn 0700-1900\n\nneuro:a&ox3.follows commands,mae's equally,strength wnl.sensation intact to all ext.denies tingling,numbness.solumedrol gtt continues until 2300.c/o lower back pain.given 1mg dilaudid ivp x 1 w/ relief.denies thoughts of harming herself. conversation and behavior appropriate.sitter at bedside.\n\ncv:sbp low 100s,map>60.hr 70-80s,sr,occasionally irregular.\n\nresp:ls clear.sao2>95% on room air.uses i.s. appropriately.\n\ngi:+bs.taking clear liquids well.\n\ngu:u/o adequate,>100ml/hr,but has slowed this afternoon.will monitor. ivf decreased to 75ml/hr.\n\nskin:intact.\n\nid:afebrile.\n\nheme:heparin sq discontinued(for OR?).pnuematic boots on.\n\nendo:covered x 2 per ss.\n\nsocial:parents and sister at bedside.updated by psychiatry,icu and orthospine mds.family and pt tearful but appropriate and supportive.\nsocial worker to speak w/ family today.\n\na/p:altered mobility r/t traumatic spinal injury.altered mental status r/t psychotic episode.continue neuro exams.monitor for changes in extremity sensation,mvmt.provide adequate pain control.monitor for s/s agitation as steroid use can precipitate manic episode.use haldol prn. provide support for pt and family.\n"
}
] |
26,398 | 157,201 | HOSPITAL COURSE: On arrival to CCU, HD stable w/ SBP in 90s-100s, brady HR 50s, but enlarging L thigh hematoma; HCT 40 => 34 post-cath on floor => 2 units then; to OR for evacuation of 25x10 cm, closure. In OR, R DP A-line placed, Swan floated; TEE w/ 30-35%, + MR, antero-apical hypokinesis. Received 5 units pRBC, 5 L LR, EBL 2 L in thigh hematoma => HCT 39.1; intraoperative hypoTN (not documented) in assx with "SVT." Transferred back to CCU intubated, sedated. Salvos of NSVT, now resolved. On return, re-bleed in late PM , seen, recommended 2 additional U pRBC, 2 U FFP, 6x PLTs, 10 U cryo for fibro 110 => 10 U cryo to 239. HCT dropped to 26 in early AM . Transfused 2 U PRBC, 4 L LR for low UOP and MAP 50s => MAPs 75. following, took back to OR PM; EBL 100cc, evacuated hematoma. POD #1 w/ fever to 102, cultured up, CXR w/ worsening effusions; hypotensive by A-line, but nl MAP on cuff. Supported w/ NS 125 and bolus (off now), hydrocort bolus; abx per on V/L/F day 3 now. Lines d/c; self-limited episode of AF-RVR to 180s w/ epigastric pain and SBP to 90s on , treated with amio, back to NSR at 60s. . 75 yo F with multiple risk factors, anterior STEMI, cath with 100% mid-LAD lesion, non-intervened. No HD or electrical instability now. Hematoma s/p cordis removal, s/p surgical closure and evacuation of hematoma. . CV: Rhythm: Arrhythmias: Pt with Afib/Aflutt with RVR. given dilt IVP, then started on Amio gtt, and Pt could not get betablocker given COPD. Discussed with EP re: cardioversion/ablation of flutter. TEE performed, no thrombi or vegetations--cardioverted--remained in NSR since. Per EP:--will benefit from ablation, but cannot do as an inpatient due to horrible access sites (groin hematomas). rec'ed scheduling as an outpatient. Pt refused to stay on amiodarone, and did not want sotalol due to COPD. Discussed with EP, no anti-ar agents until ablation as an outpatient. Well rate controlled. Pt will have an appt. with as an ouptatient for the ablation. Was discharged on diltiazem and digoxin for rate control. Patient was recommended, but refused to take a higher dose of diltiazem for rate control. . #Ischemia: non-revascularized, s/p STEMI, 100% chronic total mid-LAD. intervention was not possible, so that medical managment of patient's ischemia was recommended. Following the hematomas, patient agreed to take ASA, but refused to take ASA, plavix, and lipitor. Pt refused to take BB since she thought this would aggravate her COPD. . Pump: LVEF 45%, 2+ MR. on clinical exam, responded to IV Lasix during inpatient hospitalization. Patient continued to refuse ACEIs while in-house . #Respiratory distress - multifactorial--CHF, COPD, previously Arrythmia. patient satting 93-100% on 2L NC while on the floor. Not on home O2, though recommeded numerous times in the past. Currenlty on Prednisone taper down to 5mg PO qd, which is the patient's home dose for her COPD. . # Thigh hematoma: Hct now stable at 30-33. Still putting out small amount of serosanguinous fluid to drain. 1JP still in, draining small amount of serosang fluid. On Vanc for prophylaxis. Vasc surgery still following the drain output.- . #. ID: pt has citrobacter freundii-- sensitive. pt has been afebrile, Bx negative. has been on vanco/, vasc recs. Now growing Klebsiella, so will treat with 5 day course of ceftriaxone. - x 10 day for ?citrobacter PNA (day 9 now on ) -call vasc regarding cont vanc once drains are out?--may be d/c ed tomorrow? -Follow CBC, temp curve; culture for T >101 again. -Tylenol prn. . 8. PUD: on PPI . 9. PPX: PPI, bowel regimen. Add dulcolax suppository prn. We suggested SQ heparin and Ok'ed it with Dr. , pt's surgeon.. Discharge Disposition: Extended Care Facility: - Discharge Diagnosis: STEMI Discharge Condition: stable, afebrile, chest pain free Discharge Instructions: Weigh yourself every morning, MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Provider: , SURGERY (NHB) Date/Time: 2:15 Provider: , M.D. Phone: Date/Time: 3:00 Provider: , , MD, Gerontology Phone: Date/Time: 1 pm Provider: , MD, interventional cardiology, , 12:30 pm Completed by:[**2114-10-23** | BS COURSE WITH OCCASSIONAL EXP WHEEZES NOTED. addendum: on initial rounds noted l arm lg ecchymotic ? Rt PT pulse per doppler. DSG CHG X2 OVERNOC. Back to ORS- mouthing "phelgm". DISTENDED.BS HYPOACTIVE. BOLUSED WITH AMIODARONE->GTT 1MG/MIN. TRANSFUSED 2U PRBC, 2L LR,1 BAG CRYOPRECIPITATE. PIV X2.GI/GU: Abd softly distended, hypoactive BS noted. Lt and PT per doppler. AWAIT AM VANCO LEVEL. EKG +STEMI. Prednisone taper continues.CV: SR. PACs. GIVEN ASA, & STARTED ON HEPARIN GTT. Rt Venous sheath CDI. ?LASIX NEBS PRN. RETURNED TO CCU INTUBATED. ABG->7.46/31/200/23. AM ABG: 7.39/36/116/-. Last ABG 7.38/39/156/24. AM EKG. a line tracing very dampened, using NPB readings. LFTs) q4hr. Spontanous . HAS REMAINED IN NSR- SB ON AMIODARONE GTT AND PO CARDIAZEM AND DIGOXIN. STARTED ON INTEGRELLIN. REPEAT ABG 7.38/38/181/23. OGT placed after intubation, aspirate OB+, coiled in hiatal hernia per CXR. Aspirin to PR. DP/PT pulses dopplerable bilaterally. OR X2-> #1 ->PATCH & EVACUATION 2L #2 ->EVACUATION 1L2 JP DRAINS PLACED. HCT 24(32.7). ->EXTUBATED. PLACMENT OF JP DRAINS X2. briefly junctional HR 37-55 w/ occaional episodes PVCs/AIVR, Mg 1.0 repleted w/ 4gm mg sulfate, ICa 1.08 repleted w/ 2gm ca glu, K 4.0. Monitor Hct/plt/CK/MBs. POST-TRANSFUSION HCT 31.1, PT13, PTT 32.8, INR 1.1, FIBRINOGEN 242. RE-BOLUSED WITH AMIO. R. FOOT ALINE PLACED IN OR. lg amt oral secretions. ON IV VANCO.ENDO: BA 168->150. PT 15, PTT 43.1, INR 1.5, FIBRINOGEN 110. CORDIS LEAKING. ADM TO CCU. eval for flutter ablation this admit as pt. CVP=. TEMP MAX 97.1NEURO: A/O FOLLOWS COMMANDS AND MAE. Extubated , d/c'd to floor , readmitted for a flutter, TEE (-) for thrombus, DCCV to NSR rate/rhythm initially controlled w/ amio and dilt gtt, currently well controlled on PO dilt and dig.P: cont PO dilt/dig, monitor HR/rhythm. Foley draining minimal CYU. RECEIVING IVF & PRBC.ID: T 94.3(TD)->BAIR HUGGER ON. Cont to ooze mod s/s fluid. Echymotic c Staples. BS HYPOACTIVE. WBC 15.3.Endo-Drip off. POST-TRANSFUSION HCT 31.9. Last BS 116.A/P- Monitor Hct/e-lytes. BS clear to diminished bilateral. ABG WNL w/ hyperoxia. Noaortic regurgitatino is seen. ABG->7.36/38/151/22. Appearing to have periods of rapid a-fib 130s resolving spontaniously. Dressing CDI. Moderate (2+) mitral regurgitation isseen. Physiologic(normal) PR.PERICARDIUM: Small pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Moderate mitralannular calcification. Restingbradycardic (HR<60bpm). Resting tachycardia (HR>100bpm). + LOSR-pt extubated this am. SHORT BURST SVT 130'S.BP 89-112/40-60'S. during episode pt developed cp. for ^'d resp distress. NBP stable 94-49. post extubation ABG 7.34/38/128/21. Significant events today-extubation and rt venous sheath removal w/o complication.N-A/O x3. Encourage to CDB/IS. Atrovent and Albuterol inhalers prn. K, Ca, and Mg replaced. rightbundle-branch block with left axis deviation consistent with bifascicularblock. Afebrile Tmax98.5. Sinus rhythmIrregular atrial premature complexesLow QRS voltageIncomplete right bundle branch blockLeft anterior fascicular blockAnterior myocardial infarction with ST-T wave configuration consistent withacute processSince previous tracing of , further left axis deviation present BUN and Crt WNL. #2 -EVACUATION 1L. Sinus rhythm with atrial premature beats. Compared to the previous tracing of nosignificant change. BS coarse bilat E wheeze. by am pt w c/o sob. Underlying anterior Q wavemyocardial infarction with prior inferior wall myocardial infarction.Borderline low limb lead voltage. resolved w hr/rhythm return to baseline. CONT ON IV FLAGGYL, LEVOFLOX, & VANCO. Simple atheroma in descending aorta. rec'd iv lasix, neb tx. SX FOR SM.-MOD. DSG REINFORCED X1. ENDS IN HIATAL HERNIA. Left anterior fascicular block.Anterior myocardial infarction with ST-T wave configuration consistent with anacute process. Left anterior hemiblock. OR X2 ->#1 -PATCH & EVACUATION 2L. The remaining walls are mildyhypokinetic. WHEEZE. CO 6.1, CI 4.33, SVR 866. There is a small, likely loculatedanterior pericardial effusion without evidence for hemodynamic compromise.IMPRESSION: Severe regional left ventricular systolic dysfunction c/wmultivessel CAD. IndeterminatePA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Small pericardial effusion. WBC 14.5.ENDO: BS 106-108. BP-94-110/47-66. All pulses + per doppler. AMTS. Mild-moderate mitral regurgitation. Compared to the previoustracing of rhythm is now sinus. Sinus rhythm with atrial and ventricular premature beats. Right ventricularhypertrophy. Anterior wall myocardialinfarction, probably acute. Short P-R interval.Left anterior fascicular block. Left anterior fascicular block. Left anterior fascicular block. Marked leftaxis deviation. Since the previoustracing of frequent atrial premature beats are seen. Compared to the previous tracing of nosignificant change.TRACING #1 Probable old inferiormyocardial infarction. Sinus bradycardia. Sinus bradycardia. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Left axis deviation.Incomplete right bundle-branch block. Sinus rhythm and bradycardia, as well as junctional escape. Changes of anterior wall myocardialinfarction persist. Low limb lead voltage.Left anterior fascicular block. Incomplete right bundle-branch block.Anteroseptal myocardial infarction of indeterminate age. Supraventricular extrasystoles. Since the previous tracing sinus rhythm has been restoredwithout ectopy. The QRS width is probably alsoincreased. Right bundle-branch block with J point andST segment elevation in the precordial leads suggesting acute anterior injury.Since the previous tracing of the atrial arrhythmia pattern is moreregular. Q waves with ST segment elevations inthe anterior and anterolateral leads consistent with acute infarction. Atrial tachycardia of brief duration with pauses after the breakpoint. Acuteanterior wall myocardial infarction pattern persists.TRACING #3 Otherfeatures asre as previously described. Short P-R interval. Short P-R interval. Sinus bradycardia with acceleration and possible changein mechanism to a long R-P tachycardia and then a break. Since the previous tracing of the sinus rate hasincreased and atrial ectopy has returned. Right bundle branch block with left anterior fascicular block.Consider acute anteroseptal myocardial infarction. Consider acute infarction.Clinical correlation is suggested.TRACING #1 The changes ofearly precordial ST segment elevation persist. The Q-T interval is longer. Anterior and lateral ST segment elevations and T wave inversions.Q waves in leads VI-V6. Low voltage in the limb leads.ST segment elevations in leads V1-V3, this may be compatible with anteriormyocardial infarction. Probable anterior wall myocardial infarction in evolution. Since the previoustracing the rate is much slower. Compared to the previous tracing absence of arrhythmia. Low QRS voltage in the precordial leads. | 49 | [
{
"category": "Nursing/other",
"chartdate": "2114-10-15 00:00:00.000",
"description": "Report",
"row_id": 1607031,
"text": "CCU NPN\n\nCV: REMAINS IN NSR-SB.RATE CONTROLLED ON CARDIAZEM PO AND AMIODARONE IV. HR DROPPED INTO 54-58 SB WITH ADEQUATE SBP DURING SLEEP. AMIODARONE DECREASED TO 0.5MG IV. AM CARDIAZEM HELD HR 57. TEAM NOTIFED. MAP'S 72-91.\n\nRESP: CON'T ON ATROVENT NEBS PER RESP. Q 4-6/HR. BS COURSE WITH OCCASSIONAL EXP WHEEZES NOTED. CON'T TO RAISE THICK WHITE SECRETIONS. STRONG COUGH. RR 12-20 DEPENDING ON ACTIVITY LEVELS. SATS 93-98%.\n\nGI: TOL SIPS OF CL'S WITH MEDS. + BS NO STOOL THIS SHIFT.\n\nGU: U/O ADEQAUTE 40-100CC/HR. @ MN -886, BUT OVERALL LOS + AWAITING AM BUN CREAT\n\nSKIN: R GROIN STAPLES INTACT. JP #1 DRAINED TOTAL 55 CC JP #2 53CC. SURGERY IN THIS AM TO GROIN. SITE AROUND DRAINS CON'T TO DRAIN SEROUS DRAINAGE. DSG CHG X2 OVERNOC. R GROIN SITE DRAINAGE BAG INTACT. DRAINED 10CC. BOTH GROIN ECCYMOTIC. L GROIN HAS SIGN. ECHCYMOTIC AREA AROUND GROIN EXTENDING INTO AND DOWN L LEG. PULSES BILAT DP/PT BY DOPPLER.\n\nID: AFEBRILE CON'T ON VANCO MN DOSE HELD AS VANCO LEVEL ON DAYS 22.8 AM VFANCO LEVELS PENDING. TEMP MAX 97.1\n\nNEURO: A/O FOLLOWS COMMANDS AND MAE. LIKES TO CONTROL ENVIROMENT AND MEDS SHE TAKES. SHE HAS PERIODS WHERE SHE BECOMES INPATIENT IF THINGS ARE NOT \" JUST RIGHT\"\n\nLABS: BS 139, NO SSI REQUIERED.\n RECEIVED KCL 40 MEQ PO ( COVERED FOR LOW KCL ON DAYS)\n\nSOCIAL: NO INQUIERES OVERNOC\n\nA/P: 75 YR OLD R/I ANT/LAT STEMI- EMERGENT CATH LAB. LAD, LCX UNABLE TO INTERVENE. CATH C/B LG L GROIN HEMATOMA S/P SHEATH REMOVAL. PT TO OR EMERGENTLY FOR PATCH AND EVACUATION OF HEMATOMA X2 L. AGGRESSIVE FLUID AND BLOOD REWSUSCITATION. PLACMENT OF JP DRAINS X2. ADM TO CCU. C/O TO 6 ON , READM TO CCU ON IN A-FLUTTER RVR 150-160. ATTEMPTS MADE TO CHEMICAL CONVERT, TO NO AVAIL. S/P TEE ON NO CLOTT. S/P CDV 200J X1 ON @ 1630. HAS REMAINED IN NSR- SB ON AMIODARONE GTT AND PO CARDIAZEM AND DIGOXIN. AM EKG. AWAIT AM VANCO LEVEL. FOLLOW HR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-15 00:00:00.000",
"description": "Report",
"row_id": 1607032,
"text": "ADDENDUM: DR OF HR 53-54. PERFERS TO PT ON AMIODARONE GTT TILL ROUNDS. ADEQAUTE BP. PT ASLEEP\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-15 00:00:00.000",
"description": "Report",
"row_id": 1607033,
"text": "addendum: on initial rounds noted l arm lg ecchymotic ? bp cuff related. rad pulse in l hand +hand is warm pt does not c/o pain. bp cuff now to r arm and intervals increased.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-15 00:00:00.000",
"description": "Report",
"row_id": 1607034,
"text": "CCU NPN 7a-7p\nS: \"I had a good night last night...\"\nO: please see carevue and transfer note for complete assessment data\nNERUO: A&Ox3, initially c/o aching in L groin but declining meds, no other c/o pain. MAE, assists w/ turning, refusing to stay turned to side. Very involved in care, questioning everything and cont to refuse some meds/care.\n\nCV: HD stable, amio cont @ 0.5mg/min, d/c'd @ 1600. HR NSR/SB w/ frequent PACs. Tolerating 30mg Cardiazem PO, started 0.125mg Digoxin w/o incident. BP 110s-140s/60s-80s. R groin w/ collection bag intact, draining minimal serosang fluid. L groin grossly ecchymotic, staples intact, incision well approximated, no erythema. Cont to ooze mod s/s fluid. JPs x2 intact, draining sm. s/s apx 75cc combined total. Distal pulses by , feet cool and dusky @ times (pt. states this is baseline).\n\nRESP: breathing comfortably on 2-3L NC, SpO2 90-98%, occasionally requesting cool mist face tent to help w/ secretions. Early am pt. found tachypneic, c/o SOB, I/E wheezes t/o. Atrovent neb w/ some relief, more relief w/ prednisone (^ to 40mg -home dose 5mg). Now w/ clear apices, coarse bilat. @ bases. Intermittent cough productive of thick white sputum.\n\nGI/GU: abd soft, nontender, nondistended. +BS/-BM. C/o mild constipation->glycerine supp, awiating effects. Refusing PO meds for constipation at this time. Tol heart healty diet and PO meds. Foley draining CYU, responded well to diuresis w/ 20mg PO lasix @ 11 am almost 1L neg since MN. BUN/Cr wnl.\n\nENDO: BG wnl, no RISS coverage needed (pt. has been refusing)\n\nID: afebrile. Cont vanco and started levaquin per vascular req's for prophylaxis L groin. MRSA L foot on prior admit->contact precautions.\n\nSKIN: blister R root broken x 2, draining serous fluid, left open to air. See above for groin sites. Multiple areas of ecchymosis. L arm @ elbow swollen and warm, good radial pulse, ? d/t BP cuff. No breakdown noted on coccyx but pt. refusing to be positioned on side. R hand 22g PIV, RIJ venous introducer, patent and intact.\n\nSOC: friend in to visit briefly.\n\nA: s/p ant/lat STEMI , cath: unable to intervene on LCx/LAD, DCCV RAF->NSR, post procedure c/b lg. l femoral hematoma s/p art sheath pull requiring evac and pacth in OR x2. Extubated , d/c'd to floor , readmitted for a flutter, TEE (-) for thrombus, DCCV to NSR rate/rhythm initially controlled w/ amio and dilt gtt, currently well controlled on PO dilt and dig.\nP: cont PO dilt/dig, monitor HR/rhythm. Atrovent nebs PRN for resp distress, avoid albuterol. Encourage activity and diet. ? eval for flutter ablation this admit as pt. can not tolerate pulm toxic effects of long term amio. Support to pt. as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-10 00:00:00.000",
"description": "Report",
"row_id": 1607016,
"text": "1900-0700\n\nNeuro: Pt sedated on propofol drip @ 30mcg. Pt easily arousable by verbal stimuli with + eye opening. Follows commands well and moves all ext. Unable to assess orientation due to intubation. Restraints remain off due to pt cooperation.\n\nResp: Pt remains orally intubated on mech ventilation, A/C, 450, 40%, 15, +5. O2sat remain >99% at all times. Suctions for small amounts of thick brown secretions. Lungs clear bilaterally. Rt foot aline intact with sharp waveform. AM ABG: 7.39/36/116/-. Plans to wean to extubate possible today.\n\nCV: NSR with frequent PACs noted. HR 70-120. SBP 90-135, MAP 60-80, PAP 30/20s. CVP 10-13. No c/o of pain. RIJ swan intact/unable to wedge HO aware. L femerol site with JP X2 to bulb suction draining sang fluid. DSD intact. Pt to OR last PM for evacuation of hematoma 1 liter of clot removed. Pulses to R foot by doppler slightly dusky in color. L foot + popliteal by doppler, absent dorsal pedis-pink in color. Both feet cool to touch. Minimal edema to feet noted. Rt femerol sheath intact. PIV X2.\n\nGI/GU: Abd softly distended, hypoactive BS noted. OGT intact but clamped-all po meds held until further evaluation of OGT is confirmed. NPO. Foley to gravity draining clear yellow urine. Approx 20-40cc/hr.\nHO aware.\n\nPlan: Continue supportive care. Resp support. Vent weaning in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-10 00:00:00.000",
"description": "Report",
"row_id": 1607017,
"text": "Respiratory Care\nPt.remains on full vent. support.Abg's adequate on current settings.RSBI 139.1.No vent. changes this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-10 00:00:00.000",
"description": "Report",
"row_id": 1607018,
"text": "CCU NPN\nneuro: propofol off since 0800 d/t relative hypotension and plan to wean. Pt awake, alert. able to communicate writing and mouthing words. frustrated that she can't speak.\ncv: hypotensive this am w/ sbp 84, received 500cc ns bolus and started on maintence fluid at 125cc/hr. a line tracing very dampened, using NPB readings. for remainder of day bp 89-106/44-51. hr 79-102 sr w/ very frequent apc's, few transient episodes of svt rate ^ 130's, PAP 27-34/16-22, cvp 9-11.\nresp: changed vent mode to PS and weaned to w/ abg 7.36 38/166/22, rr 20-24 and tv mid 300's. Pt c/o feeling fatigued and not getting enough air. ps ^ to 10, now 2/ rate 15 tv 440. sx q 2-4 hrs for mod amts thick tan/brn secretions. lg amt oral secretions. Lungs w/ exp wheezes. has received all neb rx. Also received 100mg hydrocordisone since she has not been receiving prednisone.\ngi: NPO, ogt coiled in hiatal hernia, no stool\ngu: foley draining dk yellow urine 20-40cc/hr, currently ~ 1300cc + since mn, + 14 liters LOS.\nid: febrile to 102.2, receiving levo, flagyl, vanco.\nheme: hct down to 28 at 1100, currently being transfused w/ 1 unit prbc.\nskin: l leg hematoma softer, dsd w/ very scant amt lt pink drainage. JP drains total 145cc bloody drainage since 0500. r toes dusky, cold, seen by HO, left foot cool w/ normal color.\nsocial: HCP called to inquire re: condion and , sister also called.\nA: resolving hematoma, w/ continued bloody drainage,\n febrile,\n failed vent wean\n hct drop requiring tx\nP: Continue supportive care\n Monitor l foot\n follow hct\n slow vent wean,\n monitor temp curve, cont abx\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-08 00:00:00.000",
"description": "Report",
"row_id": 1607009,
"text": "Pt arrived from OR on full vent. suport set up on 500ml x 18bpm with +5peep and 50% O2. Md notified of vent settings gave verbal approval, asking only that O2 be reduced to 40% post first abg. I asked him to please put the orders in comp. BS deminished on Left side. Pt sxed for mod amt. of thick & thin bloody sputum no plugs noted. X ray has been obtained but not reviewed at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-08 00:00:00.000",
"description": "Report",
"row_id": 1607010,
"text": "ccu npn 1030a-7p\nS: \"My chest pain in labile , it never went away...\" later intubated and nonverbal, communicating by nodding when not sedated.\nO: please see admit note for PMH details and carevue for complete assessment dats\nEVENTS: presented w/ ant/lat STEMI->CATH: TO mLAD, unable to cross, no intervention. To CCU->developed vast hematoma s/p L femoral arterial sheath removal requiring evacuation and surgical repair.\nROS:\nNEURO: on arrival from cath lab, A&Ox3, MAE, c/o residual CP . S/p OR for surgial repair of punctured L femoral artery intubated and sedated on propofol gtt when BP allows, nodding appropriately and following commands when sedation off (no c/o CP at that time)\n\nCV: From cath lab w/ 8F venous sheath R fem and 6F art sheath L fem. DP/PTs all dopplerable. Brisk ooze noted on initial assessment, CCU resident and fellow in to assess->manual pressure held x ~15mins w/ resolution. Interventional fellow up to pull L fem art sheath @ 1200, manual pressure held, hematoma developing w/in 10mins, pt. complaining of severe burning pain in l groin and extending down leg. Surgery up to eval->emergently transfered to OR for exploration. In OR EBL 2000cc, hematoma evac'd and punctured L fem art patched. See carevue for blood/fluid resuscitation details. 1500 arrived back to CCU w/ ooze on transparent L fem dsg, 2 JPs draining frank blood. 1700 l thigh hematoma slightly ^firm but not distended, surgery eval'd, cont to monitor, 1745 notably more firm and distended, L DP/PT lost, dop popliteal, CCU team in surgery consulted: expressed ~100cc from incision/JP insertion sites and 100cc from each JP. JPs to cont low wall sxn per , L thigh pressure wrap applied. R femoral venous sheath remains intact w/o complication. Initially bradycardic 50s-60s (bursting into PAF briefly; s/p DCCV w/ 200j in cath lab today), on return from OR pt. SB/? briefly junctional HR 37-55 w/ occaional episodes PVCs/AIVR, Mg 1.0 repleted w/ 4gm mg sulfate, ICa 1.08 repleted w/ 2gm ca glu, K 4.0. Currently NSR/SB, occas PVCs. BP labile and fluid dependent, see careve, no pressors.\n\nRESP: intubated in OR; see carevue for current settings/changes, metabolic acidosis but oxygenating well per ABGs. Difficult to obtain SpO2. LS coarse, diminished L>R, coarse. Sxn'd for thin blood tinged secretions.\n\nGI/GU: abd soft, nontender, nondistended. +BS/-BM. OGT placed after intubation, aspirate OB+, coiled in hiatal hernia per CXR. Foley draining minimal CYU. ~10L + today.\n\nENDO: BG 190s, insulin gtt ordered.\n\nID: hypothermic, 94.4 PO from cath lab->bair hugger on. 97.4 from OR, down to 94.0->bair hugger but cont hypothermic d/t lg. quantity blood products/fluid. 2gm ancef in OR, no abx/cultures otherwise.\n\nSKIN: no breakdown noted. multiple new areas of eccchymosis s/p OR.\n\nSOC: DPA-friend , and ? family member in to visit, updated. Pt. never married, sister and nieces to be updated by (primary contact)\n\nA: 65yo adm w/ ant/lat STEMI, cath today unable to cross TO m\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-08 00:00:00.000",
"description": "Report",
"row_id": 1607011,
"text": "ccu npn 1030a-7p\n(Continued)\nLAD, post cath c/b L femoral artery puncture and hematoma requiring surgical repair and evacuation. Re-bleed into l leg s/p OR, currently HD stable w/ continued bleed from L femoral artery puncture, multiple blood products/fluid rescusitation, coagulopathic, hypothermic, sedated and requiring full ventilatory support.\nP: cont transfusion of blood products as ordered, serial Hct and Coags (? LFTs) q4hr. Monitor L femoral JPs for drainage q1hr and incision for ^^oozing/reaccumulation of hematoma. Cont to monitor temp, bair hugger, warm fluids and o2 if possible. COnt to assess peripheral circ. F/u lyte repletion, monitor u/o and renal function.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-09 00:00:00.000",
"description": "Report",
"row_id": 1607012,
"text": "75 YR. OLD WOMAN WITH PMH: COPD, OSTEOPOROSIS, SEVERE PVD(S/P MULTIPLE\nBYPASS GRAFTS), CAD->AWOKE YESTERDAY AM() WITH 10/10 CP ASS. WITH\nDIAPHORESIS, NAUSEA, & SOB. TOOK ASA 81MG & CALLED 911. BROUGHT TO ED. EKG +STEMI. HR 30-50'S SB. GIVEN ASA, & STARTED ON HEPARIN GTT. EMERGENT CATH->TO midLAD->ATTEMPTS TO CROSS UNSUCCESSFUL. STARTED ON INTEGRELLIN. RAF(RATE 130'S)->CARDIOVERSION WITH 200J X1->SR. TRANSFERRED TO CCU WITH ARTERIAL SHEATH L. GROIN & VENOUS SHEATH R. GROIN. ARTERIAL SHEATH D/C'D BY FELLOW->DEVELOPED EXPANDING L. FEMORAL HEMATOMA. SURGERY CALLED & PT. BROUGHT TO OR FOR EVACUATION HEMATOMA.\nINTUBATED IN OR. EBL 2L. FLUID RESUSCITATED WITH 5U PRBC, 5L IVF, & 2\nBAGS PLATLETS. RIJ SWAN PLACED IN OR->WAVW FORM DAMPENED, DOES NOT WEDGE, & UNABLE TO DRAW FROM PA PORT. REPOSTIONED X1->CXR DONE & PLACEMENT CONFIRMED, BUT STILL NOT FUNCTIONING. R. FOOT ALINE PLACED IN OR. RETURNED TO CCU INTUBATED. RECEIVED 2U PRBC, 2U FFP, 2 BAGS PLATLETS, 1.5L IVF. L. GROIN STILL OOZING, & COAGS ABNL. PT 15, PTT 43.1, INR 1.5, FIBRINOGEN 110. BAIR HUGGER ON FOR HYPOTHERMIA(T94).\n\nNEURO: PROPOFOL GTT AT 20MCG/KG FOR SEDATION. PROBLEMS WITH HYPOTENSION SO UNABLE TO INCREASE GTT FOR MAXIMAL EFFECT. USING FENTANYL 25-50MCG PRN WITH GOOD EFFECT. OPENS EYES SPONTANEOUSLY & ATTEMPTS TO SPEAK. AGGITATED AT TIMES & TRYING TO PULL AT ETT. SOFT WRIST RESTRAINTS APPLIED FOR SAFETY. MAE, & FOLLOWS SIMPLE COMMANDS WHEN WANTS TO. NOT ALWAYS COMPLIANT. DOES NOT LIKE ETT.\n\nRESP: ON VENT: .40/500 TV/ AC 15/ PEEP 5. ABG->7.46/31/200/23. DECREASED TV 450. REPEAT ABG 7.38/38/181/23. RR 15/15. O2 SATS 100%.\nBS CLEAR RUL, OTHERWISE DIMINISHED THROUGHOUT. SX FOR SM-MOD AMTS THICK BLOODY SECRETIONS. AM ABG->7.41/35/178/23.\n\nCARDIAC: HR 52-70 SB/SR WITH OCC. PAC'S & PVC'S. BP 123-146/67-80, THEN DROPPED TO 84-106/50-58. HCT 24(32.7). TRANSFUSED 2U PRBC, 2L LR,\n1 BAG CRYOPRECIPITATE. POST-TRANSFUSION HCT 31.1, PT13, PTT 32.8, INR 1.1, FIBRINOGEN 242. L.GROIN WITH LG HEMATOMA->OOZING THROUGH INCISION SITE DESPITE 2 JP DRAINS->LCWS. PAD17-28, CVP 9-13. LOST COMPLETELY THIS AM. AM HCT 26.9->TO RECEIVE 2U PRBC--1st U HANGING.\nSEEN PERIODICALLY BY SURGERY THROUGHOUT NOC-- NEED TO GO BACK TO OR. JP#1->290CC & JP#2->180CC FOR 12HR SHIFT.\n\nGI: OGT REPLACED. CXR DONE & PLACEMENT CONFIRMED. ABD. SL. DISTENDED.\nBS HYPOACTIVE. NO STOOL. NPO.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O ~100CC/HR UNTIL HYPOTENSIVE, THEN 0-35CC/HR. FOLEY IRRIGATED EASILY. HO AWARE OF DECREASED U/O. RECEIVING IVF & PRBC.\n\nID: T 94.3(TD)->BAIR HUGGER ON. T 98.3(TD). BAIR HUGGER OFF, NO MORE PROBLEMS WITH HYPOTHERMIA. WBC 8.7.\n\nENDO: BS 175. INSULIN GTT STARTED AT .5U/HR AS ORDERED. BS 175->66, INSULIN GTT OFF. BS 68-76.\n\nAM LABS PENDING.\n\nPLAN: CONT TO MONITOR TEMP\n Q4HR HCT & COAGS PER SURGERY.\n TRANSFUSE HCT<30.\n JP TO SX, STRIP TUBING PRN TO PREVENT CLOTTING.\n RETURN TO OR FOR FURTHER EVACUATION/CLEANING.\n\nTOTAL BLOOD PRODUCTS THUS FAR-> 10U PRBC, 2U FF\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-09 00:00:00.000",
"description": "Report",
"row_id": 1607013,
"text": "(Continued)\nP, 4 BAGS PLATLETS, 1 BAG CRYO. ~8.5L IVF.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-09 00:00:00.000",
"description": "Report",
"row_id": 1607014,
"text": "Respiratory Care\nPt received intubated and ventilated on assist/control. Vent adjustments made overnight per abgs. Currently on 450 x 15 5 of peep, 40%. ABGS are within normal limits with good oxygenation. Breath sounds are coarse, started on albutero/atrovent inhalers qid.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-09 00:00:00.000",
"description": "Report",
"row_id": 1607015,
"text": "CCU nursing progress note. Back to OR\nS- mouthing \"phelgm\". And writting desire to be suctioned frequently.\nO-See Flowsheet for complete VS.\n\nPMH significant for CAD,CHF, MI, PVD, multiple caths, c 2 fem- bypass 03' and 04'. MRSA c Lt toe amputation.\nThis admit for CP, Ant/Lat STEMI, LAD/LCX disease found per cath, unable to do any PCI. Complicated by L groin hematoma s/p arterial sheath removal. Significant Blood, plt, and fluid resuscitation. To OR for repair of fem artery and evacuation. Will return this evening for evacuation.\n\n1.N-Propofol increased from 20 to 30mcg/kg @ 1100. Alert/Anxious/uncomfortable this am to sedated but easily arousable with increase.\n\n2.CV- NSR 72-88 c occasional PAC and sinus tach. BP 103-124/55-71. MAP 70-82. CVP 9-17. PA/RIJ damp/unable to wedge or draw blood since OR placement. HO aware. Pulled back 5cm. Now with occasional wave form. Reevaluate post . Rt Venous sheath CDI. A-line to Rt foot sharp. Lt groin site evaluated this am and decision made to take back to OR. Hemotoma c extensive ecchymosis, slight increase in firmness throughout shift. Draining seriousang fluid from incision site (staples). Small fluid filled blisters forming. Pressure Ace bandage around thigh. Sterile dressing change prn. Pulse Doppler checks Q2 hr. Rt PT pulse per doppler. Lt and PT per doppler. Lost Lt DP @ 1600 check. HO and notified. JP #1 to LCWS c 75cc this shift. JP #2 25cc this shift. No boluses or blood product this shift. CPK 1328, MB 176. Q4 Hct-stable @ 34. Last PTT 31.8. Plt continue to decrease @ 141. LOS close to +14L.\n\n3.Resp-AC 450/40%/15 Peep 5. Spontanous . Sx mouth frequently for pt comfort (siliva/phlegm). Scant secretaions in ET tube. Sat 98-100%. Last ABG 7.38/39/156/24. Lungs clear to slightly diminished. Chest xray clear.\n\n4.GI- per xray distal tube in proximal portion of hiatal hernia. All PO meds held today. Aspirin to PR. Previous difficulty c advancement due to hiatal hernia. Readvancement needed after OR prior to any med administration. Hypoactive BS.\n\n5.GU-Foley-yellow/clear. Low UO since -30cc midnight. HO aware. 14L positive. 6oKg today. admit wt 45kg. Bun 19, Crt .6.\n\n6. Endo-Insulin drip off since 0200 due to low BS. Last 76 @ 1800.\n\nA/P-To OR for evacuation. Continue to monitor Lt groin sight and pulses. Monitor ABGs, fluid status prior to extubation. Monitor Hct/plt/CK/MBs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-14 00:00:00.000",
"description": "Report",
"row_id": 1607029,
"text": "75 YR. OLD WOMAN ADMITTED WITH ANT/LAT STEMI->EMERGENT CATH--TO\nLAD->UNABLE TO INTERVENE. C/B L. GROIN HEMATOMA S/P ARTERIAL SHEATH REMOVAL. OR X2-> #1 ->PATCH & EVACUATION 2L\n #2 ->EVACUATION 1L\n2 JP DRAINS PLACED. SIGNIFICANT BLOOD & FLUID RESUSCITATION. ->\nEXTUBATED. ->TRANSFERRED TO FLOOR(F6) X~15 HRS. READMITTED TO CCU WITH SOB, RESP. DISTRESS, % RAF.\n\nNEURO: A&O X3. PLEASANT & COOPERATIVE. VERY INVOLVED IN .\n\nRESP: O2->40% OFT. O2 SAT 95-97%. CHANGED TO 2L NP PER PT REQUEST.\nO2 SAT 93-95%. BS CLEAR BUT DIMINISHED AT BASES--OCC. TIGHT & WHEEZY.\nRR 19-26. NEBS PRN.\n\nCARDIAC: HR 160 AFLUTTER. BOLUSED WITH AMIODARONE->GTT 1MG/MIN. AFTER 1/2HR, AMIO D/C'D->DILT BOLUS FOLLOWED BY GTT 5MG->15MG/HR. NO CHANGE IN HR. RE-BOLUSED WITH AMIO. CORDIS LEAKING. PROBLEM WITH VALVE. CORDIS CHANGED OVER WIRE. CXR DONE & PLACEMENT CONFIRMED. NOT SURE PT WAS GETTING ALL IV MEDS D/T LEAKING SO RE-BOLUSED WITH AMIO. HR TRANSIENTLY DOWN TO 130-110 AF, BUT BACK TO 160. SPOKE WITH MD'S AGAIN, DILT NO WORKING->D/C'D. AMIO GTT 1MG/MIN. HR 150'S. BP 86-126/45-81. DENIES CP. PULSES BY DOPPLER. R. GROIN CONT TO LEAK FLUID->DRAINAGE BAG INTACT. L.GROIN ECCHYMOTIC & OOZING. JP DRAINS DRAINING SM-MOD AMTS SERO-SANG DRAINAGE.\n\nGI: ABD. SOFT. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR AMBER URINE. U/O 15-50CC/HR.\n\nID: AFEBRILE. CONT. ON IV VANCO.\n\nENDO: BA 168->150. REFUSING SLIDING SCALE COVERAGE.\n\nAM LABS PENDING.\n\nPLAN: AMIO GTT 1MG/MIN UNTIL 0930->DECREASE .5MG/MIN X18HRS.\n ??LASIX\n NEBS PRN.\n POSSIBLE CARDIOVERSION TODAY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-14 00:00:00.000",
"description": "Report",
"row_id": 1607030,
"text": "ccu nursing progress note\ns: i'm upset about the lasix...i feel that that will make the difference in my heart rate\no: pls see carevue flowsheet for complete vs/data/events\nremained in raf this am w rate 150-160 aflutter. unresponsive to iv dilt overnoc and amiodarone infusion. added digoxin and rec'd 1st of 2 loading iv doses of .25mcg. remained in af, bp tol well, no acute resp decompensation. decision made for tee/cdv. pt underwent tee at 11:30am, no clot noted. tol procedure well w 1mg midaz and 25mcg fentanyl w good response. awaited cdv unit anesthesia available around 4:30pm. sedated w 40mg propofol and cdv w 1 200j to sr.\nremains in sr. amiodarone cont to infuse at 1mg/min presently and team wishes to remain on this dose currently as discussed w fellow dr . also on diltiazem at 30mg qid.\nbp 110-130/50-60.\nr fem site w external bag to collect serous drg. l fem site w lrg amt serous drg req dsd change q2-3hrs. 2 jp drains intact.\nresp: congested cough in eve, clearing clear sputum. bs scatt coarse w occ exp wheeze. no resp distress. on 4l nc most of day w sats 92-97%. using cn face tent in eve for ^'d moisture to ease clearing of sputum.\ngi: npo until eve. bs 156. refusing insulin coverage. no stool.\ngu: rec'd lasix at 5pm. good response. currently 300cc-.\nid: afeb. on vanco. trough level 22.8.\nms: alert, cooperative except controlling about medications. family/friends in touch by phone. no visitors today\na: raf. tee/cdv\np: follow cardiac/resp exam. response to lasix. skin care. support to pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-12 00:00:00.000",
"description": "Report",
"row_id": 1607026,
"text": "NPN: Review of Systems\nNeuro: \"I don't like things to be overtreated.\" Pt is alert and oriented. Calm and conversing with Nurse. Refuses paxil, because \"it makes me bleed, and Vitamin D and Niacin because are not the doses she takes at home. Also would not allow regular insulin to be administered for blood glucose of 164. Residents from CCU team aware that Pt has refused medications. A list of home medications has been made and given to Dr. . Pt is able to MAEs, but requires assistance turning.\n\nResp: Breathing has been unlabored. BS are diminished bilaterally. Using albuterol and atrivent inhalers independently. Sao2 on 3L NC=95-97%. Prednisone taper continues.\n\nCV: SR. PACs. SBP has been 80s-90s with mean in upper 50s to 60s. Skin warm/dry. DP/PT pulses dopplerable bilaterally. CCU team plans to remove swan. CVP=. Please see flowsheet for PAP. Left groin JPs draining small amt of bloody fluid.\n\nGI: Pt tolerating soft diet. Ate oatmeal and banana for breakfast w/ ornage juice. No c/o nausea. Abdomen is soft. (+) bowel sounds. Multiple soft light brown BMs.\n\nGU: Foley to gravity. Dark brown urine.\n\nID: Afebrile. Continues on vancomycin/ flagy; and levofloxacin.\n\nSkin: Small skin tears in groin area wear dressing changes have occured. Duoderm placed around left groin incision, which is draining serosanguinous fluid, to minimize tape on her skin and drainage bag placed over right groin puncture sight which is draining copious amounts of serosanguinous fluid. Backside intact. Skin all over is very fragile.\n\nA: Pt refusing medications despite rationale for giving them. Hemidynamically stable. Tolerating cardiac healthy diet.\n\nP: Anticipate swan removal. ? placement of triple lumen catheter vs. peripheral IV. IV Nurse for peripheral access. Continue to monitor per plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-13 00:00:00.000",
"description": "Report",
"row_id": 1607027,
"text": "resp care\npt transferred back to ccu for resp distress. bs bilat i/e wheezing, improves with bronchodilator therapy. also coughing/raising thick yellowish sputum. only requiring 40% face tent presently. c/w nebs./bipap if tires.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-13 00:00:00.000",
"description": "Report",
"row_id": 1607028,
"text": "ccu nursing progress note\ns: i think i need another dose of prednisone...that will make a difference\no: pls see carevue flowsheet for complete vs/data/events\nreadmitted from 6 this am w sob, resp distress. had transfered to 6 last eve. during the night pt had raf that req diltiazem iv and eventually amiodarone gtt. during episode pt developed cp. resolved w hr/rhythm return to baseline. by am pt w c/o sob. ^^wheezing, crackles. labored. rec'd iv lasix, neb tx. pt felt that prednisone helped the most in improving symptoms. adm to ccu.\narrived w mod resp effort, rr 25-30. able to speak in short sentences. maintaining sats 94-98% on cn face tent at 40% bs w i/e wheezes, scatt coarse. occ prod cough.\nimproved over next few hours. intern attempted but was unable to obtain abg.\nhr 70-90s w freq apcs most of day unitl 6pm when pt spon converted to raf w rate 160-190. had just rec'd po diltiazem dose of 60mg(pt had refused sr dose and requested 30mg qid instead) w ^hr pt initially tol well but now w ^'d resp effort and feeling of fatigue. sats 94-96%.\nbp trending down w iv dilt doses(10mg iv x3) which have been unsuccessful in converting or slowing her hr. team discussing resuming iv amiodaore(had arrived from floor on 1mg/min but this was not ordered on admit to ccu and on discussion team stated this med was not to be continued as pt refusing to take oral doses d/t her concern about the potential pulmonary complications associated w amiodarone)\n\nskin: r fem site w ostomy bag in place w serous drg. l fem site w mod-lrg amt drg from staples/surgical site and around jps.\nsang drg in jps. 2 fluid filled blisters on top of r foot.\naccess: r ij cortis.\ngi: tol diet this eve, ate potatoes and apple sauce. no n/v. concerned about constipation.\ngu: foley w good uop, slowing over day but 1.4 neg from mn w last lasix on 6.\nms: awake alert. controlling. adamant about participating and directing her medical care esp regarding medications. several visitors today.\na: afib, resp compromise.\np: response to meds for rhythm/rate management, follow hemodynamics. for ^'d resp distress. support to pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-12 00:00:00.000",
"description": "Report",
"row_id": 1607025,
"text": "CCU 7P-7A\nRESP:- Nasal cannula, 3L, SA02 95-99%, good spontaneous cough using yankar to remove secretions by self. Resp rate 15-22bpm. Bilateral airentry heard to all lung field but quiter at the bases.\n\nCV:- Had episodes of self terminating VT rate 130-140, but at 2300 had rate of 165bpm, SBP intially not affected. HO aware given x 2 dose of 10mg Diltiazem, little effect to heart rate but SBP 80-90. Given loading dose of amiodarone 150mg over 15 mins, then infusion commenced at 1mg/min. Also given 20 mmeq of K+ as K+3.7. Back in SR at 0200 with frequent PVCs and PACs. SBP also improved to 100-130. All pedal pulses dopplerable\n\nGI:- Refused Protonix last night as normally takes omeprazole at home HO informed and ordered omeprazole, Dr was not prepared to wait the 48 hours for pharmacy to get the omeprazole, she was happy to take her own tablets from home, (specified on order). Complained on feeling constipated requested glycern suppository given with mininmal effect, Bowel movement small amount, hard stool. NPO just taking oral meds.\n\nGU:- Good urine output overnight.\n\nID:- Oral ABx given. Afebrile overnight, expectorating sputum yellowy secretions.\n\nWOUNDS:- Dressings changed x2 overnight. Oozing ++ heamoserrous fluid, Femoral drains draining moderate amounts overnight. Marking easily from sheets and lines.\n\nNEURO:- Alert and orientated x3, making her requests clear when needed. Movement limited by lines, drains and general condition.\n\nSKIN:- Dressings changed, lines appear clean, Aloe vesta cream applied to bottom and heels to prevent pressure damage. Redened Heels also elevated on pillow over night.\n\nPLAN:- To maintain SR with amiodarone infusion, to monitor drainage from femoral sites. To promote normal bowel habits.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-10 00:00:00.000",
"description": "Report",
"row_id": 1607019,
"text": "Resp Care: Pt remains intubated via #7 ETT secured 21cm at lip. BS coarse bilat E wheeze. MDI's given as ordered. Weaned to PSV. tol fair. ABG WNL w/ hyperoxia. Cxray \"ETT 6.5cm above carina, minor atelectatic changes @ lung bases. Plan: cont vent support. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-11 00:00:00.000",
"description": "Report",
"row_id": 1607020,
"text": "Respiratory Care\nPt.remains on PSV and tolerating well.abg's adequate with excellent oxygenation.BBS+,with occasional mild exp wheezes,MDI's given.Sutioned for small to moderate amounts of brownish and tan secretions t/o night.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-11 00:00:00.000",
"description": "Report",
"row_id": 1607021,
"text": "75 YR. OLD WOMAN WITH PMH SIGNIFICANT FOR CAD, CHF, MI, SEVERE PVD, & COPD, ADMITTED WITH 10/10 CP->ANT/LAT STEMI. EMERGENT CATH DONE\n->TO LAD--UNABLE TO INTERVENE. C/B L. GROIN HEMATOMA S/P ARTERIAL SHEATH REMOVAL. OR X2 ->#1 -PATCH & EVACUATION 2L. #2 -\nEVACUATION 1L. 2 JP DRAINS TO BULB SX IN L. GROIN. SIGNIFICANT FLUID &\nBLOOD(12U PRBC, 2U FFP, 4 BAGS PLATLETS) RESUSCITATION.\n\nNEURO: OFF ALL SEDATION. DOZING, BUT EASILY AROUSABLE. FOLLOWS COMMANDS. MAE. USING PEN/PAPER TO COMMUNICATE. DENIES DISCOMFORT.\n\nRESP: ON VENT: 40%/IPS 10/PEEP 5. RR 13-16. O2 SAT 100%. BS CLEAR BUT DIMINISHED AT BASES, WITH OCC. EXP. WHEEZE. SX FOR SM.-MOD. AMTS. THIN TAN SECRETIONS. ABG->7.36/38/151/22. HYDROCORTISONE 100MG Q8HRS FOR COPD.\n\nCARDIAC: HR 60-70'S SR WITH OCC. PAC'S & PVC'S. SHORT BURST SVT 130'S.\nBP 89-112/40-60'S. 1 EPISODE HYPOTENSION(SBP 84)->250CC NS BOLUS.\nPAD 16-21, CVP 7-11. DENIES CP. HCT 28.1->RECEIVED 1U PRBC ON DAYS. POST-TRANSFUSION HCT 31.9. PLAT 102K(125K), K 3.7->KCL 20MEQ PB X1.\nL. GROIN ECCHYMOTIC WITH HEMATOMA & 2 JP DRAINS. INCISION DRAINING SM-\nMOD SERO-SANG DRAINAGE. DSG REINFORCED X1. JP #1->140CC JP #2->10CC.\n+PULSES(DP,PT, & POPLITEAL) BY DOPPLER.\n\nGI: NPO, OGT IN PLACE, BUT NOT BEING USED BECAUSE OF PLACEMENT-- ? ENDS IN HIATAL HERNIA. ABD SL. DISTENDED. BS HYPOACTIVE. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING YELLOW URINE WITH SEDIMENT. U/O 4-40\nCC/HR.\n\nID: T 99.2->98.6(TD). CONT ON IV FLAGGYL, LEVOFLOX, & VANCO. BLOOD, URINE, & SPUTUM CX'S PENDING. WBC 14.5.\n\nENDO: BS 106-108. NO INSULIN COVERAGE REQUIRED.\n\nAM LABS: WBC 15.3(14.5), HCT 28.5, PT 13.9, PTT 31.2, INR 1.3, FIBRINOGEN 491, IONIZED CA 1.16, LACTIC ACID 1.4, K 3.7, MG 1.6, CK 146 WITH MB 14, BUN/CREAT 16/0.7.\n\nPLAN: TRANSFUSE FOR HCT<30.\n REPLACE ELECTROLYTES AS INDICATED.\n MONITOR L. GROIN & PULSES CLOSELY.\n ? EXTUBATION TODAY--IF NOT, NUTRITIONAL STATUS NEEDS TO BE\n ADDRESSED.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-11 00:00:00.000",
"description": "Report",
"row_id": 1607022,
"text": "Pt extubated on at 0945. Pt was placed on 40% via Cool Neb. Pt's HR after extubation was 124, SPO2 99% and RR 20.\n\n SRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-11 00:00:00.000",
"description": "Report",
"row_id": 1607023,
"text": "CCU Progress note. 7a-1500. Extubation\nS-\"It feels good to have that tube out and be able to talk.\"\nO-See flowsheet for complete VS.\n\n75y.o Female. PMH significant for CAD, CHF, MI, COPD, Fem- x2. This admit presented to ED c cp, ant/lat STEMI, emergent cath revealing 100% LAD occlusion. Unable to do interventions. C/B L hemotoma s/p arterial sheath removal. Emergent OR for femoral graft repair and hemotoma evacuation. 2 JPs placed to site. Evacuation again on . Significant events today-extubation and rt venous sheath removal w/o complication.\n\nN-A/O x3. MAE.\n\nCV-SR 78-125 c frequent PACs. Appearing to have periods of rapid a-fib 130s resolving spontaniously. BP-94-110/47-66. PAD 16-21, CVP 7-11. Transfused 1unit PRBC @ 0700 for HCt of 28.5. Post transfusion HCt pending. To transfuse HCt if <30. K, Ca, and Mg replaced. CO 6.1, CI 4.33, SVR 866. L groin hemotoma site stable. Echymotic c Staples. Serosang drainage and sm fluid filled blisters. 2 JPs to bulb sx putting out sm amt sanguinous fluid. R venous sheath pulled c no complications (yet prior to sheath pull site oozed moderate amt serosang). Dressing CDI. Rt foot a-line to be D/C'd this evening. All pulses + per doppler. + LOS\n\nR-pt extubated this am. Tolerated well. Put on 40% cool neb. Now on 3L NC sat 96-100%. Atrovent and Albuterol inhalers prn. RT following for Neb Tx. post extubation ABG 7.34/38/128/21. 1430 ABG pending. BS clear to diminished bilateral. Encourage to CBD/IS.\n\nGI-No BM, Refused PRN colace this am. Might want this evening. Evaluate swallow. NPO thus far. BS present.\n\nGU-Foley clear yellow. 10-80cc/hr. BUN and Crt WNL. UA neg for bacteria.\n\nID-IV Flaggyl, Levo, and Vanco. Vanco level 11 @0400. Trough level pending from 1100. Blood and sputum pending. Afebrile Tmax98.5. WBC 15.3.\n\nEndo-Drip off. Last BS 116.\n\nA/P- Monitor Hct/e-lytes. Tranfuse HCt<30. Encourage to CDB/IS. Advance diet as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-10-11 00:00:00.000",
"description": "Report",
"row_id": 1607024,
"text": "NURSING PROGRESS NOTE 3-7P\n\nPt able to tolerate ice chips and chicken broth without incident this evening. Diet to be advanced as tolerated. Meds to be changed to po as well.\nAline dc'd from right foot by team. Tolerated well. NBP stable 94-49.\n"
},
{
"category": "Echo",
"chartdate": "2114-10-14 00:00:00.000",
"description": "Report",
"row_id": 101484,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nHeight: (in) 62\nWeight (lb): 100\nBSA (m2): 1.43 m2\nBP (mm Hg): 132/80\nHR (bpm): 150\nStatus: Inpatient\nDate/Time: at 12:24\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: LV not well seen.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: There are complex (>4mm) atheroma in the aortic arch. Focal\ncalcifications in aortic arch. Simple atheroma in descending aorta. Focal\ncalcifications in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\n(normal) PR.\n\nPERICARDIUM: Small 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 sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). Local anesthesia was provided by benzocaine topical spray. The\nposterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related\ncomplications. Resting tachycardia (HR>100bpm). Echocardiographic results were\nreviewed by telephone with the MD caring for the patient. Left pleural\neffusion.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler. The left\nventricle is not well seen. Right ventricular chamber size and free wall\nmotion are normal. There are complex (>4mm) atheroma in the aortic arch. There\nare focal calcifications in the aortic arch. There are simple atheroma in the\ndescending thoracic aorta. The aortic valve leaflets (3) are mildly thickened.\nThere is no aortic valve stenosis. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is\nseen. There is a small pericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2114-10-08 00:00:00.000",
"description": "Report",
"row_id": 101485,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 62\nWeight (lb): 99\nBSA (m2): 1.42 m2\nBP (mm Hg): 90/52\nHR (bpm): 43\nStatus: Inpatient\nDate/Time: at 16:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Severe regional LV\nsystolic dysfunction. No LV mass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - akinetic; mid inferolateral - hypo; anterior apex -\nakinetic; septal apex- akinetic; inferior apex - akinetic; lateral apex -\nhypo; apex - dyskinetic;\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: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification. Mild to moderate (+) MR. [Due to acoustic shadowing,\nthe severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Indeterminate\nPA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion. Effusion is loculated.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Resting\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.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is severe regional left ventricular systolic\ndysfunction with near akinesis of the distal 2/3rds of the septum and anterior\nwall. The apex is mildly dyskinetic. The remaining walls are mildy\nhypokinetic. 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) are mildly thickened but aortic stenosis is not present. No\naortic regurgitatino is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Mild to moderate (+) mitral\nregurgitation is seen. [Due to acoustic shadowing, the severity of mitral\nregurgitation may be significantly UNDERestimated.] The pulmonary artery\nsystolic pressure could not be estimated. There is a small, likely loculated\nanterior pericardial effusion without evidence for hemodynamic compromise.\n\nIMPRESSION: Severe regional left ventricular systolic dysfunction c/w\nmultivessel CAD. Mild-moderate mitral regurgitation. Aortic valve sclerosis.\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": "2114-10-24 00:00:00.000",
"description": "Report",
"row_id": 301925,
"text": "Sinus rhythm with frequent atrial ectopy, including atrial couplets. Compared\nto the previous tracing of the same date multiple abnormalities are as\npreviously reported. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-24 00:00:00.000",
"description": "Report",
"row_id": 301926,
"text": "Baseline artifact. Sinus rhythm with frequent atrial premature beats. right\nbundle-branch block with left axis deviation consistent with bifascicular\nblock. Left and possibly biatrial abnormality. Underlying anterior Q wave\nmyocardial infarction with prior inferior wall myocardial infarction.\nBorderline low limb lead voltage. Ischemic appearing ST-T wave changes.\nCompared to the previous tracing of no diagnostic change with\npersistent ST segment elevations raising consideration of ventricular aneurysm\nif acute ischemia is excluded. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-10 00:00:00.000",
"description": "Report",
"row_id": 302164,
"text": "Sinus rhythm with atrial premature beats. Left anterior fascicular block.\nAnterior myocardial infarction with ST-T wave configuration consistent with an\nacute process. Low QRS voltage. Compared to the previous tracing of no\nsignificant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-10 00:00:00.000",
"description": "Report",
"row_id": 302165,
"text": "Sinus rhythm\nIrregular atrial premature complexes\nLow QRS voltage\nIncomplete right bundle branch block\nLeft anterior fascicular block\nAnterior myocardial infarction with ST-T wave configuration consistent with\nacute process\nSince previous tracing of , further left axis deviation present\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-21 00:00:00.000",
"description": "Report",
"row_id": 302154,
"text": "Sinus rhythm with runs of atrial ectopy or atrial tachycardia. Right\nbundle-branch block. Left anterior hemiblock. Anterior wall myocardial\ninfarction with QS deflections in leads V2-V4 with ST segment elevations.\nSmall R waves, deep S waves in lead V5 with ST segment elevation. Acute\nanterior wall myocardial infarction. Compared to the previous tracing\nof a similar pattern was present in the anterior precordial leads. If\nthe pattern persists, the diagnosis would be anterior wall myocardial\ninfarction with anterior wall aneurysm.\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-18 00:00:00.000",
"description": "Report",
"row_id": 302155,
"text": "Sinus rhythm\nAtrial premature complex\nRight bundle branch block\nLeft anterior fascicular block\nanterior myocardial infarction with ST-T wave configuration consistent with\nacute/recent/in evolution process\nSince previous tracing of , further precordial ST-T wave changes\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-16 00:00:00.000",
"description": "Report",
"row_id": 302156,
"text": "Sinus rhythm with atrial and ventricular premature beats. Short P-R interval.\nLeft anterior fascicular block. Incomplete right bundle-branch block.\nAnteroseptal myocardial infarction of indeterminate age. Right ventricular\nhypertrophy. Low QRS voltage in the precordial leads. Since the previous\ntracing of frequent atrial premature beats are seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-15 00:00:00.000",
"description": "Report",
"row_id": 302157,
"text": "Sinus arrhythmia with rate range 70-65.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-14 00:00:00.000",
"description": "Report",
"row_id": 302158,
"text": "Sinus rhythm. Compared to the previous tracing absence of arrhythmia. Acute\nanterior wall myocardial infarction pattern persists.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-13 00:00:00.000",
"description": "Report",
"row_id": 302159,
"text": "Atypical atrial flutter with a rapid ventricular response. Ventricular\nexcitation pattern is unchanged except for the arrhythmia.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-13 00:00:00.000",
"description": "Report",
"row_id": 302160,
"text": "Sinus rhythm. Atrial tachycardia of brief duration with pauses after the break\npoint. Low voltage. Right bundle-branch block. Anterior wall myocardial\ninfarction, probably acute. Clinical correlation is required. Compared to the\nprevious tracing of no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-08 00:00:00.000",
"description": "Report",
"row_id": 302385,
"text": "Poor quality tracing. Sinus bradycardia with acceleration and possible change\nin mechanism to a long R-P tachycardia and then a break. Low limb lead voltage.\nLeft anterior fascicular block. Right bundle-branch block with J point and\nST segment elevation in the precordial leads suggesting acute anterior injury.\nSince the previous tracing of the atrial arrhythmia pattern is more\nregular. The anterior ST segment elevation is new. Consider acute infarction.\nClinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-13 00:00:00.000",
"description": "Report",
"row_id": 302161,
"text": "Sinus rhythm. Supraventricular extrasystoles. Short P-R interval. Marked left\naxis deviation. Right bundle branch block with left anterior fascicular block.\nConsider acute anteroseptal myocardial infarction. Probable old inferior\nmyocardial infarction. Generalized low QRS voltage. Compared to the previous\ntracing of rhythm is now sinus.\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-13 00:00:00.000",
"description": "Report",
"row_id": 302162,
"text": "Possible atrial flutter with rapid ventricular response. Left axis deviation.\nIncomplete right bundle-branch block. Low voltage in the limb leads.\nST segment elevations in leads V1-V3, this may be compatible with anterior\nmyocardial infarction. Compared to the previous tracing of no\nsignificant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-11 00:00:00.000",
"description": "Report",
"row_id": 302163,
"text": "Atrial fibrillation with a rapid ventricular response. Right bundle-branch\nblock. Left anterior fascicular block. Q waves with ST segment elevations in\nthe anterior and anterolateral leads consistent with acute infarction. Low\nvoltage in the limb leads. Compared to the previous tracing the rate is faster.\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-09 00:00:00.000",
"description": "Report",
"row_id": 302379,
"text": "Sinus rhythm. Since the previous tracing of the sinus rate has\nincreased and atrial ectopy has returned. Changes of anterior wall myocardial\ninfarction persist. Clinical correlation is suggested.\nTRACING #7\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-08 00:00:00.000",
"description": "Report",
"row_id": 302380,
"text": "Sinus bradycardia. Since the previous tracing the rate has decreased. Other\nfeatures asre as previously described. The Q-T interval continues to prolong.\nTRACING #6\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-08 00:00:00.000",
"description": "Report",
"row_id": 302381,
"text": "Sinus bradycardia. Leftward axis. Low limb lead voltage. Right bundle-branch\nblock. Anterior and lateral ST segment elevations and T wave inversions.\nQ waves in leads VI-V6. Since the previous tracing the QRS voltage has\ndiminshed. Anterior wall myocardial infarction continues to evolve. Clinical\ncorrelation is suggested.\nTRACING #5\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-08 00:00:00.000",
"description": "Report",
"row_id": 302382,
"text": "Sinus rhythm. Short P-R interval. Left anterior fascicular block. Right\nbundle-branch block. Since the previous tracing of anterior myocardial\ninfarction in evolution proceeds with probable new appearance of small\nmid-precordial Q waves.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-08 00:00:00.000",
"description": "Report",
"row_id": 302383,
"text": "Poor quality tracing. Since the previous tracing sinus rhythm has been restored\nwithout ectopy. ST segment elevation is now more apparent in leads I and aVL\nconsistent with anterolateral myocardial infarction in evolution.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2114-10-08 00:00:00.000",
"description": "Report",
"row_id": 302384,
"text": "Sinus rhythm and bradycardia, as well as junctional escape. Since the previous\ntracing the rate is much slower. The Q-T interval is longer. The changes of\nearly precordial ST segment elevation persist. The QRS width is probably also\nincreased. Probable anterior wall myocardial infarction in evolution. Clinical\ncorrelation is suggested.\nTRACING #2\n\n"
}
] |
3,607 | 155,800 | Patient admitted to CCu from Ed with STEMI likely due to proximal RCA lesion. Patient's family was very clear that they did not want aggressive intervention (ie, No cath) and wanted the emphasis to be on comfort measures only; they confirmed that the patient was DNR/DNI. The family declined heparin or other medical intervention. Upon arrival to the CCU the patient was noted to be hypotensive with bradycardia and agonal breathing. She was started on a morphine drip. She passed away within 2 hours with her daughters at her bedside. | Nursing Progress Note 1700-1830S: Incomprehensible soundsO: Please see carevue for complete objective data.Pt arrived to unit on Dopamine 30mcg/kg/min. Inferior myocardial infarction withlateral component, probably acute. Compared to theprevious tracing of junctional bradycardia, acute inferior wallmyocardial infarction with possible lateral component, and Q-T intervalprolongation are new. MD's pronounced pt dead @ 1741. Atrial fibrillation with a slow ventricular response rate of approximately 30.Possible junctional pacemaker at rate 30. Ultimately decided to stop dopamine, HR dropped to 30's, and became apneic. IMPRESSION: Minimal costophrenic angle blunting may indicate small bilateral pleural effusions. PA and lateral views of the chest were obtained on and compared with the prior radiograph of . The patient has taken a poor inspiratory effort compared to the prior examination which is accentuating somewhat the pulmonary vascular markings at the bases. A primary CNS process is also in the differential. Bilateral costophrenic angle blunting is seen consistent with bony structures show diffuse osteopenia. Q-T interval prolongation. 11:02 AM CHEST (PA & LAT) Clip # Reason: r/o CHF, pneumonia MEDICAL CONDITION: 87 year old woman with shortness of breath REASON FOR THIS EXAMINATION: r/o CHF, pneumonia FINAL REPORT EXAMINATION: PA and lateral chest. SBP in 90's, HR-50's. Pt picking @ lines, throwing off covers, gave MSO4 1mg for agitation. INDICATION: Shortness of breath. Since the prior examination, the patient has healed rib fractures on the right side. Goal was to keep pt alive and comfortable c medical management until son could arrive from . Body to be taken to morgue. | 3 | [
{
"category": "Nursing/other",
"chartdate": "2136-09-17 00:00:00.000",
"description": "Report",
"row_id": 1308735,
"text": "Nursing Progress Note 1700-1830\nS: Incomprehensible sounds\n\nO: Please see carevue for complete objective data.\n\nPt arrived to unit on Dopamine 30mcg/kg/min. SBP in 90's, HR-50's. Goal was to keep pt alive and comfortable c medical management until son could arrive from . Pt picking @ lines, throwing off covers, gave MSO4 1mg for agitation. Ultimately decided to stop dopamine, HR dropped to 30's, and became apneic. MD's pronounced pt dead @ 1741. Three daughters and two friends of family present for passing. Body to be taken to morgue.\n"
},
{
"category": "ECG",
"chartdate": "2136-09-17 00:00:00.000",
"description": "Report",
"row_id": 253983,
"text": "Atrial fibrillation with a slow ventricular response rate of approximately 30.\nPossible junctional pacemaker at rate 30. Inferior myocardial infarction with\nlateral component, probably acute. Q-T interval prolongation. Compared to the\nprevious tracing of junctional bradycardia, acute inferior wall\nmyocardial infarction with possible lateral component, and Q-T interval\nprolongation are new. A primary CNS process is also in the differential.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-17 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 928271,
"text": " 11:02 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o CHF, pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with shortness of breath\n REASON FOR THIS EXAMINATION:\n r/o CHF, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: PA and lateral chest.\n\n INDICATION: Shortness of breath.\n\n PA and lateral views of the chest were obtained on and compared with\n the prior radiograph of . The patient has taken a poor inspiratory\n effort compared to the prior examination which is accentuating somewhat the\n pulmonary vascular markings at the bases. Since the prior examination, the\n patient has healed rib fractures on the right side. Bilateral costophrenic\n angle blunting is seen consistent with bony structures show diffuse\n osteopenia.\n\n IMPRESSION: Minimal costophrenic angle blunting may indicate small bilateral\n pleural effusions.\n\n\n"
}
] |
23,171 | 115,583 | INITIAL ASSESSEMENT AND PLAN ON ADMISSION: 68 year-old female with pancreatic cancer and colon cancer admitted with keratitis and hyperglycemia. 1. Keratitis: She was seen in the ED yesterday with blurry vision and eye swelling. A slit lap exam showed keratitis. Visual acuity was intact. She was sent home on ciporfloxacin ointments and viroptic. Continue ciprofloxacin and viroptic for now. 2. Hyperglycemia: She was noted to have sugars in the 300s yesterday. She had no evidence of DKA. Her blood surgars have been elevated above 180s for the past several years. Her hyperglycemia is likely secondary to pancreatic insufficiency after Whipple. Cover her with an insulin sliding scale for now. | FINAL VENT SETTINGS AFTER MANY ADJUSTMENTS AND ABGS (PLEASE SEE CAREVUE FOR FREQUENT ABGS AND VENT CHANGES) AC 16/450/PEEP 5/80% ABG AT 1500 ON THESE SETTINGS 7.36/30/70/18/95% LS COARSE UPPER LOBES W/ DIMINISHED BASES, SUCTIONED FOR NO SECRETIONS. 2 LR 1 LITER BOLUSES GIVEN AND DOBUTAMIN GTT @ 5MCQ/KG/MIN ADDED FOR SVO2 OF 89% PT BECAME TACHYCARDIC 118 DOBUTAMINE GTT DECREASED TO 2.5MCQ/KG/MIN THEN FINALLY SHUT OFF D/T TACHYCARDIA AND DECREASE IN BP PT 2 MORE 1LITER BOLUSES OF LR FOR NO UO AND LOW CVP 6-10 (GOAL ) NEO GTT ADDED AND AT PRESENT IS AT 4MCQ/KG/MIN ABP 80/50 MAP 63. PT HYPOTHERMIC THIS AM 96.0 BAIR HUGGER ON TILL 1400 TEMP NOW 98.3 ORALLY.RESP: ORALLY INTUBATED #7.0 22 LIP LINE. VS HR 110's, SBP 100/Review of systems:CV: Hypotensive throughout shift. ALBUTEROL MDI ORDERED PRN.CV: TELE SR-ST 80-110S SBP 79-102 MAPS >60 LEVO GTT .28MCQ/KG/MIN, VASOPRESSIN 2.4U/HR PT RECEIVED MANY LITERS OF LR AND NS FOR BOLUSES D/T LOW CVP AND UO. BUN/creat up slightly to 31/1.9.ID: Remains hypothermic with Bair Hugger in use. Aline was placed ~7am.ID: Blood cultures times 2 were sent, urine, no sputum available.ENDO: Hyperglycemic, up to 460. multiple pads/softsorb changed q4hrs overnoc.access-> right radial a-line, left ij tlcl, and right sc site continue to drain moderate amts of serous drainage. THEY REOMMENDED BACTROBAN TO OPEN BLISHER AREAS, NOTHING TO BLISTERED AREAS, AND KETOCONAZOLE 2% TP TO INTERTRIGO. CA+ LOW SINCE ADMISSION ION CA+ TODAY .9 REPLEATED X 2 W/ 2 AMPS OF CA GLUCANATE IN 100CCNS EACH. The levophed was initially .28 mcg/kg/min and was gradually titrated to .14 mcg/kg/min.Her BP remained stable for ~1hr, then it began to drift down, requiring an increased rate of .08mcg/kg/min. the vivonex tube feeding was restarted at mn.gu-> as noted above, the lasix qtt was turned off earlier in the shift d/t persistent hypotension. (Continued)ions have worsened despite q4 hour use of "magic mouthwash". PT HYPOTHERMIC THIS AFTERNOON 96.0 BAIR HUGGER PLACED. MAP MAINTAINED AT 65 OR GREATER WITH VASOPRESSIN AT 2.4U/HR AND NOREPINEPHRINE AT .080-.146 MCGS/KG/MIN. SHE HAS BLEEDING HEMRRHOIDS AS WELL.GU: PT HAD 14FR FOLEY CATH THIS AM, DRAINING MINIMAL AMOUNT OF URINE BLADDER PRESSURE DONE 7, FOLEY IRRIGATED W/ NO PROBLEMS, FOLEY CHANGED TO #16FR. uop had been >30cc/hr until 0500; over the past 2hrs, her uop has trended down to 5-10cc/hr.id-> hypothermic despite continuous use of the bair hugger. NURSING PROGRESS NOTES 0700-1900EVENTS: HCT THIS AM 25.9 DOWN FROM 28.6 PT 2 UNITS OF PRBCSNEURO: PT ALERT THIS AM, PERL 3MM SLUGGISH MAE. Remains on Cipro for e.coli sepsis.HEME: Hct up a bit to 29; plt's down to 37 (40); INR up to 1.8 (1.6); pt will recieve 2u FFP. Decreased pressor requirements; decent response to Lasix gtt.ROS:NEURO: Remains heavily sedated on Fentanyl 75mcg/hr and Versed 3mg/hr; no boluses required. Cont's to receive LR 1 liter/hr. RENAL FEELS IT WILL START TO COME DOWN.ID- HYPOTHERMIC ALL DAY ON BAIR HUGGER. RVfunction depressed.AORTA: Normal aortic root diameter. Later given a second 1L NS bolus for decreased UO despite unchanged CVP. False LV tendon (normal variant). The appearance is consistent with residua of old prior resolved thrombosis with recannulation, not recent. There is again noted unchanged right subclavian Port-A-Cath with the tip in the right atrium. There is no pericardial effusion.Impression: right and left ventricular contractile function is significantlydepressed No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. LS CTA, very diminished at bases; minimal thick white secretions.C-V: HR 70's-80's, NSR, occ PAC's. There is interval development of perihilar haziness likely representing mild fluid overload. Mg 1.9, Phos 1.8.GI: Belly firm, distended, with hypoactive BS. Able to wean Neo to off, with Levo and Vasopressin remaining at previous rates. Normal LV cavity size.Moderate-severe global left ventricular hypokinesis. Following lactates and ionized Ca+ (repleted w/ 4g X 1) thus far. Focal calcifications in aortic root.Normal ascending aorta diameter. Hypoactive BS initially, although now absent. Pt has been hypothermic, tmax 96.9. PERRL 3mm, sluggish.CV: Pt is in NSR with occas to frequent PVCs. Sigmoid diverticula are again identified without evidence of diverticulitis. BP labile as stated above, titrating vasopressors to effect. Rule out hemorrhage. LS CTA upper, diminished lower.C-V: HR 70's-80's, NSR, no ectopy observed. The aortic valve leaflets (3) are mildly thickenedbut aortic stenosis is not present. Pulmonary embolus.Height: (in) 63Weight (lb): 120BSA (m2): 1.56 m2BP (mm Hg): 88/65HR (bpm): 91Status: InpatientDate/Time: at 11:51Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. placed on airmattress.GI- ABD firm and distended. BS are clear, diminished at the bases. ET tube and NG tube are unchanged in position. TECHNIQUE: Non-contrast head CT. Normal tricuspid valvesupporting structures. Sinus tachycardiaRight bundle branch blockInferior T wave changes are nonspecificSince previous tracing, no significant change BP somewhat labile, requiring small adjustments in Levo dose; Vasopressin remains at 2.4u/hr. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Pt's oral cavity is impaired with ulcers t/o using magic mouthwash Q4H.GI: Abd is firm, distended. Neutropenic precautions observed. Right ventricular systolicfunction appears depressed. Assess left IJ placement. Sinus rhythmRight bundle branch blockNonspecific ST-T wave changesSince previous tracing, no significant change FINDINGS: Endotracheal tube, nasogastric tube, implanted right venous access device and left jugular venous lines are all unchanged. FINDINGS: There is a small left-sided pleural effusion. LS bronchial t/o with some insp/exp. Subsequently noted to have BP spikes for no apparent reason, which were assumed to be d/t pain/discomfort. CVP 10-17, goal and has required 1L fluid bolus x3 to maintain CVP. Dilated IVC (>2.5 cm), with minimal respiratory variation c/welevated RA pressure of >20 mmHg.LEFT VENTRICLE: Normal LV wall thickness. Resp CarePt remains intubated on A/C. Pt is grossly edematous t/o, pulses audible via doppler. No response to 1L NS bolus.ID: Remains under Bair Hugger; Lactate stable at 3-4; WBC 0.3. | 40 | [
{
"category": "Nursing/other",
"chartdate": "2197-02-23 00:00:00.000",
"description": "Report",
"row_id": 1565100,
"text": "focus; addendum\nCARDIAC- SPOKE WITH DR CONCERNING FLUID BALANCE. POS 418 CC SO FAR TODAY. AS CVP IS ONLY 11 WITH GOAL AROUND 14 WILL JUST CONT ON LASIX DRIP AT 20MCG/HR FOR NOW. HE IS AWARE THAT PATIENT WILL PROBABLY NOT BE NEG AT ALL TODAY.\nENDO- BS 176 AT 1800. INSULIN DRIP UP TO 1.5 U/HR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-24 00:00:00.000",
"description": "Report",
"row_id": 1565101,
"text": "Resp Care\nPt remains on MV in AC mode as noted on Careview. Peep decreased from 20 to 18 cm H2O due to continued hypotension. ETT retaped at 22 Lip with no noted complications. BBS-coarse. Pt sx'ed for scant amts blood tinged secretions. Bag and mask at bedside with Peep valve in place. Alarms on and functioning. Esophageal balloon in place with no readings ordered this shift. Continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-24 00:00:00.000",
"description": "Report",
"row_id": 1565102,
"text": "pmicu npn 7p-7a\n\n\n the pt has continued to do poorly overnoc, requiring the addition of a neo qtt to support her blood pressure. later this morning, a repeat abg revealed a worsening acidosis and the pt was treated with 2 amps of nahco3 with the expected transient improvement in her blood pressure. at the present time, the pt is now receiving maximum doses of levophed, neo, and vasopressin. she is also more hypoxic and has been placed on 100% o2. the pt's son and dtr were updated twice by the micu intern and are now at the pt's bedside.\n\nreview of systems\n\nrespiratory-> the pt remains intubated and vented on ac 24x370 w/peep20 and o2 now ^100%. srr 0-2/min. last abg: 7.23/44/57(po2)/19/\n-8. o2 increased to 100% based on this abg. she was suctioned x1 only for a small amt of thick, blood tinged sputum.\n\ncardiac-> pt was very hemodynamically unstable thruout the shift and repositioning her only exacerbated the instability. the lasix qtt was turned off ~2100, and the neo qtt was added @0030 after the levo qtt was maxed out at that time. as noted above, there was trnasient improvement in her blood pressure s/p the 2 amps of bicarb, but the pt's bp is now trending downward w/sbp 70's and hr 110-120's, st no ectopy. per discussion with the micu team, no additional bicarb will be given.\n\nneuro-> pt is unresponsive although she does consistently become transiently hypertensive with any turning and repositioning. no spontaneous movement noted, perrl @2mm.\n\ngi-> abd is firm, distended w/hypoactive bs. although she had bilious emesis x2 earlier in the shift, her ogt aspirates have been minimal. the vivonex tube feeding was restarted at mn.\n\ngu-> as noted above, the lasix qtt was turned off earlier in the shift d/t persistent hypotension. she continued to have an enormous insensible fluid loss d/t multiple open blisters over her arms and legs. uop had been >30cc/hr until 0500; over the past 2hrs, her uop has trended down to 5-10cc/hr.\n\nid-> hypothermic despite continuous use of the bair hugger. serial lactate levels are rising. no change in abx coverage overnoc for an e. coli sepsis.\n\nendocrine-> fingersticks ranging 140-155 on units of regular insulin/hr via continuous qtt.\n\nskin-> no change in multiple open blisters over arms and legs. bactroban applied to open areas while ketoconazole cream applied to ares of intertrigo. multiple pads/softsorb changed q4hrs overnoc.\n\naccess-> right radial a-line, left ij tlcl, and right sc site continue to drain moderate amts of serous drainage.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-24 00:00:00.000",
"description": "Report",
"row_id": 1565103,
"text": "FOCUS; NURSING PROGRESS NOTE\nFAMILY ALL HERE AND REQUESTING THAT DRIPS BE SHUT OFF. PATIENT MADE A CMO. PRESSORS OFF. FIO2 AND PEEP DECREASED. VERSED INCREASED TO 7MG/HR AND FENTANYL INCREASED TO 200MCGS/HR. PATIENT EXPIRED AT 0920. DR NOTIFIED AND UP TO PRONOUNCE THE PATIENT. HE SPOKE TO THE FAMILY. NO AUTOPSY IS TO BE DONE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-18 00:00:00.000",
"description": "Report",
"row_id": 1565077,
"text": "MICU Nursing Admission Note\n Pt is 68 yo female with pancreatic cancer and colon cancer. She was admitted with keratits and hyperglycemia on . While on floor , pt became increasinly lethargic and had a SBP of 60. Rescusitated with fluids and transferred to MICU for further treatment.\n\nPMH: Prior hx of localized pancreatic cancer s/p whipple () and treated sucessfully with chemo & radiation. New dx of adeno CA of colon stage III. Underwent Right colectomy on c/b wound infection. Ventral hernia repair , HTN, Hx of asthma, newly dx of IDDM.\n\n Arrived to MICU ~11pm, accompanied by RN from floor. Transferred to be with full assist. VS HR 110's, SBP 100/\n\nReview of systems:\n\nCV: Hypotensive throughout shift. Received multiple IVF bolus throughout night (~7 liters). Currently maxed out on levophed and pitressin started ~6am, with SBP still in the 80's. Cont's to receive LR 1 liter/hr. ~8l + since arrival to MICU. Please refer to carevue for detailed data and titration of meds. She has also been receiving electrolyte replacement, K+ and K+ phos.\n\nResp: Pt tiring and by 6am required intubation. Currently attempting to place aline in order to monitor ABG's.\n\nGI: NPO. +BS. Abdomen distended and tender to touch. Pt experienced 2 large melanotic stools. Rectal tube placed due to amt and consistency of stool. Pt is now intubated and an OGT was placed.\n\nGU: Foley cath placed on arrival. Urine culture sent. Pt has been making adequate u/o.\n\nNeuro: Throughout this ordeal, pt has remained alert and aware of surroundings, even though she is very weak and lethargic.\n\nSocial: Lives alone, has 5 children. Attempts were unsuccessful to contact family last night. Her son did call back this am. she lives alone, a retired school teacher.\n\nLines: Arrived with 2 peripherals. Her POC was accessed last night, and a quad LIJ was placed. Aline was placed ~7am.\n\nID: Blood cultures times 2 were sent, urine, no sputum available.\n\nENDO: Hyperglycemic, up to 460. Placed on Insulin gtt and titrated accordingly. Currently at 8u/hr.\n\nHeme: Neutropenic, s/p chemo. Received 2units FFP and 1 unit PLTS prior to line placement. Hct has dropped, written for transfusion when consent is available (son to sign?)\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-18 00:00:00.000",
"description": "Report",
"row_id": 1565078,
"text": "NURSING PROGRESS NOTES 0700-1900\nEVENTS: HCT THIS AM 25.9 DOWN FROM 28.6 PT 2 UNITS OF PRBCS\n\nNEURO: PT ALERT THIS AM, PERL 3MM SLUGGISH MAE. FOLLOWS COMMANDS RECEIVED SEDATION FENTANYL 50MEQ AND VERSED 1MG IVP AT 1000 AND 1330 WHEN SEDATED SHE CAN OPEN HER EYES TO VOICE AND LOCALIZES PAIN BUT DOES NOT FOLLOW COMMANDS. PT HYPOTHERMIC THIS AM 96.0 BAIR HUGGER ON TILL 1400 TEMP NOW 98.3 ORALLY.\n\nRESP: ORALLY INTUBATED #7.0 22 LIP LINE. FINAL VENT SETTINGS AFTER MANY ADJUSTMENTS AND ABGS (PLEASE SEE CAREVUE FOR FREQUENT ABGS AND VENT CHANGES) AC 16/450/PEEP 5/80% ABG AT 1500 ON THESE SETTINGS 7.36/30/70/18/95% LS COARSE UPPER LOBES W/ DIMINISHED BASES, SUCTIONED FOR NO SECRETIONS. HER MOUTH HAS ORAL ULCERS FROM CHEMO TX THAT ENDED LAST TUESDAY, \"MAGIC MOUTHWASH\" APPLIED, MOUTH IS NOTED TO BE BLEEDING AT TIMES FOR A SCANT AMOUNT OF BLD. ALBUTEROL MDI ORDERED PRN.\n\nCV: TELE SR-ST 80-110S SBP 79-102 MAPS >60 LEVO GTT .28MCQ/KG/MIN, VASOPRESSIN 2.4U/HR PT RECEIVED MANY LITERS OF LR AND NS FOR BOLUSES D/T LOW CVP AND UO. PT IS NOW 17 LITERS POS. CVP 6-17 HRT SOUNDS S1S2 BUT DISTANT. PEDAL PULSES +3. K+ 2.5 REPLEATED W/ 80MEQ KCL IV BOLUSES, MG 1.4 REPLEATED W/ 3GMS OF MAG IN 250CC NS CA 1.00 REPLEATED W/ 2 AMPS OF CA+ GLUCANATE. 1000 LYTES K+ 3.2 REPLEATED W/ 80MEQ OF KCL VIA OGT., MAG 2.1. HCT AT 1000 31.9. INR 2.4 2 UNITS OF FFP GIVEN AT 1530 LABS AT 1500 HCT 37.0, PLT 60, K+ 4.7, CA 1.02 REPLEATED W/ 2 AMPS OF CA+ GLUCANATE. PHOS 1.9 WILL BE REPLACED W/ NA PHOS (AWAITING MED FROM PHARMACY) MAG 1.9. ECHO: DECREASED LVF EF ESTIMATED 30% AND RVF. ACCESS- RIGHT RADIAL ALINE, LEFT IJ QUAD LINE, RIGHT SC PORTACATH AND 2 BILAT PERIPHERALS. SVO2 70% THIS AM, AT PRESENT 86%\n\nGI: PT NPO OGT TO SUCTION THIS AM FOR 100CC OF GREEN BILIOUS OUTPUT. ABD DISTENDED SOFT BS+, PT ON PPI, MUSHROOM CATH DRAINING BROWN WATERY STOOL W/ BLEEDING HEMORRHOIDS. GUIAC POS.\n\nGU: UO POOR THIS AFTERNOON BOLUSES GIVEN AS STATED ABOVE. UO AT TIMES 0CC\n\nSKIN: PT HAS ABRASION/OPEN BLISTER ON COCCYX THAT IS OOZING SEROUS FLUID. DOUBLE GUARD PLACE ON REDENED PERI AREA.\n\nENDO: INSULIN GTT OFF FOR BS 68 AT 1600 (WAS AT 5UNIT/HR) SOLU-CORTEF Q8HRS\n\nID: GRAM NEG RODS NOTED IN ONE BOTTLE FROM PORTACATH BC\nON MEROPENEM . LACTATE 9.7 AND AT PRESENT 5.8\n\nSOCIAL: ALL CHILDREN HAVE BEEN AT BEDSIDE THROUGHOUT SHIFT AND HAVE BEEN UDATED CONTINOUSLY. ON CALL PRIEST HAS BEEN CALLED TO GIVE SUPPORT TO FAMILY AND SACREMENT OF THE SICK,.\n\nCODE: FULL\n\n\nPLAN:\nGOALS: TX FOR HCT <30, PLT<50, INR >1.5\nBOLUS FOR MAP <60\nHCT Q 6HRS NEXT LABS 2100 AND 0300\nWILL CHANGE SEDATION TO GTTS INSTEAD OF BOLUSES Q 2HRS PRN\nGIVE EMOTIONAL SUPPORT TO FAMILY\nMOUTHCARE W/ MAGIC MOUTHWASH\nCONT TO DO FINGERSTICKS Q 1HR\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-19 00:00:00.000",
"description": "Report",
"row_id": 1565079,
"text": "MICU NPN 1900-0700\nEvents: Received a total of 3 units FFP and 1 unit Platelets. Able to titrate levophed by just a small amt. Priest came by last eve, while family was still here.\n\nCV: Cont's to require pressor support. BP has been in the 90's-100's\nwith MAP's 65-70. Vasopressin remains at 2.4 u/hr. The levophed was initially .28 mcg/kg/min and was gradually titrated to .14 mcg/kg/min.\nHer BP remained stable for ~1hr, then it began to drift down, requiring an increased rate of .08mcg/kg/min. K+ 4.4, Ca 7.0, Mg 1.9, Phos 3.5. At midnight, pt was 17 L positive, since admission. Required no fluid bolus' this shift.\n\nResp: LS occasionally coarse otherwise clear, diminished at bases. Remains intubated and ventilated. On A/C 80%/450/x16 with 5 peep. AM ABG 27/71/7.34/-. Averaging approx. 8 spontaneous resps.\n\nHeme: Hct at 2120 was 35.1. Repeated a few hours later, and it was found to be 31.8. There was no apparent bleeding noted, VS unchanged. Eccymotic area on abdomen, that was noted as NEW, in the late afternoon yesterday, was unchanged in size or color. A look back at the HCT results show an appropriate bump in the Hct results after the first unit, and an abnormally high result after the 2nd unit. Below are the HCT results and the *** indicate when the blood was given.\n\n 28.6/ 25.9/ ***/31.9/ ***/ 37.0/ 32.4/ 35.1/ 31.8\n\nPLT were 42, transfused with 1 unit, post PLT count, up to 60. Received 2 units FFP for an INR of 2.0. AM level 1.6 with goal of 1.4. An additional unit was given at 5am. Additional labs to be drawn at 0700.\n\nSkin: +Mucocytis, very uncomfortable for pt when mouth care is performed. Third spacing, weeping serous fluid from old needle sticks\nsites. A skin tear was noted on the buttock area. Double guard ointment and adaptic applied. Eccymotic area on abdomen unchanged in size from last eve.\n\nGU: U/O 8-30cc's hr. BUN/cr 18/.8 this am.\n\nGI: OGT in place. NPO at present. + BS. Stool out via mushroom catheter. Brown liquid OB+.\n\nNeuro: Definate discomfort noted with turning and mouth care/ bath. Fentanyl and versed gtts initiated ~2330. Versed begun at .5 mg/hr, and fentanyl at 25mcg/hr. She seems comfortable at these levels. PERRLA.\n\nSocial: 3 sons and daughter and daughter in law into visit. The priest arrived ~8pm after another page. He visited with pt and family. family left to go home 10pm. They called once this am, and are expected to be in later this am.\n\nLines: 1 periperal, quad lumen and , . All in working order.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-19 00:00:00.000",
"description": "Report",
"row_id": 1565080,
"text": "Respiratory Care\nVentialtor changes noted on Carevue as well as corresponding ABG results. Incresing bladder pressures resulting in difficulties in oxygenation as well as metabolic status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-19 00:00:00.000",
"description": "Report",
"row_id": 1565081,
"text": "NURSING PROGRESS NOTES 0700-1900\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT SEDATED ON FENTANYL GTT 25MCQ/HR AND VERSED .5MG/HR. PT OPENS HER EYES TO PAINFUL STIMULI, PERL 3MM BRISK SHE DOES NOT FOLLOW COMMANDS. PT HYPOTHERMIC THIS AFTERNOON 96.0 BAIR HUGGER PLACED. PT HAS SCLERA EDEMA AQUA TEAR OINT APPLIED\n\nRESP: PLEASE SEE CAREVUE FOR VENT CHANGES AND FREQUENT ABGS. ABG AT 1300 7.25/28/68/13/93% ON VENT SETTINGS AC 16/ 450/5/70% FIO2 INCREASED TO 100% PEEP INCREASED TO 15. ABG REPEATED 7.27/27/75/95% ABG AGAIN REPEATED AT 1730 7.25/29/86/13/96%. LS CLEAR W/ DIMINISHED BASES. SUCTIONING NO SECRETIONS. SINCE CHEMO TX LAST TUESDAY PT HAS HAD THRUSH AND BLEEDING MOUTH ULCERS, MAGIC MOUTHWASH APPLIED.\n\nCV: PT ON VASOPRESSIN 2.4U/HR AND LEVOPHED GTT TO KEEP MAPS >60 THIS AM LEVOPHED GTT WAS WEANED DOWN TO .12MCQ/KG/MIN FOR MAP>60 LATE THIS AM PT BP STARTED FALLING AND LEVOPHED GTT WAS MAX AT .28MCQ/KG/MIN. 2 LR 1 LITER BOLUSES GIVEN AND DOBUTAMIN GTT @ 5MCQ/KG/MIN ADDED FOR SVO2 OF 89% PT BECAME TACHYCARDIC 118 DOBUTAMINE GTT DECREASED TO 2.5MCQ/KG/MIN THEN FINALLY SHUT OFF D/T TACHYCARDIA AND DECREASE IN BP PT 2 MORE 1LITER BOLUSES OF LR FOR NO UO AND LOW CVP 6-10 (GOAL ) NEO GTT ADDED AND AT PRESENT IS AT 4MCQ/KG/MIN ABP 80/50 MAP 63. HRT RATE 110 ST SAT 92-96% CVP 21. PT HCT 30 PLT THIS AFTERNOON 35 (GOAL >50) 6 UNITS OF PLTS GIVEN REPEAT 139 INR 2.3 (GOAL <1.5) 2 UNITS OF FFP GIVEN INR TAKEN AFTER 1 UNIT .8. CA+ LOW SINCE ADMISSION ION CA+ TODAY .9 REPLEATED X 2 W/ 2 AMPS OF CA GLUCANATE IN 100CCNS EACH. SVO2 AT 1500 95%.\n\nGI: PT NPO HAS OGT WHICH HAS DRAINED BILIOUS LIQUID 50CC WHEN PUT TO SUCTION ABD DISTENDED SOFT TENDER ECCYMOTIC WHICH HAS BECOME INCREASINGLY WORSE OVER THE COURSE OF THIS SHIFT. MICU TEAM AWARE CT HEAD AND ABD DONE THIS AM ? BLEEDS BOTH NEG. PT HAS MUSHROOM CATH WHICH HAS DRAINED MINIMAL BROWN TO DRK RED LIQUID STOOL GUIAC POS. SHE HAS BLEEDING HEMRRHOIDS AS WELL.\n\nGU: PT HAD 14FR FOLEY CATH THIS AM, DRAINING MINIMAL AMOUNT OF URINE BLADDER PRESSURE DONE 7, FOLEY IRRIGATED W/ NO PROBLEMS, FOLEY CHANGED TO #16FR. UO POOR 0-20CC/HR\n\nSKIN: PT MOTTLED FROM NIPPLE LINE TO KNEES MICU TEAM AWARE. PT HAS 3 OPEN BLISTERS NOTED ON COCCYX AND LEFT BUTTUCK DOUBLE GUARD OINT AND ADAPTIC APPLIED SKIN WEEPING FROM OLD IV SITES AND FROM MULTYPLE BLISTERS ON BOTTOM. MOUTH HAS OPEN ULCERS THAT BLEED DURING MOUTH CARE.\n\nENDO: INSULIN GTT OFF SINCE YESTURDAY FINGERSTICKS 120-130S PT ON 50MG QID\n\nSOCIAL: PT HAS 5 CHILDREN AND THEY HAVE BEEN AT BEDSIDE MOST OF SHIFT. THE HOSPITAL PRIEST CAME LAST EVENING FOR SUPPORT.\n\nCODE: TONIGHT FAMILY MADE PT DNR, BUT CONT CURRENT TX\n\nID: BC POS 2/4 BOTTLES GRAM NEG RODS PT ON VANCO QD AND MEROPENEM TID.\nCDIFF STILL PENDING. LACTATE TRENDING UP TODAY FROM 5-10.7\n\nPLAN:\nCONT TO FOLLOW LABS/ABG\nGOALS HCT >30\nPLT >50\nINR <1.5\nSAT >95%\nMAP >60\nCVP 12-15\nGIVE EMOTIONAL SUPPORT TO FAMILY\nKEEP PT COMFORTABLE USING FENT AND VERSED GTTS\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-22 00:00:00.000",
"description": "Report",
"row_id": 1565091,
"text": "(Continued)\nions have worsened despite q4 hour use of \"magic mouthwash\". Despite drainage and need to change linens, pt has been turned only q4 hours d/t hemodynamic instability and desaturation with turning.\nACCESS: All lines are functioning well and are without evidence of infection, however all sites have significant serous drainage and are impossible to keep dry despite many dressing changes.\nSOCIAL: Family members taking turns in room until about MN; spent rest of night in waiting area and at nearby hotel.\n\nA: overall worsening condition\n\nP: Plan after yesterday's family meeting was to continue aggressive measures till all options have been exhausted (though she remains DNR). Ensure pt comfort. Readdress overall goals of care with family today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-22 00:00:00.000",
"description": "Report",
"row_id": 1565092,
"text": "Micu Nursing Progress Notes\nEvents: Stable on levo and vasopressin, Having difficulty ventilating her due to her volume overload. She is now on 100% with 18 Peep with sat of 94%.\n\nResp: initial vent settings A/C 450 x24 FiO2 60% and Peep 15. She was turned at 10am with her desaturating to the 80%, she responded to 100% for 3min and then returned to her sats of 93-94%. However when she was turned at 1500 she desaturated to 78% initially responded to 100% but again dropped to the low 80% when back on 60%. She required 100% and peep to increase to 18 to maintain sats of 93-94%. She was suctioned x1 for no secretions.\n\nGU: She had only 7cc urine out in 4hours by 12n despite a CVP of 25. She was started on a lasix gtt at 5mg/hr with her U/O increasing to 15cc/hr. At 1500 she was bolused with lasix 100mg, while maintaing the lasix gtt. Her U/O has increased to 75cc/hr. The lasix gtt was increased to 10mg/hr and will receive 500mg duiril.\n\nCardiac: she has remained hemodynamically stable. Remains off Neosynephrine. The Vasopressin remains at 2.4u/hr and the levophed has been decreased slightly to .25mcg/kg/min.\n\nNeuro: Fentanyl is at 75mcg/hr and the midazolam is at .25mg/hr. She appears comfortable. She does not respond to commands.\n\nGI: Abd firm and distended, absent bowel sounds. Pt noted to have bili colored emesis coming from her mouth around 1500 OGT placed to low suction but no stomach contents were withdrawn. Tube feedings of nepro at 10cc/hr were held.\n\nEndo: insulin received at 14u/hr. Her blood sugar has been decreasing all day requiring the insulin gtt to be decreased to 8u/hr, last blood sugar was 110.\n\nID: She remains hypothermic with temps 95.6-97.0. She remains on the bair hugger at it's max temp. She continues to receive cipro IV for her E.Coli sepsis.\n\nHeme: She received the total of 3 bags of FFP and one bag platlets. The post transfusion plat ct was 56, HCT was 26.1. Labs sent at 1830.\n\nSkin: Serous filled Blisters appearing all over her body. Her skin is very fragil. The stitches around her multilumen catheter were pulled out of her skin and the catheter almost pulled out while preparing to place her on a triadyne bed. Will attempt the bed transfer again when the night sift arrives for more help. She is oozing serous fluid from the multiple blisters, her labia are bright red from broken blisters and the labia are very swollen.\n\nSocial: sons and daughters in and out all day. They spoke with SW- . They spoke with Dr for an update. There is no change in the current treatment plan.\n\nPlan: Change pt to a triadyne bed when staff becomes available, monitor resp status carefully, give diurel when arrives from pharmacy, maintain lasix gtt at 10mg/hr and monitor U/O closely, turn q4h to attempt to keep skin from breaking down more but maintain O2 sats.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-22 00:00:00.000",
"description": "Report",
"row_id": 1565093,
"text": "Respiratory care\nPt with increased vent support, fio2 increased to 100% for desat to 70's. Peep increased peep to 18. Pt recieving Lasix with poor urine output. Pt recieved MDI as ordered. Plan to duirese and decrease vent support as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-23 00:00:00.000",
"description": "Report",
"row_id": 1565094,
"text": "Respiratory Care Note:\n patient remains on full vent support at this time. FIO2 raised to 100%, due to a po2 of 54. SX for minimal secretions, yellow thick in nature. BS are essentially clear, diminished at the bases. No RSBI this am due to peep level of 18. MDI's administered as ordered. patient remains under bear hugger. Plan is to maintain full support and wean fio2 when tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-23 00:00:00.000",
"description": "Report",
"row_id": 1565095,
"text": "NPN 1900-0700:\n\nEVENTS: Oxygenation initially improved, allowing FiO2 to be reduced to 70%, but later required increase back to 100% for pO2 54. Decreased pressor requirements; decent response to Lasix gtt.\n\nROS:\nNEURO: Remains heavily sedated on Fentanyl 75mcg/hr and Versed 3mg/hr; no boluses required. Pt is essentially unresponsive with no spontaneous movement observed. Pupils equal and sluggishly reactive.\nRESP: As above, oxygenation improved for part of the night; FiO2 was weaned to 70% with sats initially remaining 93-94%. At 0410 sats acutely dropped to high 80's and SBP to low 80's when bed rotated to left. Pt had previously tolerated bed rotation without difficulty. Bed returned to supine position and FiO2 increased to 80% with only partial recovery after several minutes. ABG revealed pO2 of 54, therefore pt was returned to 100% with sats improving to 95-96%. No need ot recheck ABG per HO. No other vent changes were made. LS CTA upper, diminished lower; minimal secretions.\nC-V: Able to wean Levo quite a bit, in spite of acute (transient) drop noted above. Remains on Vasopressin. HR 70's, NSR, rare PAC's. CVP 13-15. K 3.4 this AM; pt to recieve 40meq. Phos a bit low at 2.5; no order to replete. Other lytes WNL.\nGI: Belly firmly distended, no stool. Nepro TF started at 10cc/hr; no increase ordered; no residuals.\nGU: Remains on Lasix gtt at 10mg/hr with UO 110-140cc/hr. BUN/creat up slightly to 31/1.9.\nID: Remains hypothermic with Bair Hugger in use. WBC up a bit to 0.3; lactate remains elevated but is decreasing. Remains on Cipro for e.coli sepsis.\nHEME: Hct up a bit to 29; plt's down to 37 (40); INR up to 1.8 (1.6); pt will recieve 2u FFP. Bleeds quite a bit from fingerstick sites; scattered ecchymotic areas on back and arms.\nENDO: Insulin gtt down to 1u/hr.\nSKIN: Scattered ecchymosis as noted above. Mucositis has improved significantly. Pt has increasing numbers of fluid-filled blisters of various sizes over entire body, some of which have broken. Labia and buttocks have large opened areas which we are covering with DoubleGard (though it does not stick very well). She is oozing copious amounts of serous fluid from all the open areas as well as all her line sites. She tolerates turning poorly, therefore absorbant pads are changed only q4 hours. She was transferred to Triadyne bed without incident.\nACCESS: All line sites are weeping copious amounts of serous fluid. Dressings are impossible to keep intact d/t drainage. LIJ QLC has only 1 suture holding it in place.\nSOCIAL: Family in room all evening, then to waiting room for the night. They remain hopeful but realistic. The fully understand how sick she is, and that even if she recovers from this illness she still has the underlying cancer to deal with, for which treatment options are unclear now, considering her extreme response to her first dose of chemo.\n\nA: remains extremely ill\n\nP: Replete K; transfuse FFP; recheck labs. Continue all aggressive measures at this time. Continu\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-23 00:00:00.000",
"description": "Report",
"row_id": 1565096,
"text": "(Continued)\ne daily updates and ongoing support for family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-23 00:00:00.000",
"description": "Report",
"row_id": 1565097,
"text": "resp care\nremains intub/vented in ac mode. esophageal balloon placed to facilitate optimal peep, determined to be underpeeped at 18, subsequently as bp increased we were able to increase peep to 20. very slowly weaning fio2 maintaining paO2>60. minimal brownish secretions,minimal to no cough effort. remains hemodynamically unstable, following protective lung strategy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-23 00:00:00.000",
"description": "Report",
"row_id": 1565098,
"text": "NURSING PROGRESS NOTE\n68 OLD FEMALE WITH PMH SIGNIFICANT FOR PANCREATIC CA S/P WHIPPLE, RADIATIONA DN CHEMO. ALSO WITH COLON CA S/P HEMICOLECTOPY . HAD FIRST AND LATEST CHEMO 2.21. ADMITTED TO HOSPITAL WITH HYPERGLYCEMIA. TRANSFERRED TO MICU ON WITH LETHARGY AND SBP OF 60. TX WITH FLUIDS, PRESSORS, AND BLOOD PRODUCTS. REQUIRED INTUBATION. FOUND TO HAVE ECOLI SEPSIS AND ECOLI AND KLEBSIELLA IN HER URINE.\nREVEIW OF SYSTEMS-\nNEURO- SHE IS SEDATED. DOES NOT MOVE ANYTHING SPONTANEOUSLY. PUPILS 2MM EQUAL AND SLUGGISHLY REACTIVE TO LIGHT. SHE WAS ON 75MCGS/HR OF FENTANYL AND 3MG/HR VERSED. ON THIS THIS AM WITH TURNING HER SBP WENT FROM 80-160. SHE APPEARED UNCOMFORTABLE SO HER FENTANYL WAS INCREASED TO 100MCGS/HR. ON THIS SHE HAS APPEARED COMFORTABLE WITH NO INCREASED VS WITH CARE.\nRESP- SHE IS ORALLY INTUBATED AND VENTED. THIS AM WAS ON 100% FIO2/ TV 450/ A/C RATE OF 24 BREATHING 24 AND 18 PEEP. ESOPHAGEAL BALLOON WAS DROPPED BY RESP. UNABLE TO INCREASE PEEP WITHOUT DROP IN BP. ONLY VENT CHANGE MADE WAS DROP IN TV TO 370CC. LATER DROPPED TO 80% FIO2 AND PEEP INCREASED TO 20. ON THIS ABG 7.30/35/87/18. AFTER THIS ABG DROPPED FIO2 TO 70%. SATS HAVE BEEN 92-93%. AT TIMES PLETH ON O2 SAT DIFFICULT TO OBTAIN. BS ARE CLEAR WITH DIMINISHED SOUNDS AT THE BASES. SUCTIONED FOR SCANT BROWN THICK BLOODTINGED SECRETIONS. DR DID ASSESS PATIENTS BILAT PLEURAL EFFUSIONS WITH U/S TODAY. NOT ENOUGH TO PLACE A CT IN.\nCARDIAC- HR 60-80'S NSR WITH RARE PVC. HAD K 3.4 TX WITH 40MEQ KCL THIS AM. REPEAT K THIS AFTERNOON 4.0. WILL RECHECK LYTES AT 1800. MAP MAINTAINED AT 65 OR GREATER WITH VASOPRESSIN AT 2.4U/HR AND NOREPINEPHRINE AT .080-.146 MCGS/KG/MIN. HE IS PRESENTLY ON 0.146MCGS/KG/MIN AS HE DROPPED HIS BP AFTER BEING TURNED FOR DRESSING CHANGES THIS AFTERNOON. OUR GOAL WAS TO DIURESE HIM 1-2 L TODAY. HE IS ON DIURIL 500MG AND LASIX DRIP INCREASED FOR 10MG/HR TO 20MG/HR. AT NOON TIME HE WAS STILL 400 POS DISPITE THIS AND 80MG IV LASIX WAS GIVEN. DESPITE THIS HE IS STILL 400 POS WITH CVP 12 GAOL CVP IS 14. DR WAS MADE AWARE BUT NEEDED TO SEE ANOTHER PATIENT SO WILL BE BACK TO ASSESS THIS.\nGI- ABD DISTENDED WITH HYPOACTIVE BS. TF CHANGED TO VIVONEX AT 10CC/HR IT IS NOT TO BE ADVANCED. RESIUALS TO BE CHECKED Q 4 HOURS AND TO HOLD TF IF > 100CC. TF IS TO BE FLUSHED WITH 30CC H20 Q 4 HOURS. NO SOOL TODAY.\nGU- FOLEY PATENT DRAINING CLEAR YELLOW URINE AT 100CC/HR OR GREATER. STILL POS 400CC TODAY.\nRENAL- CONT TO BE FOLLOWED BY RENAL. CREAT STILL 1.9 DESPITE URINARY OUTPUT. RENAL FEELS IT WILL START TO COME DOWN.\nID- HYPOTHERMIC ALL DAY ON BAIR HUGGER. CONT ON CIPRO FOR ECOLI SEPSIS. CONT TO GET CIPRO EYE DROPS FOR KERATOSIS.\nHEME- HCT THIS AM 29 DOWN TO 26 AT NOON. GOAL IS TO TRANSFUSE FOR < 25. REPEAT DUE AT 1800. PLTS THIS AM 32 DOWN TO 20 AT NOON. RECIEVED ONE APHERESIS UNIT FOR THIS. NO SIGNS OR SYMPTOMS OF REACTION NOTED. INR 1.8 THIS AM TX WITH 2 U FFP WITHOUT SIGNS OR SYMPTOMS OF REACTION. REPEAT INR 1.7 AT NOON. GOAL I TO TX\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-23 00:00:00.000",
"description": "Report",
"row_id": 1565099,
"text": "NURSING PROGRESS NOTE\n(Continued)\nIF > 1.8.\nSKIN- PATIENT WITH MULT BLISTERS AND OOZING OF ARMS, THIGHS, LABIA, LEGS AND COCCYX. THIS NURSE ASKED TEAM TO CONSULT SKIN CARE NURSE. SKIN CARE NURSE SUGGESTED CONSULTING DERM WHICH WAS DONE. THEY REOMMENDED BACTROBAN TO OPEN BLISHER AREAS, NOTHING TO BLISTERED AREAS, AND KETOCONAZOLE 2% TP TO INTERTRIGO. THIS WAS DONE. SOFT SORB DRESSINGS WERE APPLIED.\nENDO- ON 1U/HR OF INSULIN BS HAVE RANGED 113-146. CONT ON HYDROCORTISONE AND FLUDROCORT.\nPROPHYLAXIS- ON PPI. VENODYNES OFF AS BLISHTERS ON LEGS THAT WOULD BE POPPED BY VENODYNES. DR AWARE. FEEL PATIENT IS OK AS SHE HAS ELEVATED INRS.\nSOCIAL - PATIENT'S CHILDREN IN AND UPDATED BY DR . ALSO UPDATED BY THIS NURSE.\nPLAN- DIC AND LYTES Q 6 HOURS. DR TO DETERMINE WAHT TO DO WITH PATIENT'S DIURESIS. CONT PRESENT LEVEL OF SEDATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-20 00:00:00.000",
"description": "Report",
"row_id": 1565082,
"text": "Micu Nursing Progress Notes\nEvents: Increasing pressor and insulin requirements, Lactate up to 11.7.\n\nCardiac: initially B/P 78-86/50's, Levophed increased to .3 mcg/kg/min and Neo incresed to 5 mcg/kg/min. B/P did not change until she received 500cc NS with 3amps bicarb then her B/P increased into the 100-110/60. HR 104-111 =>91-98. She was repleted wtih 3 gms bicarb. CVP 16-17.\n\nResp: Vent settings A/C 450 x 16, FiO2 100%, Peep 15. O2 sats 95-97%. Suctioned x1 for scant amount of clear secretions.\n\nGI: Remains NPO, aspiration bili colored secretions from OGT. Abd firm with absent bowel sounds. Mushroom catheter draining marroon colored liquid.\n\nEndo: insulin requirements increasing overnight. Insulin gtt started at for blood sugar 261. The insulin has been increased steadly for increasing blood sugar, high of 358. Insulin up to 10u/hr.\n\nGu: Foley drained a total of 5cc over 12h. She is currently 1300cc (+) since MN.\n\nNeuro: Received on fentanyl at 30 mcg/hr and Midazolam at 0.5mg/hr. She was uncomfortable with turning so the fentanyl was increased to 30mcg/hr. She responds to painful stimuli with withdrawal but little other responses.\n\nSocial: Sons and daughters in and out during the night so she was never alone. Family very realistic and cooperative, leaving when necessary. She remains a DNR but full treat.\n\nPlan: continue to monitor hemadynamics and adjust pressors as needed. Maintain her comfort, support the family, Frequent finger sticks to monitor blood sugar.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-20 00:00:00.000",
"description": "Report",
"row_id": 1565083,
"text": "Respiratory Care\nPt remains on full ventilatory support as noted in Carevue. Decrease Fi02 to 90% based on early ABG results and continious SA02 in the upper 90's. Bilateral breath sounds diminished throughout. Pt changed to more comfortable bed for long term use.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-20 00:00:00.000",
"description": "Report",
"row_id": 1565084,
"text": "NPN 7a-7p\n\n Pt. remains pressor dependent. Neosynephrine titrated off for about 30min and then turned on low dose. Given 2L NS for low u/o, pressor dependence and CVP <16. Family meeting with SW and updated by nursing and team.\n\nReview of Systems-\n\n Pt. received on Fentanyl and Versed low dose. Turned off for daily wake up and pt. has not required reinitiation of gtts thus far. Pt. was nodding appropriately this am and grimacing w/ potentially painful mouthcare. Will keep sedation off until pt. appears to be in pain, follows commands or is becoming compromised re: ventilatory status.\n\nResp- Recently titrated to 90% as sat's stable w/ PaO2, ABG pending. Lactate decreasing throughout the day. Metabolic acidosis compensated for w/ increasing RR to 24 from 16. Will cont w/ lung protective strategies despite pt. not meeting criteria for ARDS (does not have bilateral infiltrates on CXR). Vanco d/c'd, conts on meropenum for GNR sepsis. Mouthcare done q 4 hours and magic mouthwash applied for mucosytis. Minimal to no secretions when sx'd.\n\n PT. remains on levo, neo and vasopressin as well as steroids and abx. for overwhelming sepsis. Goal CVP 12-16, MAP 65. Following lactates and ionized Ca+ (repleted w/ 4g X 1) thus far. Afternoon elytes pending. Pt. appearing grossly fluid overloaded w/ compromised skin integrity (blistering noted throughout extremeties and perirectal area- double guard and anti-fungal ointment applied w/ aquaphor and soft sorb pads. Pt. placed on airmattress.\n\nGI- ABD firm and distended. U/S done and tap site marked d/t fluid seen on CT. However, team feels that there is not enough acites to tap at this time. TF remain off given overwhelming pressor dependence and critical state. Mushroom cathter d/c'd given its potential exacerbation of perianal breakdown and no stool output.\n\nEndo- Significant insulin resistance, just now starting to respond to insulin infusion. BS >200 most of shift.\n\nGU- U/o 20-30 cc/hr, marginal. Urine lytes sent this am. Would cont to bolus for low u/o. CREAT up from 0.6 on admission to 1.3.\n\nID- Afebrile. Conts on abx regimen as described for GNR w/ speciation at this time. Neutropenic precautions observed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-21 00:00:00.000",
"description": "Report",
"row_id": 1565085,
"text": "Respiratory Care Note:\n patient remains on ventilatory support. FIO2 adjusted according to ABG's. For specifics please see carevue. BS are clear, diminished at the bases. Patient remained afebrile. SX for a scant amount of yellow thick secretions. No RSBI this am due to peep level of 15. Plan is to continue support and wean FIO2 as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-21 00:00:00.000",
"description": "Report",
"row_id": 1565086,
"text": "NPN 1900-0700:\n\nEVENTS: Increased O2 needs; worsening neutropenia; no real progress in weaning pressors.\n\nROS:\nNEURO: Pt remains off all sedation. She rests comfortably when left alone, arouses to pain. Does not f/c; no eye contact. Minimal movement, no observed movement of LE's.\nRESP: Sats drifted down a bit overnight, to 93-94%. ABG this AM 7.45/24/62 on CMV .7/450/24/15; FiO2 increased to 90% with sats improving to 96-98%. No other vent changes made. Minimal thick yellow secretions. LS CTA upper, diminished lower.\nC-V: HR 70's-80's, NSR, no ectopy observed. BP somewhat labile, requiring small adjustments in Levo dose; Vasopressin remains at 2.4u/hr. CVP of 8 early in shift (along with decreased UO) improved to 13-15 after 1L NS bolus. Later given a second 1L NS bolus for decreased UO despite unchanged CVP. Ca and K repleted overnight with normal values this AM. Mg 1.9, Phos 1.8.\nGI: Belly firm, distended, with hypoactive BS. Small green stool X 1. Remains NPO except meds.\nGU: UO transiently improved after 1st fluid bolus, but no response to second one. BUN/creat up slightly to 22/1.4.\nID: Bair Hugger remains in use, though now on ambient setting for temp of 98. WBC down to 0.4 with ANC of 30. Lactate down to 3.4. Meropenum D/C'd and pt started on Cipro instead.\nHEME: Hct stable at 32.9; INR up to 3.6 (2.2); plt and FDP pending. No evidence of active bleeding.\nENDO: Insulin gtt weaned off d/t significantly lower sugars.\nSKIN: Pt has developed numerous fluid-filled blisters, primarily on thighs, but also scattered on lower legs, arms, buttocks, and perineum. These have increased in both number and size overnight. Those on her buttocks and perineum have started to open up, leaving open red areas which are draining large amounts serous fluid. Open areas covered with double ointment; padding in use to absorb drainage. Ecchymotic area on abdomen remains within marked borders. Mucusitis treated with KBL solution q4 hours.\nSOCIAL: Family members taking turns staying in room with patient. They appear to fully understand the situation and are mutually supportive of each other.\n\nA: little change in overall condition\n\nP: ensure pt comfort; continue all supportive measures; ongoing communication and support to family; possible CMO status soon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-21 00:00:00.000",
"description": "Report",
"row_id": 1565087,
"text": "Resp Care\nPt remains intubated on A/C. Decreased FIO2 from 90% to 60% due to improving ABG's. Family decided to keep PT on full support, but Pt still remains with DNR status. retaped and changed ETT position. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-21 00:00:00.000",
"description": "Report",
"row_id": 1565088,
"text": "NPN 7a-7p\nEvents: Pt has continued to be vasopressor dependent, requiring max doses of Vasopressin and Levophed and adding on Neo-titrating to maintain MAP>65. BP has been extremely labile. Pt is in ARDS and has tolerated fio2 to be decreased to 60% with ABG 7.37/28/77/17 sats 93-96%. WIll repeate ABG before further decreasing of fio2. Family met with this RN and and plan is to continue agrresive care until we run out of treatment options, pt is DNR.\n\nNEURO: Pt does not follow commands,although does grimace to pain. No spontaneous movement observed in extremities. Pt has been off of sedation gtts since Sunday, and is now ordered prn Fent/versed. Pt has not required either this shift. PERRL 3mm, sluggish.\n\nCV: Pt is in NSR with occas to frequent PVCs. BP labile as stated above, titrating vasopressors to effect. Pt is grossly edematous t/o, pulses audible via doppler. CVP 10-17, goal and has required 1L fluid bolus x3 to maintain CVP. Of note, Pts BP and O2 stat is best when pt is supine.\n\nRESP: Pt is vented on AC450/24/15 60%. ABG as stated above. Plan to wean fio2, team will tolerate paO2 in 60s. Proning of pt may be re-addressed this evening. Sats>93%. Rare SRR's. LS bronchial t/o with some insp/exp. wheezes in upper lobes at times. Suctioning scant thin yellow secretions via ETT. Orally pt has copious amounts of thick yellow/clear mucous-like secretions. Pt's oral cavity is impaired with ulcers t/o using magic mouthwash Q4H.\n\nGI: Abd is firm, distended. Hypoactive BS initially, although now absent. Team aware. NPO. ? whether or not to feed gut or to use TPN. Will address this evening. No BM this shift, although did pass small amount of green mucous.\n\nGU: U/O scant, amber and clear. Pt has not responded to total of 3L fluid boluses. BUN 22 Cr 1.4.\n\nHEME: INR 3.2, platelets 42, WBC 0.6. Pt is getting 2u FFP. No active signs of bleeding. Hct is stable @32.2\n\nID: Pt is now on Cipro for echoli in urine and blood. Pt has been hypothermic, tmax 96.9. Bear hugger on t/o shift.\n\nENDO: Insulin gtt has been off this shift. Last BS 166, waiting for new bag of insulin and will restart.\n\nSKIN: Pt has blisters on buttox, area, arms and legs. They are in multi stages of healing. Some in vesicle form, some weaping and some old where skin has pealed. These sites weaping large amounts of serous drainage. Doubleguard ointment applied to area and buttox and arms wrapped. Ecchymotic area on abd is marked and has not passed borders.\n\nSOCIAL: Pt has children very involved in care. All have been staying in hospital overnight, taking shifts so that pt is not alone. They are very cooperative with staff regarding coming and going as necessary.\n\nPLAN: Continue agressive care. Titrating pressors to maintain MAP>65. CVP goal . Wean fio2 as pt tolerates. Monitor ABGs. Monitor U/O as pt may need further fluid rescusitation. Q6H labs follow INR and platelet count, monitor for bleeding. Continue support to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-22 00:00:00.000",
"description": "Report",
"row_id": 1565089,
"text": "Respiratory Care Note:\n patient remains on ventilatory support with no changes made this shift. For specifics, please see carevue. tube retaped and secured. SX for a scant amount of white thick secretions. BS are diminished at the bases. No RSBI this am due to peep level of 15. Plan is to maintain support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-02-22 00:00:00.000",
"description": "Report",
"row_id": 1565090,
"text": "NPN 1900-0700:\n\nOverall pt cont's to deteriorate despite aggressive treatment.\n\nROS:\nNEURO: Pt appeared more uncomfortable at start of shift, evidenced by grimacing and BP spikes to any intervention (even touching her arm). Given Fent 50mcg X 2 and Versed 1mg X 2 with no improvement. Subsequently noted to have BP spikes for no apparent reason, which were assumed to be d/t pain/discomfort. Fentanyl and Versed gtts resumed; current rates are 75mcg/hr and 3mg/hr respectively with good effect. Able to provide nursing care without grimaces, and BP has been much more stable. No spontaneous movement noted; does not f/c, make eye contact, or attempt to communicate in any way. Family made it clear that she should be comfortable above all else.\nRESP: Remains on unchanged vent settings of CMV .6/450/24/15. ABG at start of shift 7.33/29/90; sats stable at 93-94% most of the night. Pt was turned side to side at 0400, during which her sat dropped to 86-88%; subsequently placed supine with HOB elevated, but sats only recovered to 90-91%. ABG at this time 7.35/26/61; HO aware, no vent changes at present. Of note, pt had also just recieved 1L fluid bolus, with increase in CVP from 16 to 21. LS CTA, very diminished at bases; minimal thick white secretions.\nC-V: HR 70's-80's, NSR, occ PAC's. BP spikes at start of shift attributed to pain/discomfort; with cont infusions of Fentanyl and Versed her BP stabilized out. Able to wean Neo to off, with Levo and Vasopressin remaining at previous rates. CVP 15-16 initially, increased to 21 after fluid bolus. Electrolytes repleted prn; overnight recieved 12 amps of CaGlu and 2 amps of MgSO4. AM labs as follows: Ion Ca 1.15; K 3.8;Mg 1.9; Phos 2.5. Will check with team regarding further repletion.\nGI: Belly firmly distended with hypoactive BS; no stool. She remains NPO and has not been fed since admission.\nGU: Poor UO with rising BUN/creat. No response to 1L NS bolus.\nID: Remains under Bair Hugger; Lactate stable at 3-4; WBC 0.3. No change in abx.\nHEME: Hct down to 27 at 2300; given 1U PRBC's with further drop in Hct to 25.3; plt ct 28 late afternoon; given 1U plt's with transient bump in count to 50, but subsequent drop to 30 this AM. INR 1.9 late afternoon; given 1U FFP with repeat INR of 1.8, for which she was given another 2U FFP; AM INR pending. Will check with team regarding further transfusions. No evidence of active bleeding, but is oozing from mouth sores and perirectal area.\nENDO: Significant increase in insulin needs; current rate 11U/hr.\nSKIN: Blistering of skin has increased in both size and number. Worst areas are thighs, but she has blisters on buttocks, lower legs, arms, and peri area as well. Some of the blisters have opened up, primarily on the labia and buttocks; these areas are draining large amounts serous fluid, as are her line sites. Open areas liberally convered with double ointment. She has been draining serosanguinous fluid from her nares, though this has decreased overnight. Oral ulcerat\n"
},
{
"category": "Echo",
"chartdate": "2197-02-18 00:00:00.000",
"description": "Report",
"row_id": 68400,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pulmonary embolus.\nHeight: (in) 63\nWeight (lb): 120\nBSA (m2): 1.56 m2\nBP (mm Hg): 88/65\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 11:51\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler. Dilated IVC (>2.5 cm), with minimal respiratory variation c/w\nelevated RA pressure of >20 mmHg.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.\nModerate-severe global left ventricular hypokinesis. No resting LVOT gradient.\nNo LV mass/thrombus. False LV tendon (normal variant). No VSD.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Mildly dilated RV cavity. RV\nfunction depressed.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nNormal ascending aorta diameter. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Normal mitral\nvalve supporting structures. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. Mild to moderate [+] 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 mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. There is moderate to severe global left\nventricular hypokinesis (ejection fraction 30 percent). No masses or thrombi\nare seen in the left ventricle. There is no ventricular septal defect. The\nright ventricular cavity is mildly dilated. Right ventricular systolic\nfunction appears depressed. The aortic valve leaflets (3) are mildly thickened\nbut aortic stenosis is not present. No 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: right and left ventricular contractile function is significantly\ndepressed\n\n\n"
},
{
"category": "ECG",
"chartdate": "2197-02-18 00:00:00.000",
"description": "Report",
"row_id": 147330,
"text": "Sinus rhythm\nRight bundle branch block\nNonspecific ST-T wave changes\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2197-02-17 00:00:00.000",
"description": "Report",
"row_id": 147331,
"text": "Sinus tachycardia\nRight bundle branch block\nInferior T wave changes are nonspecific\nSince previous tracing, no significant change\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-02-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 903059,
"text": " 4:00 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please eval for position.\n Admitting Diagnosis: HYPERGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 yof with fevers, sepsis, now s/p L IJ placement.\n REASON FOR THIS EXAMINATION:\n Please eval for position.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old female with fever and neutropenia. Assess left IJ\n placement.\n\n COMPARISONS: Comparison is made to radiograph performed on .\n\n TECHNIQUE: AP supine single view of the chest.\n\n FINDINGS: There is interval placement of a left IJ central line with tip in\n the lower SVC. There is no evidence of pneumothorax. There is again noted\n unchanged right subclavian Port-A-Cath with the tip in the right atrium. There\n is interval development of perihilar haziness likely representing mild fluid\n overload. Again noted is left retrocardiac opacity and associated small left\n pleural effusion which could represent pneumonia.\n\n IMPRESSION:\n 1. Interval placement of left IJ central line with tip in the lower SVC.\n There is no evidence of pneumothorax.\n 2. Mild fluid overload.\n 3. Left retrocardiac opacity could represent pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-02-20 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 903264,
"text": " 11:03 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: Please mark abdomen for paracentesis\n Admitting Diagnosis: HYPERGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with ascites\n REASON FOR THIS EXAMINATION:\n Please mark abdomen for paracentesis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 68-year-old woman with ascites.\n\n TECHNIQUE: Limited abdominal ultrasound to evaluate for ascites.\n\n FINDINGS: There is a small left-sided pleural effusion. Although there is a\n small amount of ascites on these images, which is visualized within all four\n quadrants, no safe site to mark for paracentesis is identified. The findings\n of this report were discussed with Dr. shortly after the study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-02-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 903062,
"text": " 6:40 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval for et tube position.\n Admitting Diagnosis: HYPERGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 yof with fevers, sepsis, has L IJ now s/p intubation.\n REASON FOR THIS EXAMINATION:\n Eval for et tube position.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old male with febrile neutropenia, status post intubation\n and NG tube placement.\n\n COMPARISONS: Comparison is made to study performed on the same day\n approximately two hours earlier.\n\n FINDINGS: There is interval placement of an ET tube with the tip in good\n position. There is also interval placement of a NG tube with the tip in the\n stomach. Note that the distal aspect of the tube is not visualized. There is\n interval apparent worsening of the fluid overload. There is persistent left\n retrocardiac consolidation and small left pleural effusion.\n\n IMPRESSION:\n 1. Lines and tubes in appropriate position.\n 2. Interval worsening of fluid overload.\n 3. Persistent left retrocardiac opacity could represent pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-02-19 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 903164,
"text": " 9:54 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? intra-abd bleed\n Admitting Diagnosis: HYPERGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with fall, coagulopathic\n REASON FOR THIS EXAMINATION:\n ? intra-abd bleed\n CONTRAINDICATIONS for IV CONTRAST:\n renal fxn\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old female status post fall. Evaluate for intra-\n abdominal bleed.\n\n COMPARISONS: CT abdomen and pelvis dated .\n\n TECHNIQUE: MDCT contiguous axial images from the lung bases through the pubic\n symphysis were obtained without oral or IV contrast.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are new bilateral large pleural\n effusions, right greater than left with associated bibasilar\n consolidation/atelectasis. Study of the abdomen and pelvis is limited due to\n the lack of IV and oral contrast. Allowing for this, there is diffuse fatty\n infiltration of the liver. There is no evidence of intrahepatic biliary\n ductal dilatation. Numerous surgical clips are identified within the right\n upper abdomen. There is no definate evidence of recurrent mass in the\n surgical bed or remaining pancreas. The spleen, adrenal glands, and kidneys\n are unchanged. There is no evidence of hydronephrosis or renal calculi within\n either kidney. There is diffuse intra-abdominal ascites. No pathologically\n enlarged mesenteric or retroperitoneal lymph nodes are identified. There is\n no evidence of intra-abdominal bleed. The abdominal aorta is of normal\n caliber. There is diffuse edema within the soft tissues.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: A Foley catheter is identified within a\n nondistended bladder. There is focal air within the fundus of the bladder,\n likely iatrogenic. There is significant fluid within the cul-de-sac. The\n uterus, adnexa, sigmoid colon, and rectum are stable in appearance. Sigmoid\n diverticula are again identified without evidence of diverticulitis. No\n pathologically enlarged retroperitoneal or pelvic lymph nodes are identified.\n\n BONE WINDOWS: No fractures are identified. There are no suspicious\n osteolytic or sclerotic lesions.\n\n IMPRESSION:\n 1. Fatty infiltration of the liver.\n 2. Significant intra-abdominal ascites.\n 3. No evidence of intra-abdominal bleed.\n 4. Bibasilar pleural effusions and adjacent atelectasis/consolidation.\n (Over)\n\n 9:54 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ? intra-abd bleed\n Admitting Diagnosis: HYPERGLYCEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-02-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 903436,
"text": " 10:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change.\n Admitting Diagnosis: HYPERGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 yof with fevers, sepsis.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW CHEST\n\n INDICATION: Fever and sepsis.\n\n COMPARISON: .\n\n FINDINGS: Endotracheal tube, nasogastric tube, implanted right venous access\n device and left jugular venous lines are all unchanged. Heart size and\n mediastinal contours are stable. The pulmonary vasculature is less prominent\n than before, but there are new bilateral pleural effusions.\n\n IMPRESSION: Bilateral pleural effusions likely related to fluid overload.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-02-19 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 903168,
"text": " 10:22 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: SWELLING BILAT LEGS BEDRIDDEN\n Admitting Diagnosis: HYPERGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with hypoTN\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 68-year-old woman with hypotension. Question deep vein\n thrombosis.\n\n COMPARISONS: No prior ultrasound.\n\n TECHNIQUE: Bilateral lower extremity venous ultrasound and Doppler\n examination were performed portably.\n\n FINDINGS: Grayscale and Doppler son of the bilateral common femoral,\n superficial femoral, and popliteal veins were performed. These show\n thickening along the walls of the common femoral veins bilaterally, which are\n mostly but not completely compressible. However, normal color and spectral\n Doppler waveforms are present among the bilateral common femoral, superficial\n femoral, and popliteal veins. Because of the presence of these findings,\n augmentation and compression studies were not performed.\n\n IMPRESSION: No evidence of deep vein thrombosis. Thickening along the walls\n of the bilateral common femoral veins. The appearance is consistent with\n residua of old prior resolved thrombosis with recannulation, not recent.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-02-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 903043,
"text": " 11:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: HYPERGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n neutropenic and septic\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON .\n\n The history is neutropenic and septic.\n\n REFERENCE EXAM: .\n\n Compared to the prior study, there has been no significant interval change in\n the subclavian line with tip in the right atrium. There is a small left\n pleural effusion with left lower lobe volume loss/consolidation that is\n increased compared to the prior study. The remainder of the lungs are clear.\n\n IMPRESSION: Increased left lower lobe consolidation/volume loss/effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-02-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 902956,
"text": " 9:45 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n Admitting Diagnosis: HYPERGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with pancytopenia chemotherapy s/p fall\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n HISTORY: Chemotherapy status post fall. Rule out hemorrhage.\n\n Contiguous axial images were obtained through the brain. No contrast was\n administered. Comparison to a brain CT of .\n\n FINDINGS: There have been no significant changes since the previous\n examination. There is no evidence of hemorrhage, edema, fracture, or\n infarction. A tiny calcified mass apparently arising from the inner table of\n the right vertex likely represents a 6-mm meningioma.\n\n CONCLUSION: No change since . No evidence of hemorrhage or fracture.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-02-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 903163,
"text": " 9:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ICH\n Admitting Diagnosis: HYPERGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with fall, coagulopathic\n REASON FOR THIS EXAMINATION:\n ? ICH\n CONTRAINDICATIONS for IV CONTRAST:\n renal fxn\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 68-year-old woman status post fall, with coagulopathy.\n\n Question intracranial hemorrhage.\n\n COMPARISONS: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of hemorrhage. The appearance of a small\n hyperdense lesion abutting the calvarium along the right frontal convexity is\n not significantly changed. This was felt previously to represent a\n meningioma. There is no mass effect, hydrocephalus, or shift of the normally\n midline structures. The -white matter differentiation is preserved. The\n osseous structures are unremarkable.\n\n IMPRESSION: No significant interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 903675,
"text": " 3:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval line repositioning\n Admitting Diagnosis: HYPERGLYCEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 yof with fevers, sepsis.\n\n REASON FOR THIS EXAMINATION:\n assess for interval line repositioning\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and sepsis.\n\n PORTABLE AP CHEST. ET tube and NG tube are unchanged in position. The left IJ\n catheter is not completely visualized and its tip appears to lie in the right\n IJ but may be present in the SVC and not clearly seen. There are bilateral\n layering pleural effusions. The cardiomediastinal silhouette is stable.\n\n IMPRESSION: Given for difference in technique there is no significant change\n compared to .\n\n"
}
] |
19,859 | 142,679 | Respirtory Distress - was likely from aspiration pneumonia. Non invasive measures were continued - antibiotics initially in ICU with nebs. In the ICU, a discussion was done with the health care proxy and the patient was made 'CMO" and was sent home with home hospice. Antibiotic was stopped. All catheters were remopved and the patient was made DNR/DNI. Palliative care team was involved in care ofthe patient and for arrangement of hospice care. Other medical prblems include - atrial fibrillation, peptic ulcer diease and hypertension with failure to thrive. the patient was non-verbal and has advanced Alzheimers dementia. Given the finding of dilated ventricles on CT head, neurology was consulted but given the patient's poor prognostic state they did not recommend any further evaluation for possible NPH. DPA: (cousin) : (home) | pedal pulses weakly palpable, no edema.Respi: in respiratory distress @ 2200, sats dropping low 80's; suctioned by nares thick yellowish secretions. EKG showed new Wenckebach vs Sinus pause. CV: 100-110's Afib with occasional PVC's, history of hypertension; SBP 130-140's, on hydralazine and lisinopril @ home. Rhonchi on bases, patient was given Albuterol x 1 dose. Comparedto the previous tracing atrial fibrillation is now present. CXR in ED suggest PNA and was given flagyl, ceftriaxone and Vanco. Caretaker in for visit early of shift.plan:monitor hemodynamic status, continue on non-rebreather, monitor for respiratory distress. urine output > 60cc/hrSkin: multiple ecchymosis lower extremeties. Sat's > 95% since 0100.GI/GU: NPO, bowel sounds present, abdomen soft and non-tender. History of sacral decubitus ulcer.ID: started on Levaquin and Flagyl, temp max - 99.6Social: DNR/DNI per health care proxy , patient's cousin. Compared to the previous tracing of atrialfibrillation has converted to probable atrial flutter. NPN 0700-1900:Please see Transfer Note and carevue for details:Pt is called out, waiting for a bed, he's non-verbal, opens eyes to voice, has noncomrehensible sounds, on non-rebreather, SPO2 94-100% even with turning, BP high started on Lopressor 2.5 mg IV Q 6 hrs with good effect, NPO, aspiration precautions, passed one BM, turned frequently, has a second stage decubitus ulcer at coccyx, aloe vesta applied, son called and caregiver visited and updated on , pt is /DNR and could be placed on CMO if not responding respiratory wise. pulmonary edema vs aspiration PNA. Repeat tracing isrecommended. Atrial fibrillation with a controlled ventricular response.The QTc interval is prolonged. normal bowel movement x 1. Received 2 mgs of Morphine @ 2315. appears comfortable thereafter.CV: hypertensive 170's, responding moderately with increased dose of Lopressor and new order of Hydralazine. CT of head - increased ventricles nuerology recommends no shunt or large volume tap this time. 1.3L negative for LOS.ID: continues on Flagyl and Levofloxacin, afebrile the whole shift.Skin: stage II at coccyx, turning every 2 hrs, barrier cream to buttocks.Social: HCP was by team during episode of respiratory distress. Probable atrial flutter with variable A-V block, but isdifficult to assess due to baseline artifact. SBP < 100 post 40 mgs of Lasix. switched to 95% high flow with 6 lpm of O2 via nasal cannula. Afib with frequent PVC's. CXR done ? Patient had temp spike of 102 prior to admission, @ ED temp 97.0. ST segment is difficule to assessdue to baseline artifact. access PIV Left forearm.Respi: sats >95% on nonrebreather 15 lpm, desatting < 80's during turning. 40 mgs of lasix given , diuresing well. morphine for comfort. tachypneic 24-40 at its highest with repositioning. Family wants patient to be comfortable.plan:continue antibiotic, lopressor for SBP > 120's HR > 95; transfer to floor once with available bed. monitor respiratory status. All extremities contracted, wiggles toes spontaneously.Patient appears uncomfortable, in respiratory distress, diaphoretic, mottling noted. Continue on Levaquin and flagyl. localizes pain, tremors noted intermitently. Eyes open when name is called, localizes pain. S/P CVA , patient noted by his 24hr caretaker to be less responsive and more fatigue past 2-3 days. no edema noted, pedal pulses weakly palpable. Diffuse non-specific ST-T wave changes. no bowel movement this shift, last bowel movement per caretaker was yesterday, normal consistency. Urine output 26-30cc/hr put out > 200 cc of urine post lasix. unable to assess well breath sounds, patient not cooperative with breathing deeply, mainly diminished. patient is 89 yo non verbal male with history of end stage dementia with worsening multiple sclerosis was brought by EMS after being unresponsive to caretaker. eyes open to speech inconsistently. most of the time very difficult to open eyes, pupils 2mm equal. patient was given 40 mgs of Lasix for increasing respiratory distress, put out 1.5 L.neuro: non verbal, contracted. Baseline non-verbal, utters incomprehensible words at times. Rpt CXR was clear. bowel sounds positive, soft and non-tender. patient has history of bilateral pneumonia.GI/GU: NPO due to increased risk for aspiration. Baseline artifact. Baseline artifact. No aggressive procedures/ treatment per HCP. No beta blockers per cardiology. no beta-blocker per cardiology consult. consistently chewing motion of mouth. Patient is called out to floor, waiting for a bed. Patient was on puree diet at home. | 6 | [
{
"category": "Nursing/other",
"chartdate": "2135-11-12 00:00:00.000",
"description": "Report",
"row_id": 1523510,
"text": "patient is 89 yo non verbal male with history of end stage dementia with worsening multiple sclerosis was brought by EMS after being unresponsive to caretaker. S/P CVA , patient noted by his 24hr caretaker to be less responsive and more fatigue past 2-3 days. Patient had temp spike of 102 prior to admission, @ ED temp 97.0. EKG showed new Wenckebach vs Sinus pause. No beta blockers per cardiology. CXR in ED suggest PNA and was given flagyl, ceftriaxone and Vanco. Rpt CXR was clear. CT of head - increased ventricles nuerology recommends no shunt or large volume tap this time. patient was given 40 mgs of Lasix for increasing respiratory distress, put out 1.5 L.\n\nneuro: non verbal, contracted. eyes open to speech inconsistently. most of the time very difficult to open eyes, pupils 2mm equal. localizes pain, tremors noted intermitently. appears comfortable, no signs of pain. consistently chewing motion of mouth.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-11-12 00:00:00.000",
"description": "Report",
"row_id": 1523511,
"text": "CV: 100-110's Afib with occasional PVC's, history of hypertension; SBP 130-140's, on hydralazine and lisinopril @ home. no edema noted, pedal pulses weakly palpable. access PIV Left forearm.\n\nRespi: sats >95% on nonrebreather 15 lpm, desatting < 80's during turning. tachypneic 24-40 at its highest with repositioning. unable to assess well breath sounds, patient not cooperative with breathing deeply, mainly diminished. patient has history of bilateral pneumonia.\n\nGI/GU: NPO due to increased risk for aspiration. Patient was on puree diet at home. bowel sounds positive, soft and non-tender. no bowel movement this shift, last bowel movement per caretaker was yesterday, normal consistency. 40 mgs of lasix given , diuresing well. urine output > 60cc/hr\n\nSkin: multiple ecchymosis lower extremeties. History of sacral decubitus ulcer.\n\nID: started on Levaquin and Flagyl, temp max - 99.6\n\nSocial: DNR/DNI per health care proxy , patient's cousin. Caretaker in for visit early of shift.\n\nplan:\n\nmonitor hemodynamic status, continue on non-rebreather, monitor for respiratory distress. no beta-blocker per cardiology consult. Continue on Levaquin and flagyl.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-11-12 00:00:00.000",
"description": "Report",
"row_id": 1523512,
"text": "NPN 0700-1900:\nPlease see Transfer Note and carevue for details:\n\nPt is called out, waiting for a bed, he's non-verbal, opens eyes to voice, has noncomrehensible sounds, on non-rebreather, SPO2 94-100% even with turning, BP high started on Lopressor 2.5 mg IV Q 6 hrs with good effect, NPO, aspiration precautions, passed one BM, turned frequently, has a second stage decubitus ulcer at coccyx, aloe vesta applied, son called and caregiver visited and updated on , pt is /DNR and could be placed on CMO if not responding respiratory wise.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-11-13 00:00:00.000",
"description": "Report",
"row_id": 1523513,
"text": "Patient is called out to floor, waiting for a bed. Baseline non-verbal, utters incomprehensible words at times. Eyes open when name is called, localizes pain. All extremities contracted, wiggles toes spontaneously.Patient appears uncomfortable, in respiratory distress, diaphoretic, mottling noted. Received 2 mgs of Morphine @ 2315. appears comfortable thereafter.\n\nCV: hypertensive 170's, responding moderately with increased dose of Lopressor and new order of Hydralazine. SBP < 100 post 40 mgs of Lasix. Afib with frequent PVC's. pedal pulses weakly palpable, no edema.\n\nRespi: in respiratory distress @ 2200, sats dropping low 80's; suctioned by nares thick yellowish secretions. switched to 95% high flow with 6 lpm of O2 via nasal cannula. Rhonchi on bases, patient was given Albuterol x 1 dose. CXR done ? pulmonary edema vs aspiration PNA. Sat's > 95% since 0100.\n\nGI/GU: NPO, bowel sounds present, abdomen soft and non-tender. normal bowel movement x 1. Urine output 26-30cc/hr put out > 200 cc of urine post lasix. 1.3L negative for LOS.\n\nID: continues on Flagyl and Levofloxacin, afebrile the whole shift.\n\nSkin: stage II at coccyx, turning every 2 hrs, barrier cream to buttocks.\n\nSocial: HCP was by team during episode of respiratory distress. No aggressive procedures/ treatment per HCP. Family wants patient to be comfortable.\n\nplan:\n\ncontinue antibiotic, lopressor for SBP > 120's HR > 95; transfer to floor once with available bed. morphine for comfort. monitor respiratory status.\n"
},
{
"category": "ECG",
"chartdate": "2135-11-11 00:00:00.000",
"description": "Report",
"row_id": 262863,
"text": "Baseline artifact. Probable atrial flutter with variable A-V block, but is\ndifficult to assess due to baseline artifact. ST segment is difficule to assess\ndue to baseline artifact. Compared to the previous tracing of atrial\nfibrillation has converted to probable atrial flutter. Repeat tracing is\nrecommended.\n\n"
},
{
"category": "ECG",
"chartdate": "2135-11-11 00:00:00.000",
"description": "Report",
"row_id": 263085,
"text": "Baseline artifact. Atrial fibrillation with a controlled ventricular response.\nThe QTc interval is prolonged. Diffuse non-specific ST-T wave changes. Compared\nto the previous tracing atrial fibrillation is now present.\n\n"
}
] |
7,445 | 183,334 | ?pneumoboots. cv- dopa grad. Left atrial enlargement. dopamine weaned off, still with occ. Mild (1+) mitral regurgitationis seen. Pneumoboots. -pleural effusion/ - CHF/ -pna. ekg done. with zofran 4mg iv x1 with some effect. ck neg. pulses 2+/1+ dp/pt. There is noaortic valve stenosis.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Compared to the previous tracingof sinus tachycardia has appeared and T waves remain inverted inleads I, aVL and V4-V6. Left anterior fascicular block. Hypotensive in cath to 70s. +BS. Start NPH in am since pt's appetite has returned. INR WNL. drop in bp which resolves spont. There has been arm lead reversal. L groin CDI. Remains of Dopa overnight. Theaortic root is mildly dilated. hr down to 90s from 130s sr/st with rare pvc with dopa wean. Initially c/o Nausea. k-4.2. Compared to the previoustracing sinus rhythm is no longer present.TRACING #3 Follow BS and RISS as indicated. Foley patent draining cyu q2-3hrs. hct 37, plts 244, creat .8. mg 1.4, 4amps mgso4 started iv. Left ventricular function. SC heparin started. cad, s/p stents to rcaccu npn- see fhpa alsoo- afebrile. Indeterminate regular supraventricular rhythm, possibly accelerated junctionalmechanism, with ventricular premature depolarizations. gi- follow, zofran prn. Hypotensions/p cath.History of right pneumonectomyHeight: (in) 69Weight (lb): 180BSA (m2): 1.98 m2BP (mm Hg): 98/54HR (bpm): 114Status: InpatientDate/Time: at 16:14Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Overall left ventricular systolic function is severelydepressed.RIGHT VENTRICLE: The right ventricular cavity is unusually small.AORTA: The aortic root is mildly dilated. Sheath removed 1600. ?start protonix. Left atrial abnormality.Left axis deviation. l/s sl. drops to 80s-70s but recheck is up to 90s. H/H and electolytes stable. hr improved off dopamine. The right atriumappears markedly compressed, apparently extrinsically by liver. Lbase interstitial infiltrate.ID: Afebrile. Palpable pulses 2+/1+ bilaterally. Abd soft. follow u/o. follow fs, ? denies cpain. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. echo done. The ascending aorta is mildly dilated. The ascending aorta is mildlydilated.AORTIC VALVE: The aortic valve leaflets are mildly thickened. No further c/o CP. Xray. D/t low pressure diuresed 300cc w/ 10mg IV Lasix. ? ? Maps 60s. Pt denies CP. Diffuse non-diagnosticrepolarization abnormalities. Theaortic valve leaflets are mildly thickened. Pressure tolerated gentle diuresis of 300cc. No further c/o N/V. transfer to floor. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: The tricuspid valve is not well visualized.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is normal in size. coarse l, dim/absent r. urine sl. Autonomic neuropathy secondary to DM/chemo.Access: 2 PIV's. HR 80-100. Remains off pressors. Coarse on left. The right ventricular cavityis unusually small and may be compressed (probably by liver). Occ-Frequent PVCs. Tolerated well. Gently diuresed 300cc urine w/ 10mg iv lasix. NBP very labile 84-106/42-69. Continue gentle diuresis as tolerated. WBC 13.3GI/GU: No further c/o N/V. Otherwise, without diagnostic interim change.Ventricular ectopy is no longer recorded. groin d+i, no hematoma with tegaderm dsg. Echo decrease LV , 20% inferior hypokinesis.Resp: Absent on right ( pneumonectomy ). r groin d+i with sheaths. ivf for 2l, monitor for pul edema, chf. RR 15-26. no bm. No BM. Overall left ventricular systolic functionis severely depressed with inferior hypokinesis/akinesis and septalhypokinesis/akinesis with hypokinesis elsewhere. Transferred here for cath today. on ivf n/s at 100cc/hr for 2000cc.resp- on 2l sat 97-98. no sob. Compared to the previous tracing multiple abnormalitiespersist without diagnostic change.TRACING #2 Remains on IVF 100cc/hr for 2L> currently on 2nd liter. No emesis. Resolved and pt tolerated pm snack. side to back with skin care with some relief. able to take tylenol with sips gingerale, only po so far.dm- bs up 240, covered with reg. bld tinged, u/o slowly drifting down, 5-6pm 26cc.gi- c/o nausea off/on, no vomiting, med. restart nph when eating. There is no aortic valve stenosis.The mitral valve leaflets are mildly thickened. Dopa gtt started and weaned by late this afternoon.Allergies: PCN, CEPHALAOSPORINS, PREVACHOL, ZESTRIL & FOSAMAX.S: "I am feeling better"O: Neuro: A&Ox3. O2 sats >96% on 2.0L. activity at home was limited d/t sxs of sob/weakness.a/p- s/p stents, rotoblation. insulin.ms- a+o x3, c/o back pain, repos. There is apressure gradient (peak gradient of about 16 mm) in the tricuspid inflowregion which is probably due to compression of the atrium and inflow area. Rested comfortably overnight.CV: SR/ST. Remains +360cc for 24hrs/ +1450 LOS.Endo: DM- NPH at home. Antecub good site for blood draw.Social: No visitors or calls this shift.A/P: Hemodynamically stable overnight. Compared to the previous tracing the heart rateis now faster with manifest left anterior fascicular block and non-diagnosticrepolarization abnormalities.TRACING #1 BS 250-329 requiring 4-8U insulin. weaned off by 5pm with bp 90s-111/, occ. Developed pulmonary edema, echo revealed EF of 15-20% and cath showed multivessel CAD. There is no pericardial effusion. Cooperative & pleasant. CCU Nursing Progress Note74 yo male w/ hx of lung CA s/p R pneumonecomy, DM, COPD and CAD admitted to NEB for UGI series r/t weakness, SOB & abd pain. tylenol given.lines- 2nd iv started in r antecub, #20.social- wife in this eve, supportive to pt. Pt has inhalers from home at bedside. O2 sats 89-92 on RA while sleeping. Tolerating po meds, pm snack and fluids without difficulty. Rotoblade and stent x2 placed to heavily calcified RCA prox 90% and midvessel 90% occluded. No ooze or hematoma. PATIENT/TEST INFORMATION:Indication: Coronary artery disease. Started on Protonix and Creon w/meals and at night. sheaths pulled at 4pm by sheath puller with act 147, tol well. | 7 | [
{
"category": "Nursing/other",
"chartdate": "2184-10-27 00:00:00.000",
"description": "Report",
"row_id": 1362200,
"text": "cad, s/p stents to rca\nccu npn- see fhpa also\no- afebrile. cv- dopa grad. weaned off by 5pm with bp 90s-111/, occ. drops to 80s-70s but recheck is up to 90s. hr down to 90s from 130s sr/st with rare pvc with dopa wean. k-4.2. hct 37, plts 244, creat .8. mg 1.4, 4amps mgso4 started iv. denies cpain. r groin d+i with sheaths. sheaths pulled at 4pm by sheath puller with act 147, tol well. groin d+i, no hematoma with tegaderm dsg. pulses 2+/1+ dp/pt. echo done. ekg done. ck neg. on ivf n/s at 100cc/hr for 2000cc.\nresp- on 2l sat 97-98. no sob. l/s sl. coarse l, dim/absent r. urine sl. bld tinged, u/o slowly drifting down, 5-6pm 26cc.\ngi- c/o nausea off/on, no vomiting, med. with zofran 4mg iv x1 with some effect. no bm. able to take tylenol with sips gingerale, only po so far.\ndm- bs up 240, covered with reg. insulin.\nms- a+o x3, c/o back pain, repos. side to back with skin care with some relief. tylenol given.\nlines- 2nd iv started in r antecub, #20.\nsocial- wife in this eve, supportive to pt. is retired, married with 5 children, 1 child and their fx live in separate apt in pt/wife's house. activity at home was limited d/t sxs of sob/weakness.\na/p- s/p stents, rotoblation. dopamine weaned off, still with occ. drop in bp which resolves spont. hr improved off dopamine. ivf for 2l, monitor for pul edema, chf. follow u/o. gi- follow, zofran prn. ?start protonix. follow fs, ? restart nph when eating. ?pneumoboots.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-10-28 00:00:00.000",
"description": "Report",
"row_id": 1362201,
"text": "CCU Nursing Progress Note\n74 yo male w/ hx of lung CA s/p R pneumonecomy, DM, COPD and CAD admitted to NEB for UGI series r/t weakness, SOB & abd pain. Developed pulmonary edema, echo revealed EF of 15-20% and cath showed multivessel CAD. Transferred here for cath today. Rotoblade and stent x2 placed to heavily calcified RCA prox 90% and midvessel 90% occluded. Hypotensive in cath to 70s. Dopa gtt started and weaned by late this afternoon.\n\nAllergies: PCN, CEPHALAOSPORINS, PREVACHOL, ZESTRIL & FOSAMAX.\n\nS: \"I am feeling better\"\n\nO: Neuro: A&Ox3. Cooperative & pleasant. Initially c/o Nausea. No emesis. Resolved and pt tolerated pm snack. No further c/o N/V. Rested comfortably overnight.\n\nCV: SR/ST. HR 80-100. Occ-Frequent PVCs. NBP very labile 84-106/42-69. Maps 60s. Remains of Dopa overnight. D/t low pressure diuresed 300cc w/ 10mg IV Lasix. Tolerated well. Remains on IVF 100cc/hr for 2L> currently on 2nd liter. Sheath removed 1600. L groin CDI. No ooze or hematoma. Palpable pulses 2+/1+ bilaterally. Pt denies CP. H/H and electolytes stable. INR WNL. SC heparin started. Echo decrease LV , 20% inferior hypokinesis.\n\nResp: Absent on right ( pneumonectomy ). Coarse on left. RR 15-26. O2 sats >96% on 2.0L. O2 sats 89-92 on RA while sleeping. Pt has inhalers from home at bedside. Xray. -pleural effusion/ - CHF/ -pna. Lbase interstitial infiltrate.\n\nID: Afebrile. WBC 13.3\n\nGI/GU: No further c/o N/V. Tolerating po meds, pm snack and fluids without difficulty. Abd soft. +BS. No BM. Started on Protonix and Creon w/meals and at night. Foley patent draining cyu q2-3hrs. Gently diuresed 300cc urine w/ 10mg iv lasix. Remains +360cc for 24hrs/ +1450 LOS.\n\nEndo: DM- NPH at home. BS 250-329 requiring 4-8U insulin. Autonomic neuropathy secondary to DM/chemo.\n\nAccess: 2 PIV's. Antecub good site for blood draw.\n\nSocial: No visitors or calls this shift.\n\nA/P: Hemodynamically stable overnight. No further c/o CP. Remains off pressors. Pressure tolerated gentle diuresis of 300cc. Continue gentle diuresis as tolerated. Start NPH in am since pt's appetite has returned. Follow BS and RISS as indicated. ? Pneumoboots. ? transfer to floor.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2184-10-27 00:00:00.000",
"description": "Report",
"row_id": 102679,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Hypotension\ns/p cath.History of right pneumonectomy\nHeight: (in) 69\nWeight (lb): 180\nBSA (m2): 1.98 m2\nBP (mm Hg): 98/54\nHR (bpm): 114\nStatus: Inpatient\nDate/Time: at 16:14\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: Overall left ventricular systolic function is severely\ndepressed.\n\nRIGHT VENTRICLE: The right ventricular cavity is unusually small.\n\nAORTA: The aortic root is mildly dilated. The ascending aorta is mildly\ndilated.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\naortic valve stenosis.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve is not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Overall left ventricular systolic function\nis severely depressed with inferior hypokinesis/akinesis and septal\nhypokinesis/akinesis with hypokinesis elsewhere. The right ventricular cavity\nis unusually small and may be compressed (probably by liver). The right atrium\nappears markedly compressed, apparently extrinsically by liver. There is a\npressure gradient (peak gradient of about 16 mm) in the tricuspid inflow\nregion which is probably due to compression of the atrium and inflow area. The\naortic root is mildly dilated. The ascending aorta is mildly dilated. The\naortic valve leaflets are mildly thickened. There is no aortic valve stenosis.\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\nis seen. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2184-10-30 00:00:00.000",
"description": "Report",
"row_id": 292780,
"text": "Sinus tachycardia. Left atrial enlargement. Compared to the previous tracing\nof sinus tachycardia has appeared and T waves remain inverted in\nleads I, aVL and V4-V6. Otherwise, without diagnostic interim change.\nVentricular ectopy is no longer recorded.\n\n"
},
{
"category": "ECG",
"chartdate": "2184-10-29 00:00:00.000",
"description": "Report",
"row_id": 292781,
"text": "Indeterminate regular supraventricular rhythm, possibly accelerated junctional\nmechanism, with ventricular premature depolarizations. Compared to the previous\ntracing sinus rhythm is no longer present.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2184-10-27 00:00:00.000",
"description": "Report",
"row_id": 292782,
"text": "Sinus tachycardia. Compared to the previous tracing multiple abnormalities\npersist without diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2184-10-27 00:00:00.000",
"description": "Report",
"row_id": 293002,
"text": "There has been arm lead reversal. Sinus tachycardia. Left atrial abnormality.\nLeft axis deviation. Left anterior fascicular block. Diffuse non-diagnostic\nrepolarization abnormalities. Compared to the previous tracing the heart rate\nis now faster with manifest left anterior fascicular block and non-diagnostic\nrepolarization abnormalities.\nTRACING #1\n\n"
}
] |
|
93,381 | 119,547 | 54-year-old male with history of COPD, PE on warfarin, schizophrenia, hypothyroidism, obstructive sleep apnea who was an OSH transfer for respiratory failure caused by COPD exacerbation and obstructive sleep apnea. | trace bilateral pleural effusions. Trace bilateral pleural effusions. A band of atelectasis in the right mid lung is probably unchanged. Possible inferior myocardial infarction. Marginal criteria for old inferior myocardialinfarction. Endotracheal tube ends in the mid trachea. IMPRESSION: AP chest compared to : Nasogastric tube passes into the stomach and out of view. Subsegmental bilateral atelectasis. The endotracheal tube ends in the mid trachea. bilateral subsegmental atelectasis. Possible tracheobronchomalacia. IMPRESSION: Endotracheal tube ends 2.4 cm above the carina. Nasogastric tube ends in the stomach. Nasogastric tube ends in the stomach. Sinus tachycardia. A small amount of air in the left brachiocephalic vein is likely related to injection. Possible inferolateral myocardial infarction,age undetermined, possibly acute. Left upper lobe posterior segmental atelectasis seen on the chest CT , is probably still present. The esophagus slightly deviates to the right. A nasogastric tube ends in the stomach. Evaluate endotracheal tube placement. The endotracheal tube ends 2.4 cm above the carina. CT scan showed atelectasis. Non-diagnostic inferior and lateral Q waveswith mild ST segment elevation. Sinus or ectopic atrial rhythm. FINDINGS: A frontal supine view of the chest was obtained portably. (Over) 2:43 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: Evaluate PE, dissection Contrast: OMNIPAQUE Amt: FINAL REPORT (Cont) Mild sclerosis at superior sternal body may be sequelae of old trauma. Clinical correlation issuggested.TRACING #1 The lower trachea is collapsed onto the endotracheal tube, suggesting possible tracheobronchomalacia. Poor R wave progression in leads V1-V4 of unclear significance,may be normal variant. ST segment elevations in theinferior and lateral leads are now less prominent. There is mediastinal lipomatosis as well as prominent pericardial and epipericaridal fat. Subsegmental linear atelectasis is seen in the superior segment of the left upper lobe as well as at the lung bases bilaterally. Respiratory failure. Clinical correlation issuggested.TRACING #2 COMPARISON: CT Chest performed after the radiograph. COMPARISON: Chest radiograph . Sinus rhythm. The heart, pericardium and great vessels are within normal limits. The nasogastric tube within the esophagus is displaced to the right, ending in the stomach, with the side port at the gastroesophageal junction. Nasogastric tube side port is at the gastroesophageal junction and could be advanced. Clinicalcorrelation and repeat tracing are suggested. Bibasilar opacities are atelectasis on subsequent chest CT. Widening of the mediastinum is due to mediastinal lipomatosis on subsequent CT. ET tube and nasogastric tube are in standard placements. Of note, the CTA showed likely a substantial tracheobronchomalacia, although this study was not designed for that determination. CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: The thoracic aorta is normal in caliber without acute intramural hematoma or dissection. Pulmonary arterial vasculature is visualized to the subsegmental level without filling defect to suggest pulmonary embolism. Since the previous tracing of therate is slower. Evaluate for pulmonary embolism or dissection. Bibasilar atelectasis. The patient's true identity is not known at the time of dictation. However, compared to the tracingof ST-T wave abnormalities are new. 4:22 AM CHEST (PORTABLE AP) Clip # Reason: compare to prior, atelectesis?, infiltrate? The patient's true identity is not known at the time of reporting. IMPRESSION: 1. 2:43 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: Evaluate PE, dissection Contrast: OMNIPAQUE Amt: MEDICAL CONDITION: History: 54M with SOB REASON FOR THIS EXAMINATION: Evaluate PE, dissection No contraindications for IV contrast WET READ: MDAg SUN 4:04 AM no acute aortic pathology or pulmonary embolism. This could be further investigated with CT Trachea if clinically indicated when the patient's clinical status improves. No appreciable pleural abnormality. TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed before and after administration of 100 mL Omnipaque intravenous contrast. No pathologically enlarged axillary, mediastinal or hilar lymph nodes are identified, ranging up to 9 mm in the prevascular space. Lung window images demonstrate no worrisome nodule or mass. Otherwise, unchanged. No acute aortic pathology or pulmonary embolism. The visualized portions of the liver, stomach and spleen are normal. There is no pericardial effusion. The study is not tailored for subdiaphragmatic evaluation. No pneumonia. 3. Admitting Diagnosis: RESPIRATORY FAILURE MEDICAL CONDITION: 54 year old man with COPD, schizophrenia, p/w resp failure requiring intubation, CT scan showed atelectesis, plan to wean off vent for possible extubation REASON FOR THIS EXAMINATION: compare to prior, atelectesis?, infiltrate? Multiplanar reformation images are submitted for review. There is no effusion or large pneumothorax. 2. No previous tracing available for comparison. Heart is mildly enlarged, a mediastinum that is greatly widened due to fat deposition. There is no pneumonia. FINAL REPORT AP CHEST, 5:14 A.M. HISTORY: COPD and schizophrenia. Since theprevious tracing of the rate is faster. BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen. 2:43 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate ETT placement MEDICAL CONDITION: History: 54M with SOB, intubated at OSH REASON FOR THIS EXAMINATION: Evaluate ETT placement FINAL REPORT CLINICAL HISTORY: 54-year-old male with dyspnea and intubated at outside hospital. | 6 | [
{
"category": "Radiology",
"chartdate": "2118-08-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1245605,
"text": " 4:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: compare to prior, atelectesis?, infiltrate?\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with COPD, schizophrenia, p/w resp failure requiring\n intubation, CT scan showed atelectesis, plan to wean off vent for possible\n extubation \n REASON FOR THIS EXAMINATION:\n compare to prior, atelectesis?, infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:14 A.M. \n\n HISTORY: COPD and schizophrenia. Respiratory failure. CT scan showed\n atelectasis.\n\n IMPRESSION: AP chest compared to :\n\n Nasogastric tube passes into the stomach and out of view. Left upper lobe\n posterior segmental atelectasis seen on the chest CT , is probably still\n present. A band of atelectasis in the right mid lung is probably unchanged.\n Heart is mildly enlarged, a mediastinum that is greatly widened due to fat\n deposition. Of note, the CTA showed likely a substantial\n tracheobronchomalacia, although this study was not designed for that\n determination.\n\n ET tube and nasogastric tube are in standard placements. No appreciable\n pleural abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-08-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1245511,
"text": " 2:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 54M with SOB, intubated at OSH\n REASON FOR THIS EXAMINATION:\n Evaluate ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 54-year-old male with dyspnea and intubated at outside\n hospital. Evaluate endotracheal tube placement.\n\n COMPARISON: CT Chest performed after the radiograph. The patient's\n true identity is not known at the time of dictation.\n\n FINDINGS: A frontal supine view of the chest was obtained portably. The\n endotracheal tube ends 2.4 cm above the carina. Bibasilar opacities are\n atelectasis on subsequent chest CT. Widening of the mediastinum is due to\n mediastinal lipomatosis on subsequent CT. The nasogastric tube within the\n esophagus is displaced to the right, ending in the stomach, with the side port\n at the gastroesophageal junction. There is no effusion or large pneumothorax.\n\n IMPRESSION: Endotracheal tube ends 2.4 cm above the carina. Nasogastric tube\n side port is at the gastroesophageal junction and could be advanced. Bibasilar\n atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-08-14 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1245512,
"text": " 2:43 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Evaluate PE, dissection\n Contrast: OMNIPAQUE Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 54M with SOB\n REASON FOR THIS EXAMINATION:\n Evaluate PE, dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MDAg SUN 4:04 AM\n no acute aortic pathology or pulmonary embolism. bilateral subsegmental\n atelectasis. trace bilateral pleural effusions.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 54-year-old man with dyspnea. Evaluate for pulmonary\n embolism or dissection.\n\n COMPARISON: Chest radiograph . The patient's true identity is not\n known at the time of reporting.\n\n TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed\n before and after administration of 100 mL Omnipaque intravenous contrast.\n Multiplanar reformation images are submitted for review.\n\n CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: The thoracic aorta is normal\n in caliber without acute intramural hematoma or dissection. Pulmonary\n arterial vasculature is visualized to the subsegmental level without filling\n defect to suggest pulmonary embolism. No pathologically enlarged axillary,\n mediastinal or hilar lymph nodes are identified, ranging up to 9 mm in the\n prevascular space. The heart, pericardium and great vessels are within normal\n limits. A small amount of air in the left brachiocephalic vein is likely\n related to injection. There is no pericardial effusion. There is mediastinal\n lipomatosis as well as prominent pericardial and epipericaridal fat. Trace\n bilateral pleural effusions. The esophagus slightly deviates to the right.\n\n Lung window images demonstrate no worrisome nodule or mass. Subsegmental\n linear atelectasis is seen in the superior segment of the left upper lobe as\n well as at the lung bases bilaterally. There is no pneumonia. The\n endotracheal tube ends in the mid trachea. A nasogastric tube ends in the\n stomach.\n\n The lower trachea is collapsed onto the endotracheal tube, suggesting possible\n tracheobronchomalacia.\n\n The study is not tailored for subdiaphragmatic evaluation. The visualized\n portions of the liver, stomach and spleen are normal. Nasogastric tube ends in\n the stomach.\n\n BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.\n (Over)\n\n 2:43 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Evaluate PE, dissection\n Contrast: OMNIPAQUE Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Mild sclerosis at superior sternal body may be sequelae of old trauma.\n\n IMPRESSION:\n 1. No acute aortic pathology or pulmonary embolism. Subsegmental bilateral\n atelectasis. No pneumonia.\n 2. Endotracheal tube ends in the mid trachea. Nasogastric tube ends in the\n stomach.\n 3. Possible tracheobronchomalacia. This could be further investigated with CT\n Trachea if clinically indicated when the patient's clinical status improves.\n\n"
},
{
"category": "ECG",
"chartdate": "2118-08-14 00:00:00.000",
"description": "Report",
"row_id": 250476,
"text": "Sinus rhythm. Poor R wave progression in leads V1-V4 of unclear significance,\nmay be normal variant. Marginal criteria for old inferior myocardial\ninfarction. No previous tracing available for comparison. Clinical\ncorrelation and repeat tracing are suggested.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2118-08-15 00:00:00.000",
"description": "Report",
"row_id": 250474,
"text": "Sinus tachycardia. Possible inferior myocardial infarction. Since the\nprevious tracing of the rate is faster. ST segment elevations in the\ninferior and lateral leads are now less prominent. Clinical correlation is\nsuggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2118-08-14 00:00:00.000",
"description": "Report",
"row_id": 250475,
"text": "Sinus or ectopic atrial rhythm. Non-diagnostic inferior and lateral Q waves\nwith mild ST segment elevation. Possible inferolateral myocardial infarction,\nage undetermined, possibly acute. Since the previous tracing of the\nrate is slower. Otherwise, unchanged. However, compared to the tracing\nof ST-T wave abnormalities are new. Clinical correlation is\nsuggested.\nTRACING #1\n\n"
}
] |
31,779 | 182,198 | Bilateral lower lobe consolidation with inspissated barium is identified consistent with recent aspiration. Recieving mucomyst nebs/albuterol as ordered. There is proximal dilatation of the neoesophagus with persistent barium still identified within the distal neoesophagus. RESP CARE NOTE2130 ALBUTEROL/MUCOMYST NEB GIVEN AS ORDERED. GI: Abd softly distended, pos bs, NGT to LCS, bilious drainage noted. Palp pedal pulses, +1 pedal edema noted. Fair effect noted s/p neb treatments. Bilateral consolidations at lung bases with inspissated barium consistent with aspiration. IV RN called to place a peripheral IV d/t incompatiblity of dilauded and amiodarone. Resp CarePt had bedside bronch, stent in good position. Was weaned per protocol and extubated. Lytes repleted prn. Coronal and sagittal reformats were performed. With sedation off pt follows commands consistantly, nods to yes/no questions and attempts to write. Peribronchial subtle left basal opacities have newly occurred. Pt had prod cough thick/white. Scattered mediastinal lymph nodes are identified. COMPARISON: , 8:47 a.m. As compared to the previous radiograph, there are now stents placed in the left and right main bronchus. Left subclavian catheter tip is in the superior SVC. Moments of tachypnea to the mid 40's with decreased o2 sats, resolves with suctioning and prn ativan/dilaudid as it appears to coincide with anxiety/pain. of new esophageal obstruction. Pt used his dilauded pca (.37 6 3.7) x 1. IMPRESSION: (Over) 1:51 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: evaluate patency of GI tract (pt had barium swallow at OSH e Admitting Diagnosis: ESOPHAGEAL OBSTRUCTION Field of view: 36 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) 1. ALBUTEROL/ ATROVENTMDI'S GIVEN. soft,+bs, ngt to lis draining mod. cpt/alb./atrovent/mucomsyt given as ordered. Receiving albuterol, mucomyst, and atrovent NEB's ATC. NGT to LCS, bilious drainage noted. GI: Abd softly distended, pos bs. cxr done this am.ngt draining mod amt bilious. LS clear bilat, diminished r base. cvp 3.pt slightly sedated on ppf gtt. Suctioned for sml amts thick bld tinged secretions.MDI'S given. CXR DONE. Dilaudid 1mg IVP Q2-3hrs with pos effect. Resp Care Note, Pt remains on current vent settings. Resp Care Note, Pt remains on current vent settings. PEEP and FiO2 gradually weaned this shift. started on lopressor 2.5mg iv q4hrs tolerating well.resp rate 25-32 w/ o2sats 93-95 on np 4lrs. EXTREMITES WARM WITH PALPABLE PULSES.RESP: BRONCHOSCOPY DONE THIS AM BY DR AND STINTS REPOSITIONED. temp 101-100 b/p stable aline dampens at times. EXTREMITES WARM, BPPPGI: ABD SOFTLY DISTENDED WITH HYPOACTIVE BS. CONDITION UPDATED: PLEASE SEE CAREVUE FOR SPECIFICSNEURO: SEDATED ON PROPOFOL, ABLE TO FOLLOW COMMANDS DURING "WAKE UP", MEDICATED WITH DILAUDID FOR GENERALIZED DISCOMFORTRESP: BS CLEAR. See vent flow sheet for deatils. WILL C/W PS 8 AS TOLERATED. CHANGED TO PS AS PER CV. Suctioned for mod amts thick bile looking secretions.MDI'S given.Temp 99.1.Sedated with propofol. NGT to LWCS with bilious drainage. Condition UpdateAssessment:Please see carevue for details Neuro: Pt remains sedated on propofol, opens eyes to pain and occationally voice. NGT PATENT AND DRAINING BILIOUS. RESPIRATORY CARE: PT REMAINS W/ AN 8.5 ORAL ETT IN PLACE AND ON PS AND FIO2 .50. cs-course thru-out. MDIs given per order. RESPIRATORY CARE: PT REMAINS INTUBATED W/ AN 8.5 ORAL ETT IN PLACE. temp max 98.8 hr 106-87 nsr w/o ect. BS generally CTAB though at least once incident of wheezing. KUB obtained, NGT ? Lung soudns clear. amt thick tan/yellow sputum after treatments. BS occ coarse clear after Sx.Plan: Possiblity of extubation later today, ? PROPOFOL FOR SEDATION. Will cont to monitor resp status. Will cont to monitor resp status. Trace edema noted. GI: Abd softly distended, pos bs, NGT to LCS, bilious drainage. Given Dilaudid/Ativan prn with effect.NSR. Tx'ing well with dilaudid. The pt's VS then stabilized. PEEP and O2 were weaned t/o the noc (see flowsheet for details). BRONCHOSCOPY THIS AM REVEALED THAT STENT HAD MIGRATED. Started on Vanco.LS clear to coarse. TO HAVE BRONCH IN AM.SEDATED ON PPF, FOLLOWING COMMANDS. MONITOR PAIN/COMFORT; PRN DILUADID & ATIVAN. cxr done thisam. NSR, distal pulses strongly palpable, SBP 95-110s, but becomes hypertensive when sedation lightened. An emergent chest xray and bronchoscopy was performed and the stent placement, which was noted to be slightly incorrect, was fixed. RT BAGGING PT. Condition UpdateAssessment:Please see carevue for details Neuro: Pt remains sedated on propofol, follows commands and attempts to write when sedation is off. FROM OR AFTER RECIEVING Y-STENT PLACEMENT AFTER CONFIRMATIN ON FLOOR OF TE FISTULA FROM EGD. Resp: LS clear to coarse bilat throughout. ngt on lis mod. ABG this AM shows a mild metabolic alkalosis with hyperoxygenation.Plan is to wean as tolerated. c/o pain-pointing to sternum and throath-medicated w/ dilaudid w/ good relief.abd. NSR, SBP 90-110s, with exception of hypertension s/p OR. Pt grimaces with turning/suctioning. Titrate sedation for comfort. Cuff leak noted and acceptable. WILL WEAN FIO2 AS TOLERATED BY SPO2 AND CHANGE BACK TO PS WHEN MORE AWAKE. ID: Tmax 101.7, pan cultured, abx continues as tol.Plan: monitor hemodynamics, monitor labs, pain management, pulm toileting, follow up with cultures, privide pt and family with emotional support. Updated by Drs. Continue to have airleak to esophagus, audible w/ inspiration over abdomen. Becomes tachypnic and dips sat at times with appears to coincide with pain/agitation, resolves when medicated. PULM TOILET, WEAN VENT AS TOL. Compared to tracing #1 atrial fibrillation has now converted tosinus rhythm.TRACING #2 RESPIRATORY CARE:Pt remains orally intubated, vent supported on PSV/CPAP. Sinus rhythm. ETT retaped and rotated. K+ and Ca++ repleted. Medicated with Ativan and dilauidid prn pain/anxiety with pos effect. Frequent oral care provided. | 46 | [
{
"category": "Radiology",
"chartdate": "2103-06-22 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1016509,
"text": " 4:23 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess lung fields, ett location\n Admitting Diagnosis: ESOPHAGEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with TEF, hypoxic\n REASON FOR THIS EXAMINATION:\n assess lung fields, ett location\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: , 8:47 a.m.\n\n As compared to the previous radiograph, there are now stents placed in the\n left and right main bronchus. Clips are seen in the left paracervical soft\n tissues. Newly placed endotracheal tube has its tip 5 cm above the carina.\n There is bilateral air collection in the cervical soft tissues. The lung\n parenchyma shows unchanged relatively opacities in the basal-medial\n aspect of the right lung. Peribronchial subtle left basal opacities have\n newly occurred. The partly calcified changes at the right upper lobe bases\n are unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-06-23 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1016588,
"text": " 12:00 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NGT manipulated, reverify position\n Admitting Diagnosis: ESOPHAGEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with TEF\n REASON FOR THIS EXAMINATION:\n NGT manipulated, reverify position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON \n\n HISTORY: Tracheoesophageal fistula, NG tube manipulated, re-verify position.\n\n FINDINGS: The NG tube tip is at the esophagogastric junction, too high and\n should be advanced. This finding was called to the house staff at the time of\n dictating the report. Stents in the right and left mainstem bronchi are again\n visualized. Left subclavian line tip in the SVC is unchanged. The\n endotracheal tube tip is 5 cm above the carina is unchanged. There is\n increased opacity in the left lower lung consistent with increased infiltrate\n in that region. Other opacities in the lung are not changed.\n\n IMPRESSION:\n 1. NG tube located too high, this finding was called to Dr. at the time\n of dictating this report.\n 2. Increased left lower lobe infiltrate.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-06-20 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1016119,
"text": " 1:51 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: evaluate patency of GI tract (pt had barium swallow at OSH e\n Admitting Diagnosis: ESOPHAGEAL OBSTRUCTION\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man 12 yr s/p esophagectomy. Now with ? of new esophageal\n obstruction. RLL Pneumonia\n REASON FOR THIS EXAMINATION:\n evaluate patency of GI tract (pt had barium swallow at OSH earlier today and is\n comiting contrast, no additional oral contrast needed), please use IV contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO.\n\n TECHNIQUE: MDCT axially acquired images of the chest, abdomen and pelvis were\n obtained. IV contrast was administered. Coronal and sagittal reformats were\n performed.\n\n FINDINGS:\n\n CT OF THE CHEST: Patient is status post esophagectomy and gastric pull-up.\n There is proximal dilatation of the neoesophagus with persistent barium still\n identified within the distal neoesophagus. There appears to be a short-\n segment area of narrowing (2, 23) near the level of the carina. Scattered\n mediastinal lymph nodes are identified. The largest lymph node measures\n approximately 1 cm in short axis (2, 22) in the precarinal region. A 1-cm\n right hilar lymph node is also identified. Bilateral lower lobe consolidation\n with inspissated barium is identified consistent with recent aspiration.\n Multiple other areas of ground- glass opacities within the upper lobes as well\n as tree in opacities are identified and likely represent sequelae of\n chronic aspiration/infection. There is no pericardial effusion. Heart and\n great vessels are unremarkable.\n\n CT OF THE ABDOMEN: The gallbladder contains a layer of sludge or stones.\n There is no pericholecystic fluid or gallbladder wall thickening. The liver\n demonstrates focal areas of fatty infiltration (2, 55) near the ligamentum\n teres. The spleen, pancreas, and adrenal glands are unremarkable. Bilateral\n parapelvic cysts are identified. The small bowel loops are mostly collapsed,\n however do contain some barium within them. There is no evidence of leak or\n abnormal fluid collection. There are no mesenteric or retroperitoneal\n pathologically enlarged lymph nodes.\n\n CT OF THE PELVIS: There is diverticulosis of the sigmoid colon without\n evidence of acute diverticulitis. The bladder and prostate are unremarkable.\n There is no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\n\n IMPRESSION:\n (Over)\n\n 1:51 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: evaluate patency of GI tract (pt had barium swallow at OSH e\n Admitting Diagnosis: ESOPHAGEAL OBSTRUCTION\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. Bilateral consolidations at lung bases with inspissated barium consistent\n with aspiration. Persistant barium within neoesophagus places patient at\n continued risk of aspiration.\n\n 2. Proximal neoesophagus is dilated with focal area of narrowing within the\n mid-esophagus near the level of the carina. Barium is seen distal to this and\n within small bowel loops.\n\n These findings were discussed by Dr. with Dr. at the time\n of initial review.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-06-20 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1016250,
"text": " 5:19 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p tracheal Y stent\n Admitting Diagnosis: ESOPHAGEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with\n REASON FOR THIS EXAMINATION:\n s/p tracheal Y stent\n ______________________________________________________________________________\n WET READ: JXKc WED 8:22 PM\n Bilateral consolidations in lower lobes, right more severe than left, likely\n due to aspiration and/or pneumonia. The right basilar consolidation appears\n slightly worse compared to prior study. High density airspace opacities in\n the right mid lung c/w aspirated barium as seen on CT torso . -jkang\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: S/P tracheal Y-stent.\n\n Comparison is made with prior studies from the same earlier in the morning,\n chest x-ray and CT.\n\n ET tube tip is 5.9 cm above the carina. Left subclavian catheter tip is in\n the superior SVC. There is no pneumothorax. High density opacities in the\n right mid lung are consistent with aspirated barium as seen on CT torso.\n Atelectasis of the basal segments of the lower lobes bilaterally are worse on\n the right side and have worsened from prior studies. There are no sizeable\n pleural effusions. NG tube tip is out of view below the diaphragm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-07-06 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1018565,
"text": " 7:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: cough\n Admitting Diagnosis: ESOPHAGEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with TE fistula\n REASON FOR THIS EXAMINATION:\n cough\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 19:53\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Cough.\n\n Allowing for lower lung volumes on the current study, alveolar opacification\n in the right mid and lower lung appears similar, superimposed upon aspirated\n barium, and likely representing acute pulmonary aspiration event. Subtle left\n perihilar opacity may be due to a similar process. Bibasilar areas of\n retrocardiac atelectasis are present as well as a persistent small right\n pleural effusion. Focal air collection at left cervicothoracic junction\n represents the patient's neoesophagus on prior CT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-26 00:00:00.000",
"description": "Report",
"row_id": 1666496,
"text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt remains sedated on prop, opens eyes to pain and occationally voice through sedation, grimaces with pain. With sedation off pt follows commands consistantly, nods to yes/no questions and attempts to write. Dilaudid prn pain with pos effect. Anxious at times, mostly following repositioning and coughing spells, ativan prn with pos effect.\n\n Resp: Pt wenaed to CPAP FiO2 50%, ABG wnl, maintaining O2 sat 95-98%. Suctioned prn for small to mod amounts of thick blood tinged sputum. Moments of tachypnea to the mid 40's with decreased o2 sats, resolves with suctioning and prn ativan/dilaudid as it appears to coincide with anxiety/pain. LS clear to coarse bilat throughout.\n\n CV: Remains NSR, no ectopy noted, HR 70-90's, SBP 90-130's. Lytes repleted prn. Palp pedal pulses, +1 pedal edema noted. Fluid balance approx even at MN, Currently neg 700cc since MN.\n\n GI: Abd softly distended, pos bs, NGT to LCS, bilious drainage noted. No BM, pos flatus.\n\n GU: Adequate amounts of clear yellow urine via foley cath.\n\n ID: Tmax 101.4, vanco, levo, fluconazole continue, WBC 10.\n\nPlan: Monitor hemodynaimcs, monitor labs, pain management, pulm toileting, bronch @ 0800, provide pt and family with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-26 00:00:00.000",
"description": "Report",
"row_id": 1666497,
"text": "Resp Care\nPt maintained intubated, changes made overnight see flowsheet. AM RSBI 86.4. Bilateral breath sounds course rhonchi, suctioned for thick yellow secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-26 00:00:00.000",
"description": "Report",
"row_id": 1666498,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nBronchoscopy done this morning and no leaks present from stents. Pt did not cough up any bile all night. RISBI and abg's good on SBT. Pt lethargic but following commands. MD pt extubated with IP present. Pt placed on 40% humidified face tent and given mucomyst/albuteral nebs. Pt is coughing up copious amounts of thick blood-tinged sputum now turning white. Pt is requiring very frequent assistance with yankaar suctioning. Pt remains lethargic but awake and starting to use call light for assistance in suctioning. Medicated this morning for pain but now says that he is uncomfortable at times but not in alot of pain. Medicated with ativan this morning MD but has not required any since. Pt occasionally takes ativan at home per his wife. TPN continues. NGT to LCWS with bilious output. Reddened central line evaluated by MD and ok to continue using. Please refer to carevue for all further details. Cont with pulm toileting /monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-26 00:00:00.000",
"description": "Report",
"row_id": 1666499,
"text": "Resp Care\nPt had bedside bronch, stent in good position. Was weaned per protocol and extubated. Pt had prod cough thick/white. Recieving mucomyst nebs/albuterol as ordered. Pt has been tachypnic throughout shift rr 30-40, abg's as noted resp alk. Plan to continue with nebs,pulm toilet and can use NIPPV if needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-28 00:00:00.000",
"description": "Report",
"row_id": 1666507,
"text": "RESP CARE NOTE\n2130 ALBUTEROL/MUCOMYST NEB GIVEN AS ORDERED. BS RHONCI T/O.SAO2 95, RR 21 HR 101\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-29 00:00:00.000",
"description": "Report",
"row_id": 1666508,
"text": "vss. c/o throath/neck pain-medicated w/ dilaudid .5mg x2 w/ good releif. requested ativan for sleep- 1mg iv given slept fairly well.\ncs-course w/ expiratory rhonchi. cpt q4hr and nebs given tolerated well. couhging and raising mod. amts thick whitish sputum. o2sats 95-97% on 5lrs np.\nabd. soft, hypo active bs heard. ngt draining mod. green bilious.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-29 00:00:00.000",
"description": "Report",
"row_id": 1666509,
"text": "Resp Care\n\nPt followed by resp for neb treatments and was treated with alb/3ml 20% mucomyst neb this morning. Atrovent nebs also given Q6. BS course rhonchi coughing and raising small amts of thick white secretions on own. Fair effect noted s/p neb treatments. Will cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-08 00:00:00.000",
"description": "Report",
"row_id": 1666510,
"text": "condition update\nplease see carevue for specifics.\n\nAssumed care of pt from 0645 to 0700am. Pt admitted to the sicu from 7 in rapid afib. 150mg Amio bolus finishing upon arrival. HR 170's. HR back in NSR approx 0650 am. Amio gtt up from the pharmacy and started 1mg/mn at 0700am. sbp 90's. Pt c/o incisional pain w/ turning. Pt used his dilauded pca (.37 6 3.7) x 1. IV RN called to place a peripheral IV d/t incompatiblity of dilauded and amiodarone. No c/o sob. 02 sats 95% on 2L 02 via n/c. Pt voided in the urinal. G tube is to gravity and replete w/ fiber tube feedings infusing via the J tube.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-27 00:00:00.000",
"description": "Report",
"row_id": 1666500,
"text": "condition updated\nS/P stent placement\nevents last 24hr; bronch and extubation\nNEURO:\n2episodes of \"hallucinations\" after doses of dilaudid given; bed moved around to diminish effects and reorient. otherwise alert x3 MAE. attempted to get pt OOB but still very weak and has poor balance\nCARDIO:\nHR 90-110 stable BP unless anxious\nRESP:\naggressive pulmonary toilet done CPT,percussion and deep breathing. ABG'S improving\nGI/GU:\n NGT intact not manipulated\n PAIN MANAGEMENT: dilaudid works well but thinks the hallucination are from dilaudid although never has been an issue in past\n:\ncontinue pulmonary toilet\nPT consult for activity\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-27 00:00:00.000",
"description": "Report",
"row_id": 1666501,
"text": "Please See Carevue for Specifics.\n\nPt is 3, MAE, follows commands. C/O intermittent throat and sternum pain . Received 0.5mg IV Dilaudid with good effect. Requesting Ativan ATC. NSR-ST, no ectopy. SBP 130-150's. Lungs are coarse bil with insp/exp wheezes. Receiving atrovent nebs every six hours and mucomyst nebs every twelve hours, FiO2 increased from 0.7 to 1.0 due to O2 sat 89. SICU team tolerating O2 sat 92-93% Pt OOB to chair, receiving chest PT, and is encouraged to CDB frequently. ABD is soft, NGT to LWCS with bilious drainage. Foley with c/y/u. Skin is intact.\n\n: Continue pulmonary toilet, closely monitor respir status and sputum. Monitor pain level and medicate as ordered. SW and CM to follow pt. PT and OT to follow up with pt. Continue to offer emotional support to pt and pt family throughout hospital stay.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-27 00:00:00.000",
"description": "Report",
"row_id": 1666502,
"text": "Respiratory Care\nPatient place on NIV at 1750 MD's order to rest, since MD deemed that patient was getting fatigued, patient claimed being comfortable while on 10PS 5PEEP 50%, with full-face mask, might eventually continue to rest overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-28 00:00:00.000",
"description": "Report",
"row_id": 1666503,
"text": "temp max 98.8 hr 106-87 nsr w/o ect. started on lopressor 2.5mg iv q4hrs tolerating well.\nresp rate 25-32 w/ o2sats 93-95 on np 4lrs. cs-course thru-out. cpt/\nalb./atrovent/mucomsyt given as ordered. coughing and raising mod. amt thick tan/yellow sputum after treatments. cxr done this am.\nngt draining mod amt bilious. abd. soft. hypoactive bs.\npt c/o sternal pain-medicated x1 w/ dilaudid .5mg w/ good relief.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-28 00:00:00.000",
"description": "Report",
"row_id": 1666504,
"text": "RESP CARE NOTE\nPT PLACED ON NIV FOR POST EXTUBATION FATIGUE IMPROVED THROUHGH OUT THE NIGHT RR 22-26, SAO2 93-95 ON 4LPM NC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-28 00:00:00.000",
"description": "Report",
"row_id": 1666505,
"text": "Please See Carevue for Specifics.\n\nPt A+OX3. Medicated once with 0.5mg IV dilaudid for throat and sternal pain with good effect. NSR-ST, no ectopy. Lungs remains coarse with insp and exp wheezes at times. Receiving albuterol, mucomyst, and atrovent NEB's ATC. Pt o2 sat impriving throughout today and pt is currently on 5L NC with O2 sat 94-97%. Abd is soft, one large soft guaiac negative stool this shift. NGT to LWCS with bilious drainage. Foley with clear urine.\n\n: COntinue pulmonary toileting. OOB to chair, OT and PT to follow. Transfer pt to floor . Continue to monitor pain and medicate as ordered. COntinue to offer pt and pt family emotional support throughout hospital stay. SW to follow pt/pt family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-28 00:00:00.000",
"description": "Report",
"row_id": 1666506,
"text": "BS generally CTAB though at least once incident of wheezing. No change with nebs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-20 00:00:00.000",
"description": "Report",
"row_id": 1666474,
"text": "REspiratory CAre:\nPt recieved orally intubated from OR, S/P TEE and stent placement. Pt initially placed on AC, 100% FiO2, +5, desated while getting CXR done to low 80s, PEEP increased to 10, pt did not respond, pt then bagged with 10 PEEP, SpO2 88%.Several recruitment manouvers done, lavaged then pt sats 92% on PEEP 15 and 100%. Lung soudns clear. Suctioned moderate thick tan secretions. Plan is to wean vent support as tolerated. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-24 00:00:00.000",
"description": "Report",
"row_id": 1666488,
"text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt remains sedated on propofol, opens eyes to pain and occationally voice. Localizes pain, MAE. Ativan prn anxiety with pos effect. Dilaudid prn pain with pos effect.\n\n Resp: No vent changes made over night. Pt maintaining O2 sat >95%, PaO2 94. Tidal volumes affected by NGT suction, with NGT clamped tidal volumes range 400-600 and with NGT to suction tidal volumes drop to 200-300, no change from previous shift, no intervention over night. Suctioned prn, no sputum. LS clear bilat throughout.\n\n CV: Remains NSr, no ectopy noted. Skin W&D, palp pedal pulses, trace edema noted in lower extremities.\n\n GI: Abd softly distended, pos bs. NGT to LCS, bilious drainage noted. No Bm this shift, pos flatus.\n\n GU: Adequate amounts of clear amber urine via foley cath\n\nPlan: monitor hemodynamics, monitor labs, ? bronch, continue with abx as ordered, pain management, provide pt and family with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-24 00:00:00.000",
"description": "Report",
"row_id": 1666489,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for sml amts thick bld tinged secretions.MDI'S given. Sedated with propofol. Temp 99.6.Vent remains with leak position of NGT ?ACT on.Had episodes throughout the night with decreased sats and increased RR. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-24 00:00:00.000",
"description": "Report",
"row_id": 1666490,
"text": "RESPIRATORY CARE: PT REMAINS W/ AN 8.5 ORAL ETT IN PLACE AND ON PS \nAND FIO2 .50. PEEP DECREASED TO 8 TODAY. ABG HAS BEEN STABLE. PROPOFOL FOR SEDATION. SX FOR SMALL AMTS THICK TAN SPUTUM. ALBUTEROL/ ATROVENT\nMDI'S GIVEN. WILL C/W PS 8 AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-24 00:00:00.000",
"description": "Report",
"row_id": 1666491,
"text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: SEDATED ON PROPOFOL, ABLE TO FOLLOW COMMANDS DURING \"WAKE UP\", MEDICATED WITH DILAUDID FOR GENERALIZED DISCOMFORT\nRESP: BS CLEAR. SX FOR SM AMTS RUST COLORED SPUTUM. PEEP DECREASED TO 8 WITH NO CHANGE IN ABG'S. REMAINS ON CPAP WITH 8 IPS.\nCV: T MAX 99.4. HEMODYNAMICALLY STABLE. EXTREMITES WARM, BPPP\nGI: ABD SOFTLY DISTENDED WITH HYPOACTIVE BS. NGT PATENT AND DRAINING BILIOUS. ON TPN\nGU: ADEQUATE AMTS DK AMBER URINE VIA FOLEY\nENDO: SLIDING SCALE TIGHTENED, BS TX'D X2.\nSOCIAL: WIFE IN TO VISIT X2, UPDATE GIVEN\nA/P: CONT TO MONITOR HEMODYNAMICS AND RESP STATUS, MEDICATE FOR PAIN AND ANXIETY AS NEEDED, CONT TO UPDATE FAMILY\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-23 00:00:00.000",
"description": "Report",
"row_id": 1666484,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for deatils. Suctioned for mod amts thick bile looking secretions.MDI'S given.Temp 99.1.Sedated with propofol. No RSBI done due to increased amts of peep.Cuff leak positional. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-23 00:00:00.000",
"description": "Report",
"row_id": 1666485,
"text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt remains sedated on prop gtt, opening eyes to speech, nodding head yes/no to questions, intermittently following commands, PERLA, MAE. Dilaudid 1mg IVP Q2-3hrs with pos effect.\n\n Resp: Remains on CMV, TV 550, PEEP 12, resp 12 (breathing over vent), and FiO2 increased to 60% due to low PaO2's with pos effect. LS clear bilat, diminished r base. Pt has coughing fits with turning and repositioning. At approx 0200, pt raised copious amounts of bile into ETT, residents aware CXR obtained, currently suctioned for lg amounts of thick brick color secretions. O2 sat 92-97%.\n\n CV: Remains NSR, HR 70-90's. SBP 100-130's. Palp pedal pulses. IVF and TPN to total 125cc/hr. No edema noted.\n\n GI: Abd softly distended and increasing over night, HO aware. NGT continually unable to sump, HO repositioned with no effect. KUB obtained, NGT ? appears to be kinked in one area and ? ileus present. POs BS, No BM. TPN continues as ordered.\n\n GU: Adequate amounts of clear amber urine via foley cath\n\n Tmax 100.4, abx as ordered.\n\nPlan: Bronch in AM, pain management, wean vent as tol, monitor labs, monitor hemodynamics, provide pt and family with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-23 00:00:00.000",
"description": "Report",
"row_id": 1666486,
"text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: AROUSABLE TO NAME, ATTEMPTING TO WRITE THIS AM, CONT ON PROPOFOL AT 45, ATIVAN GIVEN FOR ANXIETY AND DILAUDID FOR PAIN WITH GOOD RELIEF\nCV: T MAX 100.8, OTHER VSS. EXTREMITES WARM WITH PALPABLE PULSES.\nRESP: BRONCHOSCOPY DONE THIS AM BY DR AND STINTS REPOSITIONED. ETT PULLED BACK APPROX 1 CM PER DR . CHANGED TO CPAP WITH 8 PS, TV INITIALLY IN 4-600 RANGE. NGT PULLED BACK BY THORACIC TEAM AND SINCE THEN TV 2-300 UNLESS NGT CLAMPED.CXR DONE. BS CLEAR BUT DIMINSHED IN LEFT LOWER LOBE, SX FOR RUST COLORED SECRETIONS.\nGI: ABD SOFT, HYPOACTIVE BS, NGT REPOSITIONED BY THORACIC TEAM AND CURRENTLY DRAINING BILIOUS\nGU: DK AMBER URINE IN GOOD AMTS\nENDO: BS 160-138\nA/P: CONT TO MONITOR HEMODYNAMICS AND RESP PARAMETERS, KEEP PT SEDATED FOR COMFORT, MONTIOR ABG'S.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-23 00:00:00.000",
"description": "Report",
"row_id": 1666487,
"text": "RESPIRATORY CARE: PT REMAINS INTUBATED W/ AN 8.5 ORAL ETT IN PLACE. PT HAD ANOTHER BRONCHOSCOPY TODAY TO VISUALIZE STENT. STENT ADJUSTED BY DR. AND ETT ALSO PULLED OUT 1 CM. CHANGED TO PS AS PER CV. ABG STABLE W/ GOOD OXYGENATION SO PEEP DECREASED TO 10. NG TUBE ADJUSTED BY THORACIC TEAM AND PT'S EXHALED VT DECREASED BY ABOUT 50%.\nWHEN NG TUBE PINCHED OFF - THE VT'S RETURNED TO . ABG STABLE. NOTIFIED MD TO DETERMINE WHETHER NG TUBE IN AIRWAY V. NG TUBE AT LEVEL OF FISTULA. CXR DONE. THORACIC TEAM NOTIFIED AT ABOUT 12:30 PM BY SICU RESIDENT. WILL C/W PS .50 AS PER CV.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-21 00:00:00.000",
"description": "Report",
"row_id": 1666479,
"text": "Respiratory Care:\nPt remains orally intubated and vented. PEEP and FiO2 gradually weaned this shift. ABG showed acid base within normal with good oxygenation. Lung sounds clear. Suctioned for copious green bile. Pt bronched today without complication. MDIs given per order. Plan os to cont to wean vent support to extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-22 00:00:00.000",
"description": "Report",
"row_id": 1666480,
"text": "Respiratory Care\nPt remains intubated on vent support. Earlier in shift after pt turned in bed, cough and raised copious amounts bile colored secretions, required nursing to sx aggressively, so much secretions that some of vent tubing filled with expectorated secretions. consequently oxygenation worsened , FiO2 increased to 60% for 2 hours, last ABGs respiratory alkalosis with hyperoxia, fiO2 returned to 50%. AM RSBI 33. Pt C/O SOB when awake. BS occ coarse clear after Sx.\nPlan: Possiblity of extubation later today, ? ability of pt. to clear and protect airway of periodic aspiration of lg amounts bile through fistula especially after position changes in bed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-22 00:00:00.000",
"description": "Report",
"row_id": 1666481,
"text": "temp 101-100 b/p stable aline dampens at times. cvp 3.\npt slightly sedated on ppf gtt. follows commands. c/o sternum/throath pain-medicated w/ dilaudid 1mg q3hrs w/ good relief.\npt had one esipode(after repositioning) of coughing bringing up large amt of bilious sputum into ett and vent tubing-afterwards sat drop to 94%. fio2 increased^to .6 w/ improvement. attempting to wean fio2-abg's pending.\nabd. soft,+bs, ngt to lis draining mod. amt bilious.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-22 00:00:00.000",
"description": "Report",
"row_id": 1666482,
"text": "RN progress note\nSee Carevue for specifics\n\nPt returned to the OR today for replacement of tracheal stent. Pt desatted on arrival from OR, became hypertensive and tachycardic. An emergent chest xray and bronchoscopy was performed and the stent placement, which was noted to be slightly incorrect, was fixed. The pt's VS then stabilized. Subsequent ABG showed respiratory acidosis and chest xray showed atelectisis. Pt was put on 100% fi02 and 10 PEEP and latest ABG showing resolution but P02 low. Pt now on 12 PEEP.\n\nPt remains sedated on propofol gtt but is arousable to voice, follows all commands, nods appropriately. Frequent complaints of mediatinal pain continues. Tx'ing well with dilaudid. NSR, SBP 90-110s, with exception of hypertension s/p OR. Cuff leak noted and acceptable. Continues NPO, receiving TPN, no stool, +BS. Foley draining adequate clear urine. K+ and Ca++ repleted. Wife in to visit early in shift and updated by primary team and RN.\n\nPLAN: Monitor respiratory status closely. Repeat ABG on latest 12 PEEP setting at @19:30. Wean vent settings as soon as appropriate. Monitorre respiratory secretions for bilious fluid. Keep pt comfortably sedated. Keep wife and pt up to date on plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-22 00:00:00.000",
"description": "Report",
"row_id": 1666483,
"text": "RESPIRATORY CARE: PT WENT BACK TO OR FOR PLACEMENT OF A LARGER STENT TODAY. BACK TO SICU-A W/ A LARGER ETT 8.5 AND A LARGER STENT IN PLACE.\nSOME DIFFICULTY W/ ETT CUFF AND POSITION SO A SECOND BRONCHOSCOPY PERFORMED AT BEDSIDE. ETT REPOSITIONED AT ABOUT 21-22 LIP. ABG IMPROVING SLOWLY. WILL INCREASE PEEP TO 12 AND RECHECK ABG.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-20 00:00:00.000",
"description": "Report",
"row_id": 1666475,
"text": "NURSING PROGRESS NOTE\n\nSEE CAREVUE FOR DETAILS\n\n60 Y/O MALE W/HX ESOPHAGECTOMY FOLLOWED BY CHEMO, C/B STRICTURE REQUIRING 2 DILATION PROCEDURES. ADMITTED TO OSH W/ C/O SOB, FOUND TO HAVE OBSTRUCTION AT TRANSFERRED TO AS PT OF DR . FROM OR AFTER RECIEVING Y-STENT PLACEMENT AFTER CONFIRMATIN ON FLOOR OF TE FISTULA FROM EGD. TO HAVE BRONCH IN AM.\n\nSEDATED ON PPF, FOLLOWING COMMANDS. MILD C/O PAIN FROM ETT, DIFFICULTY BREATHING. RECEIVING PRN DILAUDID/ATIVAN.\nWHILE ON 100% FIO2 DROPPED SAT'S TO 82%, DR AT BS PLACING ALINE AT TIME. RT BAGGING PT. PAO2 54 AT TIME. MUCOUS PLUG REMOVED W/SUCCESS, SAT'S UP TO 94-99%, PAO2 154. REMAINS ON VENT FI02 WEANED TO 70%, PLETH REMAINS 99%. PEEP 15. TO HAVE BRONCH IN AM.\nNGT TO LIWS, NOT TO MANIPULATE. YELLOW DRAINAGE. + BS. TO START TPN TOMORROW.\nMAKING ADEQUATE CYU VIA FOLEY, PLACED IN OR.\nALINE PLACED. SBP 90-120. NSR NO VIEWED ECTOPY.\nDR SPOKE W/WIFE, .\n\nPOC: BRONCH IN AM. PULM TOILET, WEAN VENT AS TOL. TO START TPN IN AM. MONITOR PAIN/COMFORT; PRN DILUADID & ATIVAN. HO AWARE OF ABOVE, CALL W/ANY UPDATES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-21 00:00:00.000",
"description": "Report",
"row_id": 1666476,
"text": "Respiratory Care\nPt remains on full vent support, Assist Control. PEEP and O2 were weaned t/o the noc (see flowsheet for details). BBS were coarse and diminished, pt sx for large amounts of thick bile colored sputum. ABG this AM shows a mild metabolic alkalosis with hyperoxygenation.\n\nPlan is to wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-21 00:00:00.000",
"description": "Report",
"row_id": 1666477,
"text": "temp max 100, hr 97-75 nsr w/o ect. hypotensive sb/p 88/ fluid bolus's 500cc lr x3 w/ good response sb/p 100/50. cvp 6-4\nurines amber to yellow urine 40-86cc/hr.\npt sedated on pff 40-50mcg/kg/min for vent compliance. pt arousable to voice, following commands. c/o pain-pointing to sternum and throath-\nmedicated w/ dilaudid w/ good relief.\nabd. soft, active bs. ngt on lis mod. bilious drge.\ntolerated vent changes made overnoc-peep down to 10cm/fio2 down to 60%\nw/o2 sats 99-100% w/ acceptable agb's. ac mode rate 14 breathing over vent w/ rr 20-24. cs-course dim in bases-suctioned mod-large amt brown/rusty bile color sputum. strong productive cough. cxr done this\nam.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-21 00:00:00.000",
"description": "Report",
"row_id": 1666478,
"text": "RN progress note\nSee Carevue for specifics\n\nPt remains sedated on ppf gtt but easily arousable to voice, will follow all commands, nods and gestures appropriately. Sedation lightened at one point and pt was able to communicate by writing. Frequent c/o of mediastinal pain, tx'd with .5 of dilaudid initially but effect was minimal. Dose increased to 1 mg with good result. NSR, distal pulses strongly palpable, SBP 95-110s, but becomes hypertensive when sedation lightened. Remains on CMV but fi02 down to 50% and PEEP weaned to 5 with latest ABG pending. Pt remains NPO, TPN started. Foley draining adequate urine. Wife was in to visit during most of the day and was updated by MD .\n\nPLAN: Continue slow wean from vent with goal of extubation by tomorrow a.m. if tolerated. Assess for and tx pain frequently. Titrate sedation for comfort. Keep pt and spouse up to date on .\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-25 00:00:00.000",
"description": "Report",
"row_id": 1666492,
"text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt remains sedated on propofol, follows commands and attempts to write when sedation is off. Opens eyes to painful stimuli and occationally voice through sedation, nodding inconsistantly to yes/no questions. Medicated with Ativan and dilauidid prn pain/anxiety with pos effect.\n\n Resp: LS clear to coarse bilat throughout. No vent changes made, ABG wnl and remain relatively the same throughout shift. Tidal volumes remain low with NGT to suction, no intervention and HO aware. Becomes tachypnic and dips sat at times with appears to coincide with pain/agitation, resolves when medicated.\n\n CV: Remains NSR, no ectopy noted, HR remains 70-80's. SBP 100-130's. Palp pedal pulses. Trace edema noted. CVP 4-5.\n\n GI: Abd softly distended, pos bs, NGT to LCS, bilious drainage. No BM, pos flatus.\n\n GU: Adequate amounts of clear amber urine via foley cath.\n\n ID: Tmax 101.7, pan cultured, abx continues as tol.\n\nPlan: monitor hemodynamics, monitor labs, pain management, pulm toileting, follow up with cultures, privide pt and family with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-25 00:00:00.000",
"description": "Report",
"row_id": 1666493,
"text": "RESPIRATORY CARE:\n\nPt remains orally intubated, vent supported on PSV/CPAP. Continue to have airleak to esophagus, audible w/ inspiration over abdomen. Pt seemingly increased at times, though ABGs remained stable. BS's diminished, coarse. Sxing brown secretions. RSBI=96 this am. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-25 00:00:00.000",
"description": "Report",
"row_id": 1666494,
"text": "Nursing Progress Note\nSee Carevue for specifics\n\nEvents: Bronch at bedside revealed metal stents had migrated. Pt taken to OR to flex/rigid bronch, removal of metal stents and placement of silicone Y stent. Pt returned paralyzed, not reversed, remains on AC since procedure.\n\nPt sedated on Propofol, off sedation opens eyes to voice and intermittently follows commands. MAE. Pt grimaces with turning/suctioning. Given Dilaudid/Ativan prn with effect.\nNSR. HR 70's-80's. BP 110's and stable.\nRemains AFebrile. Cultures pending. Started on Vanco.\nLS clear to coarse. Suctioned prn for thick brown-blood tinged secretions. ETT retaped and rotated. Frequent oral care provided. Currently on AC sats 97%.\n+BS hypoactive at times. Abd softly distended. NGT to CLWS draining bilious drainage. TPN cont at 95cc/hr.\nFoley draining lge amts clear amber urine.\nMRSA/VRE swabs sent per protocol.\nWife at bedside before and after procedure. Updated by Drs. and .\n\nPlan: Continue attempt to wean vent settings as tolerated, pain control, follow labs/cultures. Continue provide support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-25 00:00:00.000",
"description": "Report",
"row_id": 1666495,
"text": "RESPIRATORY CARE: PT REMAINS INTUBATED AND NOW ON THE AC MODE AS PER CV. BRONCHOSCOPY THIS AM REVEALED THAT STENT HAD MIGRATED. BACK TO OR FOR A SILICONE STENT. WILL WEAN FIO2 AS TOLERATED BY SPO2 AND CHANGE BACK TO PS WHEN MORE AWAKE.\n"
},
{
"category": "ECG",
"chartdate": "2103-07-09 00:00:00.000",
"description": "Report",
"row_id": 215381,
"text": "Sinus rhythm. Compared to tracing #1 atrial fibrillation has now converted to\nsinus rhythm.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2103-07-08 00:00:00.000",
"description": "Report",
"row_id": 215382,
"text": "Atrial fibrillation with rapid ventricular response. Diffuse non-specific\nrepolarization abnormality. Low QRS voltage in the precordial leads. Compared\nto the previous tracing of atrial fibrillation is new.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2103-07-01 00:00:00.000",
"description": "Report",
"row_id": 215383,
"text": "Sinus rhythm\nAtrial premature complex\nLow precordial lead QRS voltages\nLow amplitude T waves\nFindings are nonspecific and may be within normal limits, but clinical\ncorrelation is suggested\nSince previous tracing of , sinus tachycardia absent and low T wave\namplitude improved\n\n"
},
{
"category": "ECG",
"chartdate": "2103-06-20 00:00:00.000",
"description": "Report",
"row_id": 215384,
"text": "Sinus tachycardia with premature atrial contractions. Non-specific T wave\nchanges. No previous tracing available for comparison.\n\n"
}
] |
|
16,723 | 122,002 | Pt admitted to cardiology service on . Underwent cardiac cath via L groin sheath on . During procedure, she had mental status changes--the procedure was stopped, and she had symptoms of L sided neglect and L extremity motor dysfunction (weakness of L arm). She was taken to the neuro-angio suite and had R cerebral lysis with resolution of the symptoms. Pt had L groin arterial sheath pulled on . Prior to the pull, whe had a palpable pulse--after the pull, pressure developed, and patient experienced pain, pallor, and loss of the L femoral pulse. Vascular surgery was emergently consulted for occlusion of the L femoral artery. The L groin was emergently explored, with thrombectomy of the L aorto-bifem limb, with patch angioplasty of the L common femoral artery and profunda. The patient's heparin drip was continued. On , the patient was stable enough to be transferred from the ICU to the VICU. The patient received 1 unit packed red blood cells for a falling hematocrit (27.3). She was restarted on coumadin, plavix and aspirin, and transferred to the floor on . Physical therapy was consulted and the patient was encouraged to get out of bed to a chair. On , the heparin drip was discontinued, as the patient was therapeutic on coumadin. On , the patient was discharged to home with physical therapy to follow the patient at home. | Cont neuro checks, circ checks. U/O 25-120CC/HR.ID: AFEBRILE. HCT 29.5. SEEN BY STROKE-NEUROLOGY->EMERGENT CEREBRAL A-GRAM. hypertensive w sbp 160-180 rxed w additional lopressor doses w limited effect. ?need for heparin. TITRATED TO KEEP SBP 150-180 BY ALINE. TX WITH IV NTG, HEPARIN GTT, 2U PRBC FOR HCT 27.5, IV LASIX. repeat head CT this am,stable post TPA for acute rt MCA stroke. M3 INJECTED WITH TPA. ccu nsg progress note.o:wo neurological deficit. ALINE BP199-213/83-91. CUFF BP 164-192/70-83. LABETOLOL GTT PRESENTLY OFF WITH BP 140'S/50'S. BS+. Follow HCT. LABETOLOL 10MG VP X2 WITH SHORT TERM EFFECT. adeq uo. L. FEMORAL SHEATHS TO BE D/C'D. PLAT CT 118K.GI: NPO UNTIL AM(ALL PO MEDS TO BE HELD--CHECK WITH HO ABOUT RESTART-ING). discuss code status-?resume dnr/dni status. CCU NPN: please see flowsheet for objective dataCardiac: HR 82-88 NSR rare PVC. am labs sent.a:hypertensive-bp control needs to be addressed.p:add antihypertensives. 1/2NS INFUSING AT 100CC/HR POST-CATH. LABETOLOL GTT STARTED AT 1MG/MIN. ALL PULSES BY DOPPLER OR PALPABLE. OD NOTE, PT WAS DNR/DNI(REVERSED WHEN SHE WENT TO CATH LAB). Prominent inferior Q waves arenon-diagnostic. Sinus rhythm. PERL.RESP: O2->2L NP. NEURO CHECKS hematoma and some oozing in left. RR 18-24. Right bundle-branch block. Goal BP 150-180/. contin present med management. Sinus rhythmConduction defect of RBBB typeMarked inferior/lateral ST-T changes suggest myocardial injury/ischemiaLeft atrial abnormalitySince previous tracing of , no significant change DP and PT pulses dopplerable bilaterally, R foot warm, L foot cool, pink. ABD. Left ventricular hypertrophy with ST-T wave abnormalities.Consider possible biventricular hypertrophy. Clinical correlation is suggested. all pulses dopperable-l fem site wo hematoma- foot cool/pale-sensation normal-leg elevated on pillow. Sinus rhythmIntraventricular conduction delayLeft atrial abnormalityLeft ventricular hypertrophy with ST-T abnormalitiesInferior/lateral ST-T changes suggest myocardial injury/ischemiaSince previous tracing of , no significant change WENT TO CATH , & DURING PROCEDURE, BECAME CONFUSED WITH L. SIDE NEGLECT(L. ARM WEAKNESS, L. VISUAL DISTURBANCE). heparin @ 600u (restarted @ 2300)-am ptt pending. follow HCT,BP and pulses provide for comfort and emotional support cont frequent neuro checks BS CLEAR. WBC 6.7.AM LABS PENDING.PLAN: MONITOR BP CLOSELY. ST-T wave abnormalities arediffuse - cannot exclude ischemia. mag 1.5 repleted with 4gms mag.Resp: on 2l NP clear sats 97-99Neuro: alert and oriented x3,moves all ext.no deficits noted. MAE. ?NQWMI->TX IN THEIR CCU THEN TRANSFERRED TO FOR FURTHER EVALUATION. down to 29.2 another unit packed cells up now. Sinus rhythmMultiform ventricular premature complexesLeft atrial abnormalityShort PR intervalIntraventricular conduction defectLVH with secondary ST-T changesMarked ST-T wave abnormalities may also indicate ischemiaSince previous tracing of , the rate has increased and ST-T waveabnormalities noted O2 SAT 97-100%.CARDIAC: HR 80-94 SR WITH OCC. DENIES CP/SOB. PVC'S. neurologically stableHeme:transfused 3 units packed cells in OR,HCT up to 34 in OR. L. GROIN OOZING WITH HEMATOMA. SPENT W/E ON F3 AWAITING CATH ON MONDAY. HAND GRASPS = & STRONG. TO CCU FOR MONITORING.NEURO: AWAKE & ALERT ON ADMISSION TO CCU. Since theprevious tracing of ST-T wave changes are slightly less prominent. support as indicated. HO AWARE. BP 123-188/48-80 prior to surgery with pain BP up to 188/with MAPS over 100. given IV labetolol 10mg x2 with good effect on arrival to CCU after surgery BP 118-123/ given 500cc fluid bolus with desired result goal SBP 150-180/ arterial sheath d/ced 7:30,leg turned yellowish white,no pulses,pain.went for emergent thrombectomy after head CT.also received 5000u heparin.currently has dopplerable pulses tibial and popiteal in left,both pulses dopplerable in rt. PRESENTED TO OSH WITH C/O WORSENING SOB OVER PREVIOUS 3 WKS. MONITOR BLEEDING FROM LINES & FEMORAL HEMATOMA. CCU NPN 7-11pmNeuro: A&Ox3, PERL, follows commands, strength equal in arms and legs bilateraly.CV: BP 140-170's/60, HR 80-90's, will get 50mg lopressor po tonight, watch BP overnight, and may resume 10mg lopressor tomorrow. Given 5mg coumadin at 2200, to restart hep at 11pm. Hematoma/eccymosis at L groin, eccymosis on L lower abdomen.Heme: transfused 1 u PRBC this eve, absorbed at 2200.GI: no c/o nauseaComfort: no c/o pain.Soc: husband visiting this pm, pt and husband were asking where pt's rings were, document in chart that they are in hospital safe along with dentures.A/P: stable post thrombectomy, post cerebral angiogram with TPA to R M3 (MCA). both feet are cool,left is still pale and rt is pink. c/o left inguinal pain received 15mg toradol with relief.GI: c/o nausea this am and again after surgery each time treated with 4mg IV zofran with relief.on IV protonix,did not feel like eating tonite.GU:UO 25-30/hr after blood and fluid in OR +over 2litersID: Tmax 99,WBC 7.3,not on abxSocial: husband in visiting,resident spoke with husbandA/P: stable post left femoral thrombectomy and TPA of rt MCA stroke. NO STOOL.GU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. ADMISSION NOTE62 YR. OLD WOMAN S/P CARDIAC CATH->EMERGENT CEREBRAL A-GRAM ADMITTED TO CCU LAST EVENING ~. APPEARS A LITTLE SLOW TO RESPOND. SOFT. goal Hct >30.to start heparin at 11pm and coumadin.Pain: c/o leg and back pain this morning after sheath pulled,given 100mcg fent x2,after surgery c/o back pain again given tylenol with some relief.pt reports that she takes ibuprofen q2 for the back pain at home. ORIENTED TO PERSON, DATE, PLACE, KNOWS WHO THE PRESIDENT IS, WHERE SHE LIVES. | 8 | [
{
"category": "ECG",
"chartdate": "2171-10-10 00:00:00.000",
"description": "Report",
"row_id": 313157,
"text": "Sinus rhythm\nConduction defect of RBBB type\nMarked inferior/lateral ST-T changes suggest myocardial injury/ischemia\nLeft atrial abnormality\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2171-10-07 00:00:00.000",
"description": "Report",
"row_id": 313158,
"text": "Sinus rhythm. Right bundle-branch block. Prominent inferior Q waves are\nnon-diagnostic. Left ventricular hypertrophy with ST-T wave abnormalities.\nConsider possible biventricular hypertrophy. ST-T wave abnormalities are\ndiffuse - cannot exclude ischemia. Clinical correlation is suggested. Since the\nprevious tracing of ST-T wave changes are slightly less prominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2171-10-05 00:00:00.000",
"description": "Report",
"row_id": 313159,
"text": "Sinus rhythm\nIntraventricular conduction delay\nLeft atrial abnormality\nLeft ventricular hypertrophy with ST-T abnormalities\nInferior/lateral ST-T changes suggest myocardial injury/ischemia\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2171-10-04 00:00:00.000",
"description": "Report",
"row_id": 313160,
"text": "Sinus rhythm\nMultiform ventricular premature complexes\nLeft atrial abnormality\nShort PR interval\nIntraventricular conduction defect\nLVH with secondary ST-T changes\nMarked ST-T wave abnormalities may also indicate ischemia\nSince previous tracing of , the rate has increased and ST-T wave\nabnormalities noted\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-08 00:00:00.000",
"description": "Report",
"row_id": 1480894,
"text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 82-88 NSR rare PVC. BP 123-188/48-80 prior to surgery with pain BP up to 188/with MAPS over 100. given IV labetolol 10mg x2 with good effect on arrival to CCU after surgery BP 118-123/ given 500cc fluid bolus with desired result goal SBP 150-180/ arterial sheath d/ced 7:30,leg turned yellowish white,no pulses,pain.went for emergent thrombectomy after head CT.also received 5000u heparin.currently has dopplerable pulses tibial and popiteal in left,both pulses dopplerable in rt. both feet are cool,left is still pale and rt is pink. hematoma and some oozing in left. mag 1.5 repleted with 4gms mag.\n\nResp: on 2l NP clear sats 97-99\n\nNeuro: alert and oriented x3,moves all ext.no deficits noted. repeat head CT this am,stable post TPA for acute rt MCA stroke. neurologically stable\n\nHeme:transfused 3 units packed cells in OR,HCT up to 34 in OR. down to 29.2 another unit packed cells up now. goal Hct >30.to start heparin at 11pm and coumadin.\n\nPain: c/o leg and back pain this morning after sheath pulled,given 100mcg fent x2,after surgery c/o back pain again given tylenol with some relief.pt reports that she takes ibuprofen q2 for the back pain at home. c/o left inguinal pain received 15mg toradol with relief.\n\nGI: c/o nausea this am and again after surgery each time treated with 4mg IV zofran with relief.on IV protonix,did not feel like eating tonite.\n\nGU:UO 25-30/hr after blood and fluid in OR +over 2liters\n\nID: Tmax 99,WBC 7.3,not on abx\n\nSocial: husband in visiting,resident spoke with husband\n\nA/P: stable post left femoral thrombectomy and TPA of rt MCA stroke.\n follow HCT,BP and pulses\n provide for comfort and emotional support\n cont frequent neuro checks\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-08 00:00:00.000",
"description": "Report",
"row_id": 1480895,
"text": "CCU NPN 7-11pm\nNeuro: A&Ox3, PERL, follows commands, strength equal in arms and legs bilateraly.\n\nCV: BP 140-170's/60, HR 80-90's, will get 50mg lopressor po tonight, watch BP overnight, and may resume 10mg lopressor tomorrow. Goal BP 150-180/. Given 5mg coumadin at 2200, to restart hep at 11pm. DP and PT pulses dopplerable bilaterally, R foot warm, L foot cool, pink. Hematoma/eccymosis at L groin, eccymosis on L lower abdomen.\n\nHeme: transfused 1 u PRBC this eve, absorbed at 2200.\n\nGI: no c/o nausea\n\nComfort: no c/o pain.\n\nSoc: husband visiting this pm, pt and husband were asking where pt's rings were, document in chart that they are in hospital safe along with dentures.\n\nA/P: stable post thrombectomy, post cerebral angiogram with TPA to R M3 (MCA). Cont neuro checks, circ checks. Follow HCT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-08 00:00:00.000",
"description": "Report",
"row_id": 1480893,
"text": "ADMISSION NOTE\n62 YR. OLD WOMAN S/P CARDIAC CATH->EMERGENT CEREBRAL A-GRAM ADMITTED TO CCU LAST EVENING ~. PRESENTED TO OSH WITH C/O WORSENING SOB OVER PREVIOUS 3 WKS. ?NQWMI->TX IN THEIR CCU THEN TRANSFERRED TO FOR FURTHER EVALUATION. OD NOTE, PT WAS DNR/DNI(REVERSED WHEN SHE WENT TO CATH LAB). SPENT W/E ON F3 AWAITING CATH ON MONDAY. TX WITH IV NTG, HEPARIN GTT, 2U PRBC FOR HCT 27.5, IV LASIX. WENT TO CATH , & DURING PROCEDURE, BECAME CONFUSED WITH L. SIDE NEGLECT(L. ARM WEAKNESS, L. VISUAL DISTURBANCE). SEEN BY STROKE-NEUROLOGY->EMERGENT CEREBRAL A-GRAM. M3 INJECTED WITH TPA. TO CCU FOR MONITORING.\n\nNEURO: AWAKE & ALERT ON ADMISSION TO CCU. ORIENTED TO PERSON, DATE, PLACE, KNOWS WHO THE PRESIDENT IS, WHERE SHE LIVES. APPEARS A LITTLE SLOW TO RESPOND. MAE. HAND GRASPS = & STRONG. PERL.\n\nRESP: O2->2L NP. BS CLEAR. RR 18-24. O2 SAT 97-100%.\n\nCARDIAC: HR 80-94 SR WITH OCC. PVC'S. CUFF BP 164-192/70-83. ALINE BP\n199-213/83-91. LABETOLOL 10MG VP X2 WITH SHORT TERM EFFECT. LABETOLOL GTT STARTED AT 1MG/MIN. TITRATED TO KEEP SBP 150-180 BY ALINE. LABETOLOL GTT PRESENTLY OFF WITH BP 140'S/50'S. DENIES CP/SOB. L. GROIN OOZING WITH HEMATOMA. HO AWARE. ALL PULSES BY DOPPLER OR PALPABLE. 1/2NS INFUSING AT 100CC/HR POST-CATH. NO IV'S OR BLOOD DRAWS S/P TPA X24HRS. HCT 29.5. PLAT CT 118K.\n\nGI: NPO UNTIL AM(ALL PO MEDS TO BE HELD--CHECK WITH HO ABOUT RESTART-\nING). ABD. SOFT. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 25-120CC/HR.\n\nID: AFEBRILE. WBC 6.7.\n\nAM LABS PENDING.\n\nPLAN: MONITOR BP CLOSELY.\n L. FEMORAL SHEATHS TO BE D/C'D.\n MONITOR BLEEDING FROM LINES & FEMORAL HEMATOMA.\n NEURO CHECKS\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-09 00:00:00.000",
"description": "Report",
"row_id": 1480896,
"text": "ccu nsg progress note.\no:wo neurological deficit. hypertensive w sbp 160-180 rxed w additional lopressor doses w limited effect. heparin @ 600u (restarted @ 2300)-am ptt pending. all pulses dopperable-l fem site wo hematoma- foot cool/pale-sensation normal-leg elevated on pillow. adeq uo. am labs sent.\n\na:hypertensive-bp control needs to be addressed.\n\np:add antihypertensives. contin present med management. ?need for heparin. support as indicated. discuss code status-?resume dnr/dni status.\n"
}
] |
21,900 | 192,614 | 1. DYSPNEA The patient was admitted with signs and symptoms of left sided heart failure, likely from poor hypertension control and flash pulmonary edema. Her chest x-ray was consistent with pulmonary edema. She initially required bipap but was given 40mg IV Lasix in the ED and 40mg IV Lasix on admission and responded. She was placed on a nitroglycerin drip on admission and this was able to be titrated down and stopped on . Her oxygen was able to be weaned to minimal settings after diuresis. She was then put on her home dose of Lasix 20mg PO qday. She was ordered for Amlodipine 5mg PO qday but refused to take this due to a history of leg swelling as a side effect. Her Lisinopril was restarted but stopped on due to rising creatinine. On discharge, she was able to maintain sats on room air and hypertension was well controled on Carvedilol, Lasix 20mg PO qday and Imdur 30mg PO qday. Her blood pressure returned to the 100s-120s systolic prior to transfer with minimal adjustments to her home medications and discontinuing her Lisinopril. On discharge, her Lasix was discontinued and Imdur was increased to 60mg PO qday for blood pressure control. . 2. CORONARY ARTERY DISEASE The patient presented with signs and symptoms of unstable angina with chest pain. ECG was unchaged from prior. She has known 3 vessel disease and is not a good candidate for CABG or stenting. Medical management was optimized and she was kept on Aspirin, Carvedilol and Imdur. Cardiac enzymes were flat. She was initially put on Lisinopril but this was stopped as her creatinine rose. . 3. CHRONIC RENAL FAILURE The patient has chronic renal failure with an allograft renal transplant. Her creatinine was elevated to 2.1 on admission from a baseline of 1.9. The renal trasplant service was consulted. She had a renal ultrasound which showed patent vasculature. She was continued on Cellcept, Tacrolimus and Prednisone for her transplant. Her creatinine increased to 2.7 by the time of discharge. She has follow-up with her transplant nephrologist after discharge. . 4. ANEMIA The patient's hematocrit was 29 on admission and trended down to 26. This was likely from anemia of chronic disease as well as renal failure and decreased erythropoetin. Iron studies were checked and the patient was not iron deficient. Retic count was 2.4. She had no signs of active bleeding and HCT was stable during the admission. She should follow-up as an outpatient for her anemia. . 5. HYPERLIPIDEMIA She was continued on Atorvastatin 40mg PO qday. . The patient was managed in the CCU initially and transferred to the floor on . She was discharged home on with instructions to follow-up with her transplant nephrologist, her cardiologist and her primary care doctor. | Diureseing. VSS HTN afebrile. ECG sinus. ECG sinus. ECG sinus. (-) edema. Transitioned to po antihypertensives. Transitioned to po antihypertensives. Transitioned to po antihypertensives. transferred from ED on NIV. w/ pedal edema w/ Norvasc. HEENT: NCAT. HEENT: NCAT. HEENT: NCAT. # Anemia. # Anemia. # Anemia. : Comments: Pt. PERRL. PERRL. PERRL. most recent eval. most recent eval. most recent eval. Received ASA in ED. Received ASA in ED. - Repeat K. . - Repeat K. . presenting w/ sx of unstable angina. presenting w/ sx of unstable angina. Continue diuresing. pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. # Scleroderma. # Scleroderma. # Scleroderma. Conservative goal of -1L o/n. Conservative goal of -1L o/n. diuresed during this time. diuresed during this time. RR, normal S1, S2. RR, normal S1, S2. RR, normal S1, S2. abd soft, hypo bsp. abd soft, hypo bsp. abd soft, hypo bsp. Sclera anicteric. Sclera anicteric. Sclera anicteric. - Scleroderma. ABIs b/l. ABIs b/l. ABIs b/l. CXR consistent w/ this. CXR consistent w/ this. CXR consistent w/ this. Respiratory failure, acute (not ARDS/) Assessment: pt w/ extensive pmh, refer to FHP. Respiratory failure, acute (not ARDS/) Assessment: pt w/ extensive pmh, refer to FHP. Respiratory failure, acute (not ARDS/) Assessment: pt w/ extensive pmh, refer to FHP. # Hyperkalemia. # Hyperkalemia. # Hyperkalemia. (+) bs. - History of zoster. Lsc. lungs cta. lungs cta. lungs cta. Likely intravascular depletion state w/ diuresis. HERPES ZOSTER. HERPES ZOSTER. Respiratory failure, acute (not ARDS/) Assessment: Alert/oriented x3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diuresed w/ lasix. Diuresed w/ lasix. Diuresed w/ lasix. Diffuse rhonchi laterally. Diffuse rhonchi laterally. Diffuse rhonchi laterally. She c/o of CP, had rales b/l. LUNGS: Pt. LUNGS: Pt. LUNGS: Pt. Now improved on BiPap s/p IV lasix ~ 1L. Now improved on BiPap s/p IV lasix ~ 1L. Now improved on BiPap s/p IV lasix ~ 1L. Sinus rhythm. Sinus rhythm. - continue immunosuppressive tx as above . - continue immunosuppressive tx as above . - continue immunosuppressive tx as above . FEN: NPO for now. FEN: NPO for now. # CORONARIES: Known mid-distal LAD, distal CFX and PL occlusion. # CORONARIES: Known mid-distal LAD, distal CFX and PL occlusion. # CORONARIES: Known mid-distal LAD, distal CFX and PL occlusion. CP likely demand ischemia. CP likely demand ischemia. AAOx3. AAOx3. AAOx3. ACCESS: PIV's b/l. U lytes pending. this am. this am. this am. BIPAP mask (since arrival from E.R. GIB SCLERODERMA. GIB SCLERODERMA. The distal PL branch was occluded. 1. - Continue BiPaP. - Continue BiPaP. Weaned off BiPAP, continued diuresis, and NTG drip. )abd soft. PROPHYLAXIS: -DVT ppx with Heparin SC. PROPHYLAXIS: -DVT ppx with Heparin SC. PROPHYLAXIS: -DVT ppx with Heparin SC. - History of GI bleed in . Cr, 2.1, mildly elevated from baseline (1.9). Cr, 2.1, mildly elevated from baseline (1.9). Two vessel CAD. Anteroseptal ST elev < 1mm, unchanged from prior . Probableanterior myocardial infarction. CARDIAC CATH: . Adm to ED w/ progressive SOB, resp distress w/ elevated BP.NSR. Adm to ED w/ progressive SOB, resp distress w/ elevated BP.NSR. Adm to ED w/ progressive SOB, resp distress w/ elevated BP.NSR. post. post. post. 3. The distal LCX was occluded after OM1 with left to left collaterals filling via a small OM2. RUE fistula, no erythema, thrill present. RUE fistula, no erythema, thrill present. RUE fistula, no erythema, thrill present. Per previous notes, pt. Per previous notes, pt. Oriented x3. Oriented x3. Oriented x3. Likely ACD, the cause of acute decrease uncertain, as likely not dilutional. Likely ACD, the cause of acute decrease uncertain, as likely not dilutional. Likely ACD, the cause of acute decrease uncertain, as likely not dilutional. ECG unchanged from prior. ECG unchanged from prior. ECG unchanged from prior. c/o mask discomfort. 2. 2. Monitoring K. ACCESS: PIV's b/l. Monitoring K. ACCESS: PIV's b/l. Right dominant system. Sinus bradycardia. Sinus bradycardiaAnterior myocardial infarction with ST-T wave configuration suggestingacute/recent/in evolution processClinical correlation is suggestedSince previous tracing of , no significant change Mood, affect appropriate. Mood, affect appropriate. Mood, affect appropriate. Also consider PDE inhibitor of no improvement. NTg drip weaned as well as o2. NTg drip weaned as well as o2. NTg drip weaned as well as o2. IMPRESSION: Mild-to-moderate regional left ventricular systolic dysfunction, c/w CAD. Late R wave progression with ST segment elevation and T waveinversion. presenting w/ sx of unstable angina, likely demand ischemia. - Complete ROMI - Continue Tele - No indication for heparin at this time as pt asymptomatic. - Telemetry - Recheck K today. Response: SBP 120-140s. Response: SBP 120-140s. Response: SBP 120-140s. Action: Ntg gtt tirated to keep SBP </= 140. diuresing from60mg Iivp Lasix givenin E.R. 1.9. Action: Pt placed on NTG drip and noninvassive ventilation. Action: Pt placed on NTG drip and noninvassive ventilation. Action: Pt placed on NTG drip and noninvassive ventilation. in showing the right ABI of 0.68, the L ABI of 0.75. in showing the right ABI of 0.68, the L ABI of 0.75. | 12 | [
{
"category": "Nursing",
"chartdate": "2201-10-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 353913,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n pt w/ extensive pmh, refer to FHP. Adm to ED w/ progressive SOB, resp\n distress w/ elevated BP.NSR. AAOx3. abd soft, hypo bsp. No nausea. NPO\n this am, poor appetite for lunch. Pt strong cough productive of small\n amts thick yellow sputum. Lungs clear bilat this afternoon. Daughter at\n bedside aware of transfer.\n Action:\n Pt placed on NTG drip and noninvassive ventilation. Diuresed w/ lasix.\n Transitioned to po antihypertensives. this am. NTg drip weaned as well\n as o2.\n Response:\n SBP 120-140\ns. HR presently SB 55-65. o2 sats 95% on r/a. lungs cta.\n Plan:\n Transfer to 3.\n"
},
{
"category": "Physician ",
"chartdate": "2201-10-27 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 353781,
"text": "TITLE:\n Chief Complaint: Worsening DOE\n HPI:\n 58 yo female w/ hx of CAD status post LAD and RCA stents, LHCath w/\n multivessel disease, CHF, HTN, Hyperlipidemia, PVD (s/p fem-fem bypass\n on L, R iliac stent, iliac stenosis prox to popl artery), end-stage\n renal disease, status post allograft transplant complicated by\n graft rejection treated with ATG, scleroderma, and GI bleed who\n presented to the ED progressively worsening SOB.\n .\n Over the past 2 weeks, she has had progressively worsening DOE and\n intermittent chest tightness. She repots that this has progressively\n gotten worse since she began to take the new medications since d/c from\n hospital (see below). She can only walk ~ 5ft w/o DOE and does not\n recall how far she could walk prior to this exacerbation. She has no\n CP or SOB at rest. There have been URI sx, she has had nonproductive\n cough. She denies dietary indiscretions. Did not notice weight gain.\n .\n She had a recent hospitalization ( - ) at which time cardiac\n cath showed proximal LAD had 40% in-stent restenosis with patent\n proximal RCA stent though there were serial 60% to 80% stenosis\n throughout the mid to distal LAD, the circumflex had proximal 40%\n stenosis, and the distal left circumflex was occluded with\n collateralization. There were also 40% stenoses in the mid and distal\n RCA. She was deemed to have two-vessel coronary artery disease that\n was not intervenable by angiography and would not be a good CABG\n candidate. Her blood pressure was very high during her hospitalization\n and peri-procedure, thus it was felt that the most useful thing to do\n would be to aggressively control her blood pressure and improve the\n flow to her transplanted kidney.\n .\n During this hospitalization, her lisinopril was increased to 30 mg and\n Imdur was added though not continued as an outpatient her PCP notes in\n .\n .\n Per , PCP was called by VNA on for hypertension (180/80); at\n this point, she had started the increased lisinopril and imdur and was\n started on Norvasc 2.5mg QD (which she did not take).\n .\n On review of systems, s/he denies any prior history of stroke, TIA, but\n endorses hx of DVT (timing unclear and unsure if its venous or\n arterial), no pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n S/he denies recent fevers, chills or rigors. She reports leg pain w/\n ambulation. All of the other review of systems were negative.\n .\n Cardiac review of systems is notable for chest pain, dyspnea on\n exertion. She denies paroxysmal nocturnal dyspnea, orthopnea, ankle\n edema, palpitations, syncope or presyncope.\n .\n In the ED, initial vitals were 98.1F, 191/90, 68, 92% on RA. She c/o\n of CP, had rales b/l. She was given SL nitro, lasix 60mg IV, started\n on NTG gtt, given ASA 325mg and was placed on BiPAP 10/5. She also\n received CaGluconate, 10U of insulin and D50 amp for K of 6.8.\n .\n In the ICU, vitals were 98F, 175/53, 97, 20 100% 50%O2 on Bipap 5/5.\n pt. was resting comfortably. Denied CP, SOB or any discomfort.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 3 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS::\n Diabetes (-)\n Dyslipidemia (+)\n Hypertension (+)\n .\n 2. CARDIAC HISTORY:\n -CABG: None known.\n -PERCUTANEOUS CORONARY INTERVENTIONS: status post anterior MI in \n with MID LAD BMS in , PCIs to the RCA in the past and brachytherapy\n in to LAD. See cath from below.\n -PACING/ICD: None known.\n 3. OTHER PAST MEDICAL HISTORY:\n .\n -Peripheral arterial disease status post left fem-fem bypass\n and right external iliac stent in .\n -Renal failure status post renal transplant x2, most recently in \n with subacute rejection, Cr. 1.9.\n - History of GI bleed in .\n - Scleroderma.\n - History of zoster.\n No family history of premature coronary artery disease, unexplained\n heart failure, or sudden death. Mother - DM, Father - brain ca.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: pack per day of tobacco, has been a smoker most of her\n life.\n She denies alcohol or illicits.\n She is married, lives with her husband and is unemployed, has two grown\n children. She is able to perform her ADLs, but limited over past 3mo\n DOE.\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Chest pain, No(t) Edema\n Respiratory: Cough, Dyspnea\n Gastrointestinal: Nausea\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 92 mL\n PO:\n TF:\n IVF:\n 92 mL\n Blood products:\n Total out:\n 0 mL\n 840 mL\n Urine:\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -747 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 5 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n SpO2: 92%\n ABG: ///19/\n Ve: 14.5 L/min\n Physical Examination\n GENERAL: NAD, w/ BiPAP. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva pink, no cyanosis of\n the oral mucosa. No bruits.\n NECK: Supple, unable to assess JVP 2/2 bipap.\n CARDIAC: PMI could not be located. RR, normal S1, S2. No m/r/g. No S3\n or S4.\n LUNGS: Pt. supine, unable to ausc. post. Unlabored resp on Bipap, no\n accessory muscle use. Diffuse rhonchi laterally.\n ABDOMEN: Obese, soft, NTND. Multiple scars,well healed. Could not\n palpate abd aorta. No abdominial bruits appreciated.\n EXTREMITIES: warm, dry, no edema. calcinosis and loss of skin texture,\n no sclerodactyly. Contractures in RUE, LE b/l. RUE fistula, no\n erythema, thrill present.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ could not appreciate DP or PT. extremity\n warm.\n Left: Carotid 2+ could not appreciate DP or PT. extremity warm.\n Labs / Radiology\n 135 K/uL\n 8.9 g/dL\n 194 mg/dL\n 2.3 mg/dL\n 37 mg/dL\n 19 mEq/L\n 108 mEq/L\n 5.5 mEq/L\n 135 mEq/L\n 26.6 %\n 7.1 K/uL\n [image002.jpg]\n \n 2:33 A12/2/ 01:47 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 7.1\n Hct\n 26.6\n Plt\n 135\n Cr\n 2.3\n Glucose\n 194\n Other labs: CK / CKMB / Troponin-T:77//, Ca++:9.9 mg/dL, Mg++:1.2\n mg/dL, PO4:3.5 mg/dL\n EKG: NSR, No peaked Tw or Twi. Anteroseptal ST elev < 1mm, unchanged\n from prior \n .\n 2D-ECHOCARDIOGRAM: .\n The left atrium is moderately dilated. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. There is mild to\n moderate regional left ventricular systolic dysfunction with\n hypokinesis of the mid- and distal septm, anterior wall and distal\n inferior wall. The apex is incompletely visualized, but is likely\n hypokinetic. The remaining segments contract normally (LVEF = 40%).\n Transmitral Doppler and tissue velocity imaging are consistent with\n Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion and no aortic\n regurgitation. The mitral valve leaflets are mildly thickened. There is\n no mitral valve prolapse. The pulmonary artery systolic pressure could\n not be determined. There is a small posterior pericardial effusion.\n There are no echocardiographic signs of tamponade.\n IMPRESSION: Mild-to-moderate regional left ventricular systolic\n dysfunction, c/w CAD.\n .\n CARDIAC CATH: \n .\n 1. Right dominant system. Two vessel CAD. The LMCA was without\n significant disease. The proximal LAD heavily calcified with patent\n stent with 40% instent restenosis. Serial 60-80% stenoses throughout\n the mid to distal LAD.\n .\n The LCX had proximal 40% stenosis extending into a large OM1. The\n distal LCX was occluded after OM1 with left to left collaterals filling\n via a small OM2.\n .\n The RCA was calcified with a patent proximal RCA stent. There were 40%\n stenoses in the mid and distal RCA. The distal PL branch was occluded.\n .\n 2. Limited resting hemodynamics demonstrated systemic arterial\n hypertension with BP 192/75\n Assessment and Plan\n 58 yo female w/ hx of CAD s/p LAD and RCA stents, LHCath w/ multivessel\n disease, CHF, HTN, Hyperlipidemia, PVD , ESRD s/p allograft transplant\n complicated by graft rejection, Scleroderma presenting with\n worsening dyspnea and chest pain.\n .\n # CORONARIES: Known mid-distal LAD, distal CFX and PL occlusion. Pt.\n presenting w/ sx of unstable angina. CP likely demand ischemia.\n ECG unchanged from prior. Per previous notes, pt. not a good\n candidate for CABG or stenting, unclear rationale from . Goal is to\n maximizing medical managment. Received ASA in ED.\n - Continue ASA 81mg, Lisinopril\n - Restart BBK and ImDur, Lisinopril in AM\n - ROMI\n - Tele\n - Will hold off on heparin gtt as HCT 29 - > 27 since admission and pt.\n diuresed during this time.\n .\n # PUMP: sCHF w/ EF 40%, mild-to-moderate regional left ventricular\n systolic dysfunction, c/w CAD on last Echo. Pt. admitted w/ signs of\n Left sided HF, likely poor HTN control, likely flash pulmonary\n edema on admission. CXR consistent w/ this. Now improved on BiPap s/p\n IV lasix ~ 1L. No signs of volume overload on exam on admission. O2\n sat > 98% on FiO2 50%. Demand ischemia also likely contributing to\n diastolic dysfunction. Conservative goal of -1L o/n.\n - Continue to monitor O2 sats and wean as tolerated.\n - Continue BiPaP.\n - Nitro gtt to titrate SBP to < 140 to reduce afterload and improve\n forward flow\n - Will give additional dose of lasix 40mg IV, if U/O < 100cc/hr\n - Will restart BBk, ImDur and lisinopril in AM\n - Repeat CXR in AM.\n .\n # RHYTHM: No hx of rhythm problems. ECG sinus. No Tw abnormalties on\n ECG.\n - Telemetry\n - Recheck K now, then daily.\n .\n # PVD - severe PVD w/ anl. ABIs b/l. most recent eval. in \n showing the right ABI of 0.68, the L ABI of 0.75. These were unchanged\n from prior.\n - Will touch base w/ vascular re: any further intervention/assessment.\n .\n # Chronic Renal Failure s/p renal transplants. Cr, 2.1, mildly\n elevated from baseline (1.9).\n - Will monitor\n - Continue Cellcept\n - Continue Tacrolimus\n - Continue Prednisone\n - Will restart lisinopril in Am.\n .\n # Scleroderma. No acute issues currently.\n - continue immunosuppressive tx as above\n .\n # Anemia. HCT 29->27 in ICU. Baseline 30-35 per . Likely ACD, the\n cause of acute decrease uncertain, as likely not dilutional. Will\n review for Fe studies.\n - Daily HCT.\n - Guiac all stools.\n .\n # Hyperlipidemia - LDL from 174. will continue , \n most likely need to increase to 80.\n .\n # Hyperkalemia. last K 6.1, no ECG changes.\n - Repeat K.\n .\n FEN: NPO for now. No IVF. Monitoring K.\n ACCESS: PIV's b/l.\n PROPHYLAXIS:\n -DVT ppx with Heparin SC.\n -Pain managment with Tylenol PRN\n -Bowel regimen\n CODE: Full\n DISPO: SVICU for now. Will reassess in AM for transfer to floor.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 12:28 AM\n 18 Gauge - 12:29 AM\n"
},
{
"category": "Physician ",
"chartdate": "2201-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 353863,
"text": "TITLE:\n Chief Complaint: DOE\n Pt improved slightly overnight in terms of SOB. She denies CP, nausea,\n vomiting. Is comfortable while supine. Weaned off BiPAP, continued\n diuresis, and NTG drip. Patient required Mg replacement.\n Allergies:\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 07:08 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 72 (61 - 78) bpm\n BP: 155/66(88) {141/59(79) - 175/76(97)} mmHg\n RR: 24 (20 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 375 mL\n PO:\n TF:\n IVF:\n 375 mL\n Blood products:\n Total out:\n 0 mL\n 1,290 mL\n Urine:\n 1,290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -915 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 50%\n SpO2: 99%\n ABG: ///19/\n Ve: 10.4 L/min\n Physical Examination\n GENERAL: NAD, w/ BiPAP. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva pink, no cyanosis of\n the oral mucosa. No bruits.\n NECK: Supple, no JVD\n CARDIAC: PMI could not be located. RR, normal S1, S2. No m/r/g. No S3\n or S4.\n LUNGS: Pt. supine, unable to ausc. post. Unlabored resp on Bipap, no\n accessory muscle use. Diffuse rhonchi laterally.\n ABDOMEN: Obese, soft, NTND. Multiple scars,well healed. Could not\n palpate abd aorta. No abdominial bruits appreciated.\n EXTREMITIES: warm, dry, no edema. calcinosis and loss of skin texture,\n no sclerodactyly. Contractures in RUE, LE b/l. RUE fistula, no\n erythema, thrill present.\n SKIN: No stasis dermatitis ulcers or scars..\n PULSES:\n Right: Carotid 2+ Femoral 2+ could not appreciate DP or PT. extremity\n warm.\n Left: Carotid 2+ could not appreciate DP or PT. extremity warm.\n Bruit appreciated over the bifem bypass.\n Labs / Radiology\n 135 K/uL\n 8.9 g/dL\n 194 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.5 mEq/L\n 37 mg/dL\n 108 mEq/L\n 135 mEq/L\n 26.6 %\n 7.1 K/uL\n [image002.jpg]\n 01:47 AM\n WBC\n 7.1\n Hct\n 26.6\n Plt\n 135\n Cr\n 2.3\n TropT\n 0.03\n Glucose\n 194\n Other labs: CK / CKMB / Troponin-T:77//0.03, Ca++:9.9 mg/dL, Mg++:1.2\n mg/dL, PO4:3.5 mg/dL\n Troponin 0.03 x2. UA w/ proteinuria, all else negative. U lytes\n pending.\n Assessment and Plan\n 58 yo female w/ hx of CAD s/p LAD and RCA stents, LHCath w/ multivessel\n disease, CHF, HTN, Hyperlipidemia, PVD , ESRD s/p allograft transplant\n complicated by graft rejection, Scleroderma presented with\n worsening dyspnea and chest pain. Now improved in terms of dyspnea,\n off BiPAP.\n .\n # CORONARIES: Known mid-distal LAD, distal CFX and PL occlusion. Pt.\n presenting w/ sx of unstable angina, likely demand ischemia. ECG\n unchanged from prior. Goal is to maximize medical management.\n - Continue ASA 81mg, Lisinopril\n - Restart BBK and ImDur, Lisinopril today (touch base w/ Renal OP\n provider : restarting Lisinopril in setting of increasing Cr.)\n - Complete ROMI\n - Continue Tele\n - No indication for heparin at this time as pt asymptomatic.\n .\n # PUMP/HTN: Patient euvolemic on exam, CXR improved significantly. Hx\n of sCHF w/ EF 40%, mild-to-moderate regional left ventricular systolic\n dysfunction, c/w CAD on last Echo. Pt. admitted w/ signs of Left sided\n HF, likely poor HTN control, likely flash pulmonary edema on\n admission. CXR consistent w/ this. Now improved on BiPap s/p IV lasix\n ~ 1L. No signs of volume overload on exam on admission. O2 sat > 95\n - 98% on RA now. Demand ischemia also likely contributing to diastolic\n dysfunction. No need for further diuresis. HTN control critical at\n this point, goal is SBP 140\n 150 and DBP < 95.\n - Continue BiPaP if pt desats or SOB worsens\n - Wean Nitro gtt\n - Restart BBk, ImDur and lisinopril\n - If pt continues to be hypertensive, Will condiser adding on\n nifedipine, as pt. w/ pedal edema w/ Norvasc. Also consider PDE\n inhibitor of no improvement.\n .\n # RHYTHM: No hx of rhythm problems. ECG sinus. No Tw abnormalties on\n ECG.\n - Telemetry\n - Recheck K today.\n .\n # PVD - severe PVD w/ anl. ABIs b/l. most recent eval. in \n showing the right ABI of 0.68, the L ABI of 0.75. These were unchanged\n from prior. This is likely contributing to poor renal perfusion and\n persistent hypertension.\n - Will touch base w/ vascular re: any further intervention/assessment\n regarding localization of the lesion and stenting to improve graft\n perfusion.\n .\n # Chronic Renal Failure s/p renal transplants. Cr, 2.3, elevated from\n baseline (1.9), now w/ Proteinuria > 500. Likely intravascular\n depletion state w/ diuresis. Enourage PO, now the BPs w/ improved\n control, EF of 40% should be sufficient for forward flow.\n - Will monitor\n - Continue Cellcept\n - Continue Tacrolimus\n - Continue Prednisone\n - Will restart lisinopril if ok w/ Renal.\n .\n # Scleroderma. No acute issues currently.\n - continue immunosuppressive tx as above\n .\n # Anemia. HCT 29->27 in ICU. Baseline 30-35 per OMR. Likely ACD, the\n cause of acute decrease uncertain, as likely not dilutional. Will\n review OMR for Fe studies.\n - Daily HCT.\n - Guiac all stools.\n .\n # Hyperlipidemia - LDL from 174. will continue , \n most likely need to increase to 80.\n .\n # Hyperkalemia. last K 5.5, but hypomagnasemic, replete K and Mg to 4\n and 2 respectively.\n - Repeat K/Mg in afternoon.\n .\n FEN: Advance diet, encourage PO. No IVF.\n ACCESS: PIV's b/l.\n PROPHYLAXIS:\n -DVT ppx with Heparin SC.\n -Pain management with Tylenol PRN\n -Bowel regimen\n CODE: Full\n DISPO: SVICU for now, can likely transfer to floor to wean NTG gtt and\n if BPs controlled to goal.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:28 AM\n 18 Gauge - 12:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2201-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 353838,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 11:45 PM\n EKG - At 12:53 AM\n Allergies:\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 07:08 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 72 (61 - 78) bpm\n BP: 155/66(88) {141/59(79) - 175/76(97)} mmHg\n RR: 24 (20 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 375 mL\n PO:\n TF:\n IVF:\n 375 mL\n Blood products:\n Total out:\n 0 mL\n 1,290 mL\n Urine:\n 1,290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -915 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 450 (450 - 450) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 50%\n SpO2: 99%\n ABG: ///19/\n Ve: 10.4 L/min\n Physical Examination\n GENERAL: NAD, w/ BiPAP. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva pink, no cyanosis of\n the oral mucosa. No bruits.\n NECK: Supple, unable to assess JVP 2/2 bipap.\n CARDIAC: PMI could not be located. RR, normal S1, S2. No m/r/g. No S3\n or S4.\n LUNGS: Pt. supine, unable to ausc. post. Unlabored resp on Bipap, no\n accessory muscle use. Diffuse rhonchi laterally.\n ABDOMEN: Obese, soft, NTND. Multiple scars,well healed. Could not\n palpate abd aorta. No abdominial bruits appreciated.\n EXTREMITIES: warm, dry, no edema. calcinosis and loss of skin texture,\n no sclerodactyly. Contractures in RUE, LE b/l. RUE fistula, no\n erythema, thrill present.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ could not appreciate DP or PT. extremity\n warm.\n Left: Carotid 2+ could not appreciate DP or PT. extremity warm.\n Labs / Radiology\n 135 K/uL\n 8.9 g/dL\n 194 mg/dL\n 2.3 mg/dL\n 19 mEq/L\n 5.5 mEq/L\n 37 mg/dL\n 108 mEq/L\n 135 mEq/L\n 26.6 %\n 7.1 K/uL\n [image002.jpg]\n 01:47 AM\n WBC\n 7.1\n Hct\n 26.6\n Plt\n 135\n Cr\n 2.3\n TropT\n 0.03\n Glucose\n 194\n Other labs: CK / CKMB / Troponin-T:77//0.03, Ca++:9.9 mg/dL, Mg++:1.2\n mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 58 yo female w/ hx of CAD s/p LAD and RCA stents, LHCath w/ multivessel\n disease, CHF, HTN, Hyperlipidemia, PVD , ESRD s/p allograft transplant\n complicated by graft rejection, Scleroderma presenting with\n worsening dyspnea and chest pain.\n .\n # CORONARIES: Known mid-distal LAD, distal CFX and PL occlusion. Pt.\n presenting w/ sx of unstable angina. CP likely demand ischemia.\n ECG unchanged from prior. Per previous notes, pt. not a good\n candidate for CABG or stenting, unclear rationale from . Goal is to\n maximizing medical managment. Received ASA in ED.\n - Continue ASA 81mg, Lisinopril\n - Restart BBK and ImDur, Lisinopril in AM\n - ROMI\n - Tele\n - Will hold off on heparin gtt as HCT 29 - > 27 since admission and pt.\n diuresed during this time.\n .\n # PUMP: sCHF w/ EF 40%, mild-to-moderate regional left ventricular\n systolic dysfunction, c/w CAD on last Echo. Pt. admitted w/ signs of\n Left sided HF, likely poor HTN control, likely flash pulmonary\n edema on admission. CXR consistent w/ this. Now improved on BiPap s/p\n IV lasix ~ 1L. No signs of volume overload on exam on admission. O2\n sat > 98% on FiO2 50%. Demand ischemia also likely contributing to\n diastolic dysfunction. Conservative goal of -1L o/n.\n - Continue to monitor O2 sats and wean as tolerated.\n - Continue BiPaP.\n - Nitro gtt to titrate SBP to < 140 to reduce afterload and improve\n forward flow\n - Will give additional dose of lasix 40mg IV, if U/O < 100cc/hr\n - Will restart BBk, ImDur and lisinopril in AM\n - Repeat CXR in AM.\n .\n # RHYTHM: No hx of rhythm problems. ECG sinus. No Tw abnormalties on\n ECG.\n - Telemetry\n - Recheck K now, then daily.\n .\n # PVD - severe PVD w/ anl. ABIs b/l. most recent eval. in \n showing the right ABI of 0.68, the L ABI of 0.75. These were unchanged\n from prior.\n - Will touch base w/ vascular re: any further intervention/assessment.\n .\n # Chronic Renal Failure s/p renal transplants. Cr, 2.1, mildly\n elevated from baseline (1.9).\n - Will monitor\n - Continue Cellcept\n - Continue Tacrolimus\n - Continue Prednisone\n - Will restart lisinopril in Am.\n .\n # Scleroderma. No acute issues currently.\n - continue immunosuppressive tx as above\n .\n # Anemia. HCT 29->27 in ICU. Baseline 30-35 per . Likely ACD, the\n cause of acute decrease uncertain, as likely not dilutional. Will\n review for Fe studies.\n - Daily HCT.\n - Guiac all stools.\n .\n # Hyperlipidemia - LDL from 174. will continue , \n most likely need to increase to 80.\n .\n # Hyperkalemia. last K 6.1, no ECG changes.\n - Repeat K.\n .\n FEN: NPO for now. No IVF. Monitoring K.\n ACCESS: PIV's b/l.\n PROPHYLAXIS:\n -DVT ppx with Heparin SC.\n -Pain managment with Tylenol PRN\n -Bowel regimen\n CODE: Full\n DISPO: SVICU for now. Will reassess in AM for transfer to floor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:28 AM\n 18 Gauge - 12:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2201-10-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 353926,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n pt w/ extensive pmh, refer to FHP. Adm to ED w/ progressive SOB, resp\n distress w/ elevated BP.NSR. AAOx3. abd soft, hypo bsp. No nausea. NPO\n this am, poor appetite for lunch. Pt strong cough productive of small\n amts thick yellow sputum. Lungs clear bilat this afternoon. Daughter at\n bedside aware of transfer.\n Action:\n Pt placed on NTG drip and noninvassive ventilation. Diuresed w/ lasix.\n Transitioned to po antihypertensives. this am. NTg drip weaned as well\n as o2.\n Response:\n SBP 120-140\ns. HR presently SB 55-65. o2 sats 95% on r/a. lungs cta.\n Plan:\n Transfer\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Height:\n Admission weight:\n 80 kg\n Daily weight:\n Allergies/Reactions:\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Precautions:\n PMH: Renal Failure, Smoker\n CV-PMH: Hypertension, MI\n Additional history: PAD s/p left fem-fem BPG & RT ILIAC STENT ,\n rEANL FAILURE S/P RENAL TRANSPLANT X2 MOST RECENTLY IN WITH\n SUBACUTE REJECTION. GIB SCLERODERMA. HERPES ZOSTER.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:128\n D:54\n Temperature:\n 99.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 61 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 728 mL\n 24h total out:\n 2,480 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 01:47 AM\n Potassium:\n 5.5 mEq/L\n 01:47 AM\n Chloride:\n 108 mEq/L\n 01:47 AM\n CO2:\n 19 mEq/L\n 01:47 AM\n BUN:\n 37 mg/dL\n 01:47 AM\n Creatinine:\n 2.3 mg/dL\n 01:47 AM\n Glucose:\n 194 mg/dL\n 01:47 AM\n Hematocrit:\n 26.6 %\n 01:47 AM\n Additional pertinent labs:\n labs pending from 1700\n Lines / Tubes / Drains:\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: none\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2201-10-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 353916,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n pt w/ extensive pmh, refer to FHP. Adm to ED w/ progressive SOB, resp\n distress w/ elevated BP.NSR. AAOx3. abd soft, hypo bsp. No nausea. NPO\n this am, poor appetite for lunch. Pt strong cough productive of small\n amts thick yellow sputum. Lungs clear bilat this afternoon. Daughter at\n bedside aware of transfer.\n Action:\n Pt placed on NTG drip and noninvassive ventilation. Diuresed w/ lasix.\n Transitioned to po antihypertensives. this am. NTg drip weaned as well\n as o2.\n Response:\n SBP 120-140\ns. HR presently SB 55-65. o2 sats 95% on r/a. lungs cta.\n Plan:\n Transfer\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Height:\n Admission weight:\n 80 kg\n Daily weight:\n Allergies/Reactions:\n Norvasc (Oral) (Amlodipine Besylate)\n edema;\n Precautions:\n PMH: Renal Failure, Smoker\n CV-PMH: Hypertension, MI\n Additional history: PAD s/p left fem-fem BPG & RT ILIAC STENT ,\n rEANL FAILURE S/P RENAL TRANSPLANT X2 MOST RECENTLY IN WITH\n SUBACUTE REJECTION. GIB SCLERODERMA. HERPES ZOSTER.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:128\n D:54\n Temperature:\n 99.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 61 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 728 mL\n 24h total out:\n 2,480 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 01:47 AM\n Potassium:\n 5.5 mEq/L\n 01:47 AM\n Chloride:\n 108 mEq/L\n 01:47 AM\n CO2:\n 19 mEq/L\n 01:47 AM\n BUN:\n 37 mg/dL\n 01:47 AM\n Creatinine:\n 2.3 mg/dL\n 01:47 AM\n Glucose:\n 194 mg/dL\n 01:47 AM\n Hematocrit:\n 26.6 %\n 01:47 AM\n Additional pertinent labs:\n labs pending from 1700\n Lines / Tubes / Drains:\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: none\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Respiratory ",
"chartdate": "2201-10-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 353798,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n 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 Ventilation Assessment\n Level of breathing assistance: Continuous non-invasive ventilation\n Non-invasive ventilation assessment: Mask discomfort; Comments: Pt. c/o\n mask hurting face. Changed to smaller mask due to leak.\n :\n Comments: Pt. transferred from ED on NIV. Pt. c/o mask discomfort.\n Frequent leaks, changed to smaller mask. . O2 Sat 99%, wean from NIV as\n tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2201-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 353806,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Alert/oriented x3. pleasant/cooperative with care. Follows all\n commands. VSS HTN afebrile. Lsc. BIPAP mask (since arrival from\n E.R.)abd soft. (+) bs. Diureseing. (-) edema. Strong pedal pulses.\n Action:\n Ntg gtt tirated to keep SBP </= 140. diuresing from60mg Iivp Lasix\n givenin E.R.\n Response:\n SBP 169-> 145. U/O > 1 Liter in 4hrs.\n Plan:\n Wean Bipao mask settings. Continue diuresing.\n"
},
{
"category": "ECG",
"chartdate": "2201-10-28 00:00:00.000",
"description": "Report",
"row_id": 284971,
"text": "Sinus rhythm. Late R wave progression with ST segment elevation and T wave\ninversion. Consider anterior myocardial infarction, age indeterminate.\nSince the previous tracing of there continues to be variable morphology\nin lead aVF but cannot exclude inferior myocardial infarction, age\nundetermined. Since the previous tracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2201-10-27 00:00:00.000",
"description": "Report",
"row_id": 284972,
"text": "Sinus rhythm. Non-diagnostic inferior Q waves but with T wave abnormalities.\nConsider inferior myocardial infarction, age undetermined. There is precordial\nR wave reversal with development of Q waves and ST segment elevation. Probable\nanterior myocardial infarction. Since the previous tracing of \nprobably no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2201-10-30 00:00:00.000",
"description": "Report",
"row_id": 284969,
"text": "Sinus bradycardia. Possible prior anterior myocardial infarction with\nperistent anterior T wave changes. Compared to the previous tracing\nof there is no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2201-10-29 00:00:00.000",
"description": "Report",
"row_id": 284970,
"text": "Sinus bradycardia\nAnterior myocardial infarction with ST-T wave configuration suggesting\nacute/recent/in evolution process\nClinical correlation is suggested\nSince previous tracing of , no significant change\n\n"
}
] |
74,354 | 118,243 | This is a 54 year old F in her usual state of health until an episode of syncope and seizure. OSH CT revealed a brain mass with vasogenic edema. Patient was transferred to where a Head CT was repeated- again showing a two rim-enhancing lesions peripherally located within the right frontal lobe with associated vasogenic edema and mass effect. Pt was admitted to the ICU under Dr. care. A Brain MRI was done on which showed two enhancing right frontal lesions most consistent with metastases with surrounding vasogenic edema and right frontal sulcal effacement A CT Torso was done on , which was negative for any primary lesion or mets, but did show ground glass opacity in RUL. She was consented and pre-oped, and went to the OR for resection of this mass on . The procedure went well without complications. The preliminary pathology report was metastatic carcinoma. She remained in the PACU overnight for Q1 hour neuro checks post-op. CT head was negative for hemorrhage. She was stable on and she was transferred to the Step down unit. Her Foley and A-line was discontinued. She had an MRI. PT and OT were ordered. She was cleared for home on with PT outpatient needs. | Right frontal edema persists, with unchanged minimal, 2 mm leftward shift of midline structures. Consolidation within the superior segment of left lower lobe and right lower lobe are unchanged since CT of the torso of .New small bilateral pleural effusions are noted. Unchanged right frontal edema and 2 mm leftward shift of midline structures. TECHNIQUE: Non-contrast head CT was obtained. TECHNIQUE: Non-contrast head CT was obtained. Persistent, unchanged right frontal edema and 2 mm leftward shift of midline structures. right frontal edema unchanged. Unchanged right frontal edema. Unchanged right frontal edema. Punctate hyperdensity of the right frontal lobe is unchanged. COMPARISON: CT of the head performed without intravenous contrast at the on . Right frontal edema is unchanged, associated with the two right frontal enhancing lesions that are better seen on the previous studies with contrast. inferiorly an unchnaged punctate focus of hemorrhage is again noted. while one does abut the dura, it lacks a characteristic dural tail, and the more inferior lesion on reformatted images does appear intraaxial. The uterus and adnexa appear grossly normal. IMPRESSION: Expected postoperative appearance status-post right craniotomy. The second, more inferior lesion is centrally necrotic, measures 1.2 cm (AP) x 0.9 cm (TRV) x 1.1 cm (SI), and demonstrates less surrounding vasogenic edema. The amount of right frontal edema is similar to the previous study. PLEASE PERFORM SWI SEQUENCE AS WELL No contraindications for IV contrast WET READ: JXRl MON 2:52 PM 2 enhancing right frontal lesions most consistent w/ metastases w/ surrounding edema. Findings: The cardiomediastinal silhouette and hilar contours are normal. The major vascular flow voids are normal. Interval resection of the two right frontal lesions. FINDINGS: On non-contrast imaging, there is extensive vasogenic parenchymal edema again identified in the right frontal lobe, with a small focus of hyperdensity inferiorly, suggestive of hemorrhage. Two curvilinear foci of residual enhancement of the right frontal lobe. IMPRESSION: Preoperative surgical planning study demonstrates two enhancing lesions in the right frontal lobe with surrounding edema without midline shift or hydrocephalus. post-contrast, two peripherally located right frontal rim-enhancing lesions are noted. no uncal or tonsillar herniation. Moreover, the more inferior lesion does appear intra-axial on coronal and sagittal reformatted images (106A:47 and 105B:15). Expected pneumocephalus overlies the right frontal lobe. The visualized paranasal sinuses and mastoid air cells remain normally pneumatized and well-aerated. The visualized paranasal sinuses and mastoid air cells remain normally pneumatized and well-aerated. unchanged 2mm leftward shift of midline structures. Unchanged 2mm leftward shift of midline structures. Gallbladder sludge without acute cholecystitis. 2-mm leftward shift of midline structures is unchanged. One lesion in the right frontal lobe convexity demonstrates significant surrounding edema. Ventricles are unchanged in size and configuration. The ventricles are unchanged in size and configuration. There is slight nodularity to the inferior aspect of the left adrenal gland. FINDINGS: The patient has undergone a right frontal craniotomy. Leftward shift of midline structures by 2 mm is unchanged. Heterogeneously enhancing focus in the posterior segment of the LLL (3.3 x 1.9 cm), could represent PNA, aspiration but cannot rule out mass lesion. The pleural surfaces are smooth, and the hilar and cardiomediastinal contours are normal. Visualized paranasal sinuses and mastoid air cells are normally aerated. Adequate positioning of endotracheal and nasogastric tubes. Two enhancing right frontal lesions most consistent with metastases with surrounding vasogenic edema and right frontal sucal effacment. Persistent right frontal parenchymal edema with 2 mm leftward shift of midline structures. Persistent right frontal parenchymal edema with 2 mm leftward shift of midline structures. right frontal lesions better seen on prevous studies w/ IV contrast. A second rim-enhancing lesion more inferiorly, the site of punctate hemorrhage seen on non-contrast images, measures 11 x 12 mm. Trace pelvic free fluid. Trace free pelvic fluid. FINDINGS: Two enhancing right frontal lesions located near the -white matter junction correspond with the lesions identified on the prior CT. CHEST, ABD, PELVIS WITH CONTRAST No contraindications for IV contrast WET READ: ENYa MON 5:59 PM 1. A second lesion seen slightly posteriorly and laterally demonstrates less edema. The right adrenal gland is normal. The -white matter differentiation is elsewhere preserved, without evidence for acute large vascular territory infarction. A curvilinear focus of enhancement in the superior right frontal lobe (14:19) is located in the area of the more superior right frontal lesion. No hydroureteronephrosis. FINDINGS: A single supine portable chest radiograph is reviewed. FINDINGS: The patient has undergone right frontal craniotomy, with resection of the two enhancing right frontal lesions. There are bilateral renal hypodensities, too small to characterize, but likely representing cysts. Less likely atelectasis (3:24). TECHNIQUE: MDCT of the chest, abdomen and pelvis was performed following the uneventful administration of nonionic intravenous contrast and oral contrast. Minimal, 2 mm leftward shift of midline structures persists, unchanged. The pelvic bowel loops are grossly normal and there is no gross adenopathy. FINDINGS: There is no intracranial hemorrhage. On coronal and sagittal reformatted images, this lesion is more clearly intra-axial in location. No acute infarct. No acute infarct. There are prominent to borderline left intrapulmonary lymph nodes. More inferiorly, a curvilinear area of linear enhancement (14:15) is identified, and may be vascular in etiology. TECHNIQUE: Multiplanar T1- and T2-weighted imaging was obtained before and after administration of gadolinium. FINDINGS: CHEST: An endotracheal tube is in satisfactory position. The inferior lesion demonstrates a punctate focus of hemorrhage. COMPARISON: MRI of the head and CT of the head with and without contrast, , . -white matter differentiation of the left hemisphere is normal. There are no suspicious lytic or sclerotic osseous lesions. mri recommended for further eval. There is no abnormal extra-axial fluid collection. (Over) 3:52 AM CT HEAD W/ & W/O CONTRAST Clip # Reason: please eval for interval change (nsgy requests contrast) Contrast: OPTIRAY Amt: 70 FINAL REPORT (Cont) Bones demonstrate no abnormality. | 12 | [
{
"category": "Radiology",
"chartdate": "2104-05-21 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1133436,
"text": " 2:20 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: BRAIN MASS\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman to OR for R crani \n REASON FOR THIS EXAMINATION:\n 54 year old woman to OR for R crani \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-operative radiograph for craniotomy.\n\n Comparison is made to the prior study of .\n\n Findings: The cardiomediastinal silhouette and hilar contours are normal.\n Consolidation within the superior segment of left lower lobe and right lower\n lobe are unchanged since CT of the torso of .New small bilateral\n pleural effusions are noted. The left PICC distal tip projects in the\n axillary vein.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-05-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1133159,
"text": " 4:46 PM\n CT HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval for herniation, progression of midline shift\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with mental status changes s/p LP\n REASON FOR THIS EXAMINATION:\n eval for herniation, progression of midline shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl MON 5:03 PM\n no intracranial hemorrhage. unchanged 2mm leftward shift of midline\n structures. no uncal or tonsillar herniation. right frontal edema unchanged.\n right frontal lesions better seen on prevous studies w/ IV contrast.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old woman with mental status changes after a lumbar\n puncture.\n\n COMPARISON: MRI of the head and CT of the head with and without contrast, , .\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: There is no intracranial hemorrhage. Leftward shift of midline\n structures by 2 mm is unchanged. There is no evidence of uncal or\n transtentorial herniation. Right frontal edema is unchanged, associated with\n the two right frontal enhancing lesions that are better seen on the previous\n studies with contrast. Punctate hyperdensity of the right frontal lobe is\n unchanged.\n\n The visualized paranasal sinuses and mastoid air cells remain normally\n pneumatized and well-aerated. There are no concerning osseous lesions.\n\n IMPRESSION:\n 1. No intracranial hemorrhage or evidence of transtentorial or uncal\n herniation.\n 2. Unchanged right frontal edema and 2 mm leftward shift of midline\n structures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-05-19 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 1133160,
"text": " 4:48 PM\n CT ABD W&W/O C; CT CHEST W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: 54 year old woman with brain mass vs. abscess. Eval for oth\n Admitting Diagnosis: BRAIN MASS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with brain mass vs. abscess. Eval for other potential\n malignancies. CHEST, ABD, PELVIS WITH CONTRAST\n REASON FOR THIS EXAMINATION:\n 54 year old woman with brain mass vs. abscess. Eval for other potential\n malignancies. CHEST, ABD, PELVIS WITH CONTRAST\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa MON 5:59 PM\n 1. Heterogeneously enhancing focus in the posterior segment of the LLL (3.3 x\n 1.9 cm), could represent PNA, aspiration but cannot rule out mass lesion.\n Less likely atelectasis (3:24). Recommend f/u after abx treatment to ensure\n clearance.\n 2. Non-specific 6-mm ground-glass opacity in RUL (3:8).\n 3. Bibasilar dependent atelectasis.\n 4. Gallbladder sludge without acute cholecystitis.\n 5. Bilateral subcentimeter renal cysts. No hydroureteronephrosis.\n 6. No bowel obstruction.\n 7. Trace free pelvic fluid.\n 8. No suspicious bone lesions. Evaluated of lower lumbar spine limited by\n patient's motion.\n 9. ETT and NGT in expected locations.\n EYeh entered wetread in CCC.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Enhancing brain lesions, evaluate for primary\n malignancy.\n\n TECHNIQUE: MDCT of the chest, abdomen and pelvis was performed following the\n uneventful administration of nonionic intravenous contrast and oral contrast.\n Initial non-contrast images were obtained through the abdomen and delayed\n images were also obtained through the abdomen. There are no prior studies for\n comparison.\n\n FINDINGS:\n\n CHEST: An endotracheal tube is in satisfactory position. There is no\n pericardial or pleural effusion. There are prominent to borderline left\n intrapulmonary lymph nodes. For example, a lymph node adjacent to the left\n pulmonary artery (3:20) measures 1.2 cm. Two lymph nodes adjacent to the left\n lower lobe pulmonary artery measures up to 0.7 cm in short axis. Lung windows\n demonstrate bibasilar atelectasis. There is a more focal area of\n consolidation in the superior segment of the left lower lobe, with a slightly\n rounded appearance more inferiorly. The central airways are patent.\n\n ABDOMEN: There are no focal liver lesions. The gallbladder contains layering\n (Over)\n\n 4:48 PM\n CT ABD W&W/O C; CT CHEST W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: 54 year old woman with brain mass vs. abscess. Eval for oth\n Admitting Diagnosis: BRAIN MASS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n sludge. There is slight nodularity to the inferior aspect of the left adrenal\n gland. The right adrenal gland is normal. There are bilateral renal\n hypodensities, too small to characterize, but likely representing cysts. The\n spleen and pancreas are normal. There are no pathologically enlarged lymph\n nodes by size criteria. The abdominal bowel loops are unremarkable. A\n nasogastric tube terminates in the stomach. There is no abdominal ascites.\n There are atherosclerotic calcifications of the aorta.\n\n PELVIS: Motion artifact slightly limits evaluation. The uterus and adnexa\n appear grossly normal. There is a small amount of free fluid. The bladder is\n decompressed with a Foley catheter. The pelvic bowel loops are grossly normal\n and there is no gross adenopathy.\n\n Allowing for motion artifact, there are no focal suspicious bony lesions.\n\n Gas is seen tracking in the posterior subcutaneous soft tissues and into the\n left paraspinal musculature and left psoas muscle. There is no focal fluid\n collection.\n\n IMPRESSION:\n 1. No definite evidence of malignancy. Consolidation within the superior\n segment of the left lower lobe may represent infection, but there is a\n slightly more rounded appearance inferiorly, and consider repeat chest CT\n following treatment. Prominent left-sided intrapulmonary lymph nodes may be\n reactive.\n\n 2. Gallbladder sludge.\n\n 3. Gas tracking in the posterior subcutaneous tissues and extending into the\n left paraspinal musculature and left psoas muscle. Findings are likely\n related to pressure erosion. There is no focal fluid collection.\n\n 4. Trace pelvic free fluid. Slightly limited evaluation of the pelvis due to\n motion artifact, but no gross abnormalities are identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-05-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1133602,
"text": " 2:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 54 year old woman s/p R frontal crani - eval for post op hem\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman s/p R frontal crani - eval for post op hemorrhage. perform\n within 4 hours post op\n REASON FOR THIS EXAMINATION:\n 54 year old woman s/p R frontal crani - eval for post op hemorrhage. perform\n within 4 hours post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 3:22 PM\n Expected postoperative pneumocephalus and soft tissue gas overlying the right\n craniotomy site. No evidence of intracranial hemorrhage. Unchanged right\n frontal edema. No hydrocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old woman status post right frontal craniotomy. Evaluate\n for postoperative hemorrhage.\n\n COMPARISON: Head CT, and MRI of the head, .\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: The patient has undergone a right frontal craniotomy. Expected\n pneumocephalus overlies the right frontal lobe. The amount of right frontal\n edema is similar to the previous study. Minimal, 2 mm leftward shift of\n midline structures persists, unchanged. High-density material in the\n peripheral aspect of the surgical bed is present. -white matter\n differentiation of the left hemisphere is normal. Ventricles are unchanged in\n size and configuration. There is no transtentorial or uncal herniation.\n\n The visualized paranasal sinuses and mastoid air cells remain normally\n pneumatized and well-aerated. There is gas in the soft tissues overlying the\n craniotomy site.\n\n IMPRESSION: Expected postoperative appearance status-post right craniotomy.\n Unchanged 2mm leftward shift of midline structures.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-05-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1133045,
"text": " 3:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval tube placement, acute cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman transferred, intubated\n REASON FOR THIS EXAMINATION:\n please eval tube placement, acute cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old female with intracranial mass, intubated at an\n outside hospital. Evaluate tube placement and for acute cardiopulmonary\n process.\n\n COMPARISON: None.\n\n FINDINGS: A single supine portable chest radiograph is reviewed.\n Endotracheal tube terminates at the thoracic inlet, 6.5 cm above the carina.\n Nasogastric tube passes into the stomach and off the inferior margin of film.\n EKG leads and oxygen tubing overlie the chest. There is no focal\n consolidation, and no effusion or pneumothorax. The pleural surfaces are\n smooth, and the hilar and cardiomediastinal contours are normal. A one-cm\n wide opacity projecting over the right lung base is more likely the right\n nipple than a solitary lung nodule.\n\n IMPRESSION: No acute cardiopulmonary process. Adequate positioning of\n endotracheal and nasogastric tubes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-05-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1133603,
"text": ", M. NSURG PACU 2:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 54 year old woman s/p R frontal crani - eval for post op hem\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman s/p R frontal crani - eval for post op hemorrhage. perform\n within 4 hours post op\n REASON FOR THIS EXAMINATION:\n 54 year old woman s/p R frontal crani - eval for post op hemorrhage. perform\n within 4 hours post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Expected postoperative pneumocephalus and soft tissue gas overlying the right\n craniotomy site. No evidence of intracranial hemorrhage. Unchanged right\n frontal edema. No hydrocephalus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-05-19 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1133094,
"text": " 9:49 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 54 year old woman with 2 known R frontal masses, VG edema. A\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 13CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with 2 known R frontal masses, VG edema. Abscess vs. mass?\n PLEASE PERFORM SWI SEQUENCE AS WELL\n REASON FOR THIS EXAMINATION:\n 54 year old woman with 2 known R frontal masses, VG edema. Abscess vs. mass?\n PLEASE PERFORM SWI SEQUENCE AS WELL\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl MON 2:52 PM\n 2 enhancing right frontal lesions most consistent w/ metastases w/ surrounding\n edema. no intracranial hemorrhage, no shift of midline structures, no uncal\n herniation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old woman with right frontal masses and vasogenic edema.\n\n COMPARISON: CT of the head with and without contrast, six hours prior and\n non-contrast head CT from , .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was performed\n before and after administration of IV gadolinium.\n\n FINDINGS: Two enhancing right frontal lesions located near the -white\n matter junction correspond with the lesions identified on the prior CT. The\n more superior lesion has a greater amount of surrounding edema and associated\n sulcal effacement and measures 1.2 cm (AP) x 1.4 cm (TRV) x 1.1 cm (SI). The\n second, more inferior lesion is centrally necrotic, measures 1.2 cm (AP) x 0.9\n cm (TRV) x 1.1 cm (SI), and demonstrates less surrounding vasogenic edema.\n 2-mm leftward shift of midline structures is unchanged. There is no uncal or\n transtentorial herniation. There are no areas of restricted diffusion to\n suggest an acute infarct. There is no intracranial hemorrhage.\n\n IMPRESSION:\n 1. Two enhancing right frontal lesions most consistent with metastases with\n surrounding vasogenic edema and right frontal sucal effacment.\n 2. 2mm leftward shift of midline structures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-05-19 00:00:00.000",
"description": "CT HEAD W/ & W/O CONTRAST",
"row_id": 1133051,
"text": " 3:52 AM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: please eval for interval change (nsgy requests contrast)\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with new right sided mass with eedema and hemorrhage, have\n outside hospital CT for reference\n REASON FOR THIS EXAMINATION:\n please eval for interval change (nsgy requests contrast)\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy MON 5:12 AM\n on non-contrast images, there is extensive right frontal parenchymal vasogenic\n edema with associated mass effect and 3 mm leftward shift. inferiorly an\n unchnaged punctate focus of hemorrhage is again noted.\n post-contrast, two peripherally located right frontal rim-enhancing lesions\n are noted. while one does abut the dura, it lacks a characteristic dural\n tail, and the more inferior lesion on reformatted images does appear\n intraaxial. ddx includes mets vs infxn/abscess. mening less likely. mri\n recommended for further eval.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old female status post syncope, with CT obtained at an\n outside hospital demonstrating parenchymal edema and a small focus of\n hemorrhage in the right frontal lobe.\n\n COMPARISON: CT of the head performed without intravenous contrast at the\n on .\n\n TECHNIQUE: MDCT imaging of the brain was performed prior to and following the\n administration of 90 cc of Optiray intravenous contrast. Multiplanar\n reformats were prepared and reviewed.\n\n FINDINGS: On non-contrast imaging, there is extensive vasogenic parenchymal\n edema again identified in the right frontal lobe, with a small focus of\n hyperdensity inferiorly, suggestive of hemorrhage. This is stable in\n appearance compared to study performed one day prior. There is resultant mass\n effect upon the right cerebral hemisphere, with sulcal effacement and\n approximately 3 mm leftward shift of normally midline structures. There is no\n abnormal extra-axial fluid collection. The -white matter differentiation\n is elsewhere preserved, without evidence for acute large vascular territory\n infarction. Ventricles are normal in size. The basal cisterns are preserved.\n\n Following contrast administration, there is avid enhancement of two\n peripherally located right frontal lesions. The first lesion, located more\n superiorly, measures 11 x 13 mm, with avid rim enhancement. While this does\n appear to abut the dura, there is no characteristic dural tail identified. A\n second rim-enhancing lesion more inferiorly, the site of punctate hemorrhage\n seen on non-contrast images, measures 11 x 12 mm. On coronal and sagittal\n reformatted images, this lesion is more clearly intra-axial in location.\n There are no further foci of abnormal enhancement identified.\n (Over)\n\n 3:52 AM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: please eval for interval change (nsgy requests contrast)\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Bones demonstrate no abnormality. There are no suspicious lytic or sclerotic\n osseous lesions. Visualized paranasal sinuses and mastoid air cells are\n normally aerated.\n\n IMPRESSION: There are two rim-enhancing lesions peripherally located within\n the right frontal lobe, as described above, with associated vasogenic edema\n and mass effect. The inferior lesion demonstrates a punctate focus of\n hemorrhage. While the superior lesion does abut the dura, it lacks\n characteristic dural tail, making meningioma a less likely consideration.\n Moreover, the more inferior lesion does appear intra-axial on coronal and\n sagittal reformatted images (106A:47 and 105B:15). Differential diagnosis\n includes metastatic disease versus abscess. MRI is recommended for further\n evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-05-22 00:00:00.000",
"description": "MR HEAD W/ CONTRAST",
"row_id": 1133516,
"text": " 4:54 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: for pre-op planning**please do at 5 am on , **\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with 2 right parietal brain masses\n REASON FOR THIS EXAMINATION:\n for pre-op planning**please do at 5 am on , **\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain.\n\n CLINICAL INFORMATION: Patient with enhancing brain lesions due to metastasis,\n for preoperative planning.\n\n TECHNIQUE: T1 sagittal, axial and coronal and MP-RAGE axial images of the\n brain were obtained following gadolinium administration. Comparison was made\n with the MRI of .\n\n FINDINGS: The examination was performed with markers on the surface of the\n skull for surgical planning. There are again noted two enhancing lesions in\n the right frontal lobe. One lesion in the right frontal lobe convexity\n demonstrates significant surrounding edema. A second lesion seen slightly\n posteriorly and laterally demonstrates less edema. There is no hydrocephalus\n seen. No midline shift is noted.\n\n IMPRESSION: Preoperative surgical planning study demonstrates two enhancing\n lesions in the right frontal lobe with surrounding edema without midline shift\n or hydrocephalus. The examination was performed with surface markers for\n surgical planning.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-05-23 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1133712,
"text": " 10:06 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 54 year old woman s/p R crani for mass x 2 resection - eval\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman s/p R crani for mass x 2 resection - eval for post op\n edema/infarct. please perform within 36 hours\n REASON FOR THIS EXAMINATION:\n 54 year old woman s/p R crani for mass x 2 resection - eval for post op\n edema/infarct. please perform within 36 hours\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl FRI 3:58 PM\n PFI: Interval resection of the two right frontal lesions. Two areas of\n curvilinear enhancement (14:19 and 14:15). Continued attention on followup\n studies is recommended. Persistent right frontal parenchymal edema with 2 mm\n leftward shift of midline structures. No acute infarct.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old woman, status post right craniotomy for resection of two\n masses. This is a postoperative examination.\n\n COMPARISON: Preoperative MRI, and .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging was obtained before and\n after administration of gadolinium.\n\n FINDINGS: The patient has undergone right frontal craniotomy, with resection\n of the two enhancing right frontal lesions. A curvilinear focus of\n enhancement in the superior right frontal lobe (14:19) is located in the area\n of the more superior right frontal lesion. More inferiorly, a curvilinear\n area of linear enhancement (14:15) is identified, and may be vascular in\n etiology. There are expected blood products within the surgical bed, and\n expected dural enhancement. Right frontal edema persists, with unchanged\n minimal, 2 mm leftward shift of midline structures. The ventricles are\n unchanged in size and configuration. Basal cisterns are preserved. The major\n vascular flow voids are normal. There is no evidence of acute infarct. No\n diffusion abnormalities are identified.\n\n IMPRESSION:\n 1. Two curvilinear foci of residual enhancement of the right frontal lobe.\n Continued attention on followup studies is recommended.\n\n 2. Interval resection of the two right frontal lesions. Persistent,\n unchanged right frontal edema and 2 mm leftward shift of midline structures.\n\n 3. No evidence of acute infarct.\n (Over)\n\n 10:06 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 54 year old woman s/p R crani for mass x 2 resection - eval\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-05-23 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1133713,
"text": ", M. NSURG PACU 10:06 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 54 year old woman s/p R crani for mass x 2 resection - eval\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman s/p R crani for mass x 2 resection - eval for post op\n edema/infarct. please perform within 36 hours\n REASON FOR THIS EXAMINATION:\n 54 year old woman s/p R crani for mass x 2 resection - eval for post op\n edema/infarct. please perform within 36 hours\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Interval resection of the two right frontal lesions. Two areas of\n curvilinear enhancement (14:19 and 14:15). Continued attention on followup\n studies is recommended. Persistent right frontal parenchymal edema with 2 mm\n leftward shift of midline structures. No acute infarct.\n\n"
},
{
"category": "ECG",
"chartdate": "2104-05-21 00:00:00.000",
"description": "Report",
"row_id": 231119,
"text": "Sinus rhythm. Findings are within normal limits. No previous tracing available\nfor comparison.\n\n"
}
] |
14,130 | 132,707 | The patient was admitted for cardiac catheterization which was performed on and revealed diffuse three vessel coronary artery disease and a normal ejection fraction of approximately 59%. Cardiac surgery consultation was obtained which recommended urgent revascularization procedure. On , the patient was taken to the Operating Room and had a coronary artery bypass graft x2 with left internal mammary artery to the LAD, saphenous vein graft to the OM. The patient tolerated the procedure well and without complication. Postoperatively, the patient was extubated on postoperative day #0. On the evening of postoperative day #1, the patient went into atrial fibrillation with rapid response. The patient was given an amiodarone bolus and an amiodarone drip was started. The patient converted to normal sinus rhythm on the morning of postoperative day #2. The patient was subsequently transferred to the floor on postoperative day #3. The remainder of his stay was largely unremarkable. He was noted to have some drainage from his right saphenous vein graft harvest site. JP had been placed interoperatively and once this had been removed, there was copious serosanguinous drainage from the old JP site. This was treated conservatively with an ACE wrap and dry sterile dressings prn. On the evening of postoperative day #5, a single 2-0 silk stitch was placed in the JP site to close it. This decreased the amount of drainage. Of note, the patient was also transfused on postoperative day #4 for a hematocrit of 27.6. Physical therapy had worked with the patient and recommended rehabilitation placement for him. Ultimately, the patient was discharged on postoperative day #6 tolerating a regular diet and had adequate pain control on po pain medications and having no anginal symptoms or anginal equivalents. | Cr stable.GI: Abd softly distended with +BS.NT. 7P-7A CSRU SHIFT SUMMARY NOTE;NEURO; ALERT ORIENTED FOLLOWS COMMANDS AND MAE'S WELL.RESP; LUNGS CLEAR DIM IN THE BASES WITH 02 SAT'S AND RR WNL. C+BD.Cardiac: ~ went into afib. Pleuravac changed.GU: Foley to gd with low uo in am. Sinus rhythmNonspecific T wave changesEarly transitionSince previous tracing, ST depression resolved; QRS changes in lead V2 - ? S/P CABG X2 REMAINS NEO DEPENDENTP. CT DRAINING MINIMAL THIN SEROSANQ. pre op confirm lg. Hypoactive bowel soounds.GU: Improved UOP. Attempted to wean Neo with decreased BP still requiring .1-.2.K and Mg repleted.Resp: Lungs decreased bases with crackles. lft's wnl,non acidotic w excellent hemodynamics,huo w paplable distal pulses. & cxr performed w/o signif. ID: Afebrile, vanco protocol. Neo weaning. Diuresis when BP can tolerate it. Sinus rhythmAnterolateral ST-T changes are nonspecificSince previous tracing, ST-T wave changes and ventricular premature complexabsent CV: BP labile earlier, neo titrated. No issues.Pulm: CS clr, diminished @ bases. kub,flat & decub. distended from o.r. Amiodarone bolus and gtt started. Remains on Neo, higher requirements w/ afib. NPN:Neuro: Alert and oriented X3..occ sl confused to date. CHEST, SINGLE VIEW: S/P CABG. Right jugular CV line is in the distal SVC. Small bilateral pleural effusions and linear atelectasis left mid and lower zones. PT ENCOURAGED TO USE I.S. R ij cordis patent.Plan: Cont to wean Neo as tol. 0555 - converted to NSR. There is right middle lobe and left basilar atelectasis seen. Abg WNL. GI: Tol water. AND REINSTRUCTED IN USE. Heme: Hct 34, CTs serosang. Low lung volumes are noted on the current exam with slight interval widening of the mediastinum appropriate for recent intervention. CSRU UPDATENeuro: A+O x 3. L shin remains sl pinkish rash.Activity: OOB to chair with assist of 2 X 3-4 hours -tol well. IMPRESSION: Findings consistent with recent CABG. Dr aware. Dr aware. Triple lumen cath for IV access. Lasix on hold until off neo. Diffuse hazy density throughout the abdomen likely represents ascites. Lasix remains on hold until Neo off.Pain: C/O incisional pain - 2 percocets given. pt is s/p CABG with abdominal distension FINAL REPORT INDICATION: Patient is status post CABG with abdominal distention. PT TOLERATED PO LOPRESSOR BUT LASIX HELD PER DR FOR BOARDERLINE BP'S. "A: Doing reasonably well.P: Needs analgesia, titrate neo. CSRU ADDEM; NEO GTT ON BRIEFLY WHEN ASLEEP AFTER RECIEVING 1 PERCOCET. UO 30/hr. amt edema generally.ogt->lws,bilious dng.propofol weaned off,awoke,mae x 4 to command but falls asleep immed. NEO OFF WHEN AWAKE AND AT THIS TIME. leadplacement Labs sent, values wnl. Balance improved today and transferring with decreased assist.Comfort: Medicated with Percocet 1 at 9am and 1615 with good effect.. need to take 2 overnight for comfort.A: Stable with sl CT dump with OOb--but serosang.P: Monitor CT output and possibly dc , Monitor lytes and replete prn. CONT ATTEMPT WEAN NEO PULM TOLIET WITH INCENTIVE SPIROMETERMONITOR U/O CALL HO < 20CCSTART LOPRESSOR AND LASIX ONCE NEO OFF unless stimulated. R leg changed and ace wrap reapplied-clean, dry without dng. No abnormal soft tissue calcifications IMPRESSION: Ascites with evidence of colonic ileus. Endo: Insulin drip titrated, now off. CSRU Progress NoteS/O: Neuro: OX3, med with MSO4 and percocet. CHEST, PA AND LATERAL: The cardiac silhoutte has a left ventricular configuration. NEURO ALERT /O X3 MAE FC PEARLA, GIVEN PERCOCET FOR INCISIONAL PAIN WITH GOOD RELIEF OOB TO CHAIR MIN WEIGHT BEARING NEEDING 3 PERSON ASSISTCARDIAC CT OUTPUT 630CC SEROSANG HCT CHECKED 31.8 CONT NEO DEPENDENT PRESENTLY ON .5MCG/KG/MIN HR 70'S NSR WITHOUT ECTOPY K+ 3.9 TX WITH 40 IV KCL REPEAT 4.9 MG 1.7 TX 2GM REPEAT 1.9 SKIN W+D PP+2 ACE REAPPLIED JP SEROUS 5CC STERNUM AND MEDIAST DSG D+IRESP 5LNP O2 SAT 96-99% LUNGS CLEAR UPPER LOBE DECREASED BASES USING INCENTIVE SPIROMETER Q POORLYGU U/O 18-45 Q HR +250 X 24 HR BUN 16 CR .9 FOLEYGI TAKING SIPS CLEAR LIQ BS+ NO STOOLID AFEB WBC 12.9 ON VANCOACCESS LLA 16G, RTH 16G, ALINE RT R, MULT RIJA. Dopplerable pedal pulses.. Extremities cold and dry with pulses. DRAINAGE.CARDIOVAS; NSR NO ECTOPY OR NOTED AFIB OVER NOC. CT/MT to sxn with no airleak-draining mod amts of serosang dng..160-150cc/hr after OOB to ch. abd. R eye bloodshot..Dr aware.CV: 70-80's NSR with rare APC, Epicardial wires to pacer-VVI at 50..no pacing seen. Strong cough, diminished bs at bases. tympanic,absent bowel sounds. MAE but bil hand swollen and discoordinated. There is symmetrical apical pleural thickening. SEE FLOWSHEET.COMFORT; DID C/O DISCOMFORT AROUND CT INSERTION SITE AND MED WITH PERCOCET 1 TAB PO X2 DURING THE NOC WITH GOOD EFFECT.ENDO; PT GIVEN 3U REG INSULIN SQ FOR BS OF 166 AT HS.PLAN; CONT. findings. Drop in HR and BP and transient nausea with turn. Skin: Skin tears right shin, pt claims "microbiosis. PT OFF OF NEO GTT ALL NOC WITH MAP > 60 AND <90.GI; BS PRESENT. FINDINGS: Newly identified sternal wires and surgical clips are consistent with recently performed CABG. The thoracic aorta is tortuous. Amiodarone gtt decreased to .5 mg/min.GI: Tol sips liqs po. With diet improving with discuss restarting oral in am.Incisions: Sternum and CT dressings D/I. Appetie good.Endo: Glucoses remain elevated 210-200-rec 8u reg sc insulin X2. TAKING AND TOLERATING PO'S WITH NO C/O'S NAUSEA.GU; AUTO DIURESING WITH GOOD HOURLY URINE OP. ? AP and lateral views of the abdomen are technically limited but demonstrate air throughot the colon suggesting ileus. The peak velocities, waveforms and direction of flow are normal bilaterally. MAE. Amiodarone gtt changed to po at 1130am and gtt dc'd at 1230pm. apneic on cpap trial.will attempt again when more awake. Extensive coronary arterial calcification is noted. | 14 | [
{
"category": "Radiology",
"chartdate": "2135-02-11 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 782779,
"text": " 4:50 PM\n PORTABLE ABDOMEN Clip # \n Reason: please perform a portable supine and lateral xray of the abd\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man w/ h/o AAA rpr in \n REASON FOR THIS EXAMINATION:\n please perform a portable supine and lateral xray of the abdomen. pt is s/p\n CABG with abdominal distension\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is status post CABG with abdominal distention.\n\n AP and lateral views of the abdomen are technically limited but\n demonstrate air throughot the colon suggesting ileus. No evidence of dilated\n loops of small bowel. Diffuse hazy density throughout the abdomen likely\n represents ascites. There is no free air. No other abnormality seen. No\n abnormal soft tissue calcifications\n\n IMPRESSION: Ascites with evidence of colonic ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-02-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 782778,
"text": " 4:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG r/o PTX and effusions\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man\n REASON FOR THIS EXAMINATION:\n s/p CABG r/o PTX and effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG rule out pneumothorax and effusions.\n\n Comparison is made to the prior examination of at 8:52 hours.\n\n FINDINGS: Newly identified sternal wires and surgical clips are consistent\n with recently performed CABG. A right internal jugular approach Swan-Ganz\n catheter is seen with its tip in the main pulmonary artery. Two chest tubes, a\n mediatinal drain, and NG tube are seen and are in satisfactory position. Low\n lung volumes are noted on the current exam with slight interval widening of\n the mediastinum appropriate for recent intervention. There is right middle\n lobe and left basilar atelectasis seen. The pulmonary vasculature is normal.\n\n IMPRESSION: Findings consistent with recent CABG. No evidence of cardiac\n failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-02-11 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 782714,
"text": " 8:46 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with pre op for CABG\n REASON FOR THIS EXAMINATION:\n pre op for CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-operative evaluation for CABG.\n\n CHEST, PA AND LATERAL: The cardiac silhoutte has a left ventricular\n configuration. The thoracic aorta is tortuous. Extensive coronary arterial\n calcification is noted. The pulmonary vasculature is normal, and there are no\n effusions. There is symmetrical apical pleural thickening. The lungs are\n clear.\n\n IMPRESSION: No CHF or pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-02-11 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 782707,
"text": " 8:23 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: pre op for CABG admitted w/syncope-r/o carotid stenosis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with as above\n REASON FOR THIS EXAMINATION:\n pre op for CABG admitted w/syncope-r/o carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative examination before CABG in an 82 year old man\n admitted with syncope.\n\n TECHNIQUE & FINDINGS: scale, color doppler and spectral doppler\n examinations were performed bilaterally at the level of the cervical portions\n of the vertebral arteries.\n\n There is no significant plaque detected on either side. The peak velocities,\n waveforms and direction of flow are normal bilaterally.\n\n CONCLUSION: No significant carotid or vertebral artery disease at the level\n of the neck.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-02-14 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 783006,
"text": " 4:10 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: please assess after CT removal\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n please assess after CT removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of CABG and chest tube removal.\n\n CHEST, SINGLE VIEW: S/P CABG. Right jugular CV line is in the distal SVC. No\n pneumothorax. Small bilateral pleural effusions and linear atelectasis left\n mid and lower zones.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2135-02-10 00:00:00.000",
"description": "Report",
"row_id": 276984,
"text": "Sinus rhythm\nAnterolateral ST-T changes are nonspecific\nSince previous tracing, ST-T wave changes and ventricular premature complex\nabsent\n\n"
},
{
"category": "ECG",
"chartdate": "2135-02-12 00:00:00.000",
"description": "Report",
"row_id": 276983,
"text": "Sinus rhythm\nNonspecific T wave changes\nEarly transition\nSince previous tracing, ST depression resolved; QRS changes in lead V2 - ? lead\nplacement\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-02-14 00:00:00.000",
"description": "Report",
"row_id": 1446611,
"text": " 7P-7A CSRU SHIFT SUMMARY NOTE;\n\nNEURO; ALERT ORIENTED FOLLOWS COMMANDS AND MAE'S WELL.\n\nRESP; LUNGS CLEAR DIM IN THE BASES WITH 02 SAT'S AND RR WNL. PT ENCOURAGED TO USE I.S. AND REINSTRUCTED IN USE. PT FORGOT HOW TO USE IT AND ONLY ABLE TO DO TV OF 250'S. CT DRAINING MINIMAL THIN SEROSANQ. DRAINAGE.\n\nCARDIOVAS; NSR NO ECTOPY OR NOTED AFIB OVER NOC. PT TOLERATED PO LOPRESSOR BUT LASIX HELD PER DR FOR BOARDERLINE BP'S. PT OFF OF NEO GTT ALL NOC WITH MAP > 60 AND <90.\n\nGI; BS PRESENT. TAKING AND TOLERATING PO'S WITH NO C/O'S NAUSEA.\n\nGU; AUTO DIURESING WITH GOOD HOURLY URINE OP. SEE FLOWSHEET.\n\nCOMFORT; DID C/O DISCOMFORT AROUND CT INSERTION SITE AND MED WITH PERCOCET 1 TAB PO X2 DURING THE NOC WITH GOOD EFFECT.\n\nENDO; PT GIVEN 3U REG INSULIN SQ FOR BS OF 166 AT HS.\n\nPLAN; CONT. TO MONITOR AND ASSESS. TRANSFER TO 2 TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-02-14 00:00:00.000",
"description": "Report",
"row_id": 1446612,
"text": " CSRU ADDEM; NEO GTT ON BRIEFLY WHEN ASLEEP AFTER RECIEVING 1 PERCOCET. NEO OFF WHEN AWAKE AND AT THIS TIME.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-02-13 00:00:00.000",
"description": "Report",
"row_id": 1446609,
"text": "CSRU UPDATE\nNeuro: A+O x 3. MAE. No issues.\n\nPulm: CS clr, diminished @ bases. O2 sats ~ 98% on 4 l NP. C+BD.\n\nCardiac: ~ went into afib. Labs sent, values wnl. Dr aware. Amiodarone bolus and gtt started. Remains on Neo, higher requirements w/ afib. 0555 - converted to NSR. Neo weaning. Amiodarone gtt decreased to .5 mg/min.\n\nGI: Tol sips liqs po. No stool. Hypoactive bowel soounds.\n\nGU: Improved UOP. Lasix remains on hold until Neo off.\n\nPain: C/O incisional pain - 2 percocets given. Pt slept ~ 5 hrs.\n\nEndo: Elevated glucoses treated w/sliding scale coverage x 2.\n\nIV Access: 2 periph IV's infiltrated. IV nurse unable to obtain access. R ij cordis patent.\n\nPlan: Cont to wean Neo as tol. ? Triple lumen cath for IV access.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-02-13 00:00:00.000",
"description": "Report",
"row_id": 1446610,
"text": "NPN:\n\nNeuro: Alert and oriented X3..occ sl confused to date. MAE but bil hand swollen and discoordinated. R eye bloodshot..Dr aware.\n\nCV: 70-80's NSR with rare APC, Epicardial wires to pacer-VVI at 50..no pacing seen. Amiodarone gtt changed to po at 1130am and gtt dc'd at 1230pm. Dopplerable pedal pulses.. Extremities cold and dry with pulses. Attempted to wean Neo with decreased BP still requiring .1-.2.\nK and Mg repleted.\n\nResp: Lungs decreased bases with crackles. O2 sats > 97% on 3l nc. cough prod of sm amts thick yellow sputum. Abg WNL. CT/MT to sxn with no airleak-draining mod amts of serosang dng..160-150cc/hr after OOB to ch. Dr aware. Pleuravac changed.\n\nGU: Foley to gd with low uo in am. Lasix on hold until off neo. U/o picked up in afternoon. Cr stable.\n\nGI: Abd softly distended with +BS.NT. No N/V. Tol clears to reg diet in afternoon. Appetie good.\n\nEndo: Glucoses remain elevated 210-200-rec 8u reg sc insulin X2. With diet improving with discuss restarting oral in am.\n\nIncisions: Sternum and CT dressings D/I. R leg changed and ace wrap reapplied-clean, dry without dng. L shin remains sl pinkish rash.\n\nActivity: OOB to chair with assist of 2 X 3-4 hours -tol well. Balance improved today and transferring with decreased assist.\n\nComfort: Medicated with Percocet 1 at 9am and 1615 with good effect.. need to take 2 overnight for comfort.\n\nA: Stable with sl CT dump with OOb--but serosang.\n\nP: Monitor CT output and possibly dc , Monitor lytes and replete prn. HR stable on po amio..Cont po load 400 TID, Discuss restarting oral diabetic .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-02-11 00:00:00.000",
"description": "Report",
"row_id": 1446606,
"text": "abd. distended from o.r. tympanic,absent bowel sounds. kub,flat & decub. & cxr performed w/o signif. findings. lft's wnl,non acidotic w excellent hemodynamics,huo w paplable distal pulses. family & staff who observed pt. pre op confirm lg. amt edema generally.ogt->lws,bilious dng.propofol weaned off,awoke,mae x 4 to command but falls asleep immed. unless stimulated. apneic on cpap trial.will attempt again when more awake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-02-12 00:00:00.000",
"description": "Report",
"row_id": 1446607,
"text": "CSRU Progress Note\nS/O: Neuro: OX3, med with MSO4 and percocet.\n CV: BP labile earlier, neo titrated. Drop in HR and BP and transient nausea with turn.\n Resp: Extubated midnight. Strong cough, diminished bs at bases.\n Renal: Wt up 14 kg. UO 30/hr.\n Heme: Hct 34, CTs serosang.\n ID: Afebrile, vanco protocol.\n GI: Tol water.\n Endo: Insulin drip titrated, now off.\n Skin: Skin tears right shin, pt claims \"microbiosis.\"\nA: Doing reasonably well.\nP: Needs analgesia, titrate neo. Diuresis when BP can tolerate it.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-02-12 00:00:00.000",
"description": "Report",
"row_id": 1446608,
"text": "s. I am HAVING ALOT OF PAIN ABD AROUND WHERE THE TUBE IS\nO. NEURO ALERT /O X3 MAE FC PEARLA, GIVEN PERCOCET FOR INCISIONAL PAIN WITH GOOD RELIEF OOB TO CHAIR MIN WEIGHT BEARING NEEDING 3 PERSON ASSIST\nCARDIAC CT OUTPUT 630CC SEROSANG HCT CHECKED 31.8 CONT NEO DEPENDENT PRESENTLY ON .5MCG/KG/MIN HR 70'S NSR WITHOUT ECTOPY K+ 3.9 TX WITH 40 IV KCL REPEAT 4.9 MG 1.7 TX 2GM REPEAT 1.9 SKIN W+D PP+2 ACE REAPPLIED JP SEROUS 5CC STERNUM AND MEDIAST DSG D+I\nRESP 5LNP O2 SAT 96-99% LUNGS CLEAR UPPER LOBE DECREASED BASES USING INCENTIVE SPIROMETER Q POORLY\nGU U/O 18-45 Q HR +250 X 24 HR BUN 16 CR .9 FOLEY\nGI TAKING SIPS CLEAR LIQ BS+ NO STOOL\nID AFEB WBC 12.9 ON VANCO\nACCESS LLA 16G, RTH 16G, ALINE RT R, MULT RIJ\nA. S/P CABG X2 REMAINS NEO DEPENDENT\nP. CONT ATTEMPT WEAN NEO\n PULM TOLIET WITH INCENTIVE SPIROMETER\nMONITOR U/O CALL HO < 20CC\nSTART LOPRESSOR AND LASIX ONCE NEO OFF\n"
}
] |
5,850 | 140,865 | the patient had a new onset atrial fibrillation and DDD pacemaker was placed and patient was started on Amiodarone. Since discharge over the past two weeks, the patient has been very fatigued, had difficulty sleeping. He went to the cardiologist, Dr. on where pacemaker was interrogated and one episode of paroxysmal atrial fibrillation was noted on the pacer. The patient was switched from Metoprolol 25 mg to Toprol 25 mg q d in order to improve his sleeping. Wife says that patient's sleeping did improve over the last couple nights since switching medication. Over the last couple of weeks the patient has also been complaining of neck and shoulder bone pain, chills and spells in which he reportedly looked , according to the wife. The patient had not had any palpitations, chest pain, shortness of breath, orthopnea, but occasional ankle swelling. He had reportedly been feeling good on day of admission, went to bed and then starting getting short of breath. The shortness of breath progressively worsened and patient was brought to the Emergency Room. The patient denied chest pain at the time. In the Emergency Room his blood pressure was found to be 200/117, pulse 130, respiratory rate 50, O2 saturation 91% on 100% non rebreather. The patient was alert but very agitated on physical exam. He was noted to have bilateral diffuse crackles of the way up. EKG at the time showed sinus tachy with questionable ST elevations in V1 and V2. The patient was put on C-pap and given Morphine and Ativan for agitation and Lasix and started on Nitro drip. His blood pressure fell and he was taken off the Nitro drip. His respiratory rate fell with the C-pap and his O2 sats improved. PAST MEDICAL HISTORY: Includes hypertension, coronary artery disease, syncopal event, atrial fibrillation, right colon cancer, status post resection in , left colon cancer status post resection in , benign prostate hyperplasia status post prostatectomy in , thalamic bleed secondary to hypertension in and a renal mass, hemorrhagic cyst in . ALLERGIES: ACE inhibitor which causes angioedema. SOCIAL HISTORY: He is an ex-smoker, used to smoke 2-3 packs per day, quit in . He lives with his wife. had been the chief of pediatrics at but then was a general pediatrician at and is now retired. FAMILY HISTORY: Noncontributory. MEDICATIONS: Outpatient medications include Amiodarone 200 mg q d, Fluconazole 100 mg q d, Nystatin 100,000 units, ml qid and Toprol 25 mg q d. In the hospital the patient was given Morphine 4 mg, Lasix 200 mg IV, Ativan 2 mg and the Nitro drip. PHYSICAL EXAMINATION: The patient had a pulse of 79, blood pressure 139/85, respiratory rate 19, pulse ox 100% on C-pap. He was lying in bed, sedated with C-pap mask on with deep breathing and no acute distress. He had positive external jugular but no internal JVP was discernible. No carotid bruit was appreciated. His rate was regular S1 and S2 with questionable S4, no murmurs, rubs or gallops. Lungs had diffuse crackles, expiratory rhonchi and rales ?????? way up. His abdomen was soft, positive bowel sounds, nontender, non distended, trace edema, 2+ radial pulses, DP pulses not palpable. Neuro, patient was sedated, was not responding to commands. LABORATORY DATA: On his admission his labs were white blood count 12.9, up from 7.5 on , hematocrit 34.8, up from 31.3 on and platelet count 405,000 with MCV of 86. His neutrophils were 70%, lymphs 21%, monocytes 2.9% and eosinophils 4.4%. Sodium 138, potassium 5.8, 106/22, 36/2.0 and 239 for glucose. His creatinine had been baseline at 1.6 to 1.8. His ABG at 2:30 a.m. was 7.3, 44, 229. His PT was 12.4, PTT 25.9. On his prior admission the patient was noted to have iron of 25, TIBC 260, TSH was 1.3 and free T4 1.0. Retic count 1.7, Vitamin B12 327, Folate greater than 20. His hemoglobin A1C was 6.0. His CEA was elevated at 11. On prior admission the patient's peak CPK was 127 and his peak troponin was 11.2. His EKG on admission was heart rate 130, sinus tachy, no axis deviation, ST depressions in V5, V6 and 1 and elevations in V1 through V3. Chest x-ray was consistent with CHF. HOSPITAL COURSE: 1. Cardiovascular: The patient has known coronary artery disease, he was started on Aspirin. Heparin was initially held secondary to his history of thalamic bleed and the fact that he had guaiac positive stools on his last admission on . Beta blockers were also initially held secondary to his CHF. On admission his CPK was 141 and troponin 2.3. The next day his CPK dropped to 129 but the MB was up at 17 with index of 13.2. His troponin peaked at 20. The patient was started on IV Heparin. His cath was reviewed two weeks earlier and showed severe three vessel disease with 90% lesions in the LAD and total occlusion of the RCA and 70% of left circumflex. Possible options were discussed with him including surgical, PCI and medical management. It was agreed upon that the patient would give a trial of medical management for the time being and if he became symptomatic, he would then go for PCI. During the hospital course his EKG returned to in terms of ST elevation. He had no longer had shortness of breath or chest pain and IV Heparin was discontinued and patient was started on beta blocker. The patient had no symptoms of angina or chest pain or shortness of breath during the rest of this hospital course. | Mildtricuspid [1+] regurgitation is seen. Mild (1+)mitral regurgitation is seen. There is mild symmetric left ventricularhypertrophy. There is moderate mitral annular calcification. Mild (1+)mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Thereis mild thickening of the mitral valve chordae. There is nomitral valve prolapse. The tricuspid valve leaflets are mildlythickened. The tips of the papillarymuscles are calcified. The left ventricular cavity size is normal. The leftventricular cavity size is normal. The estimated pulmonary artery systolic pressure is normal. No aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolicpressure is normal.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is mildly dilated. Bs clear. The number of aortic valve leaflets cannot be determined.The aortic valve leaflets are moderately thickened. Right ventricular chamber size and free wallmotion are normal. There is no resting left ventricular outflow tractobstruction.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter. Assess for CHF. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation/flutter.Height: (in) 67Weight (lb): 165BSA (m2): 1.87 m2BP (mm Hg): 111/68Status: InpatientDate/Time: at 10:53Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. UE/LE strength equal and bilateral. Probable atrial sensed - ventricular paced rhythm with ventricular fussioncomplexesInferolateral ST-T abnormalities - cannot exclude ischemia -= clinicalcorrelation is suggestedLeft atrial abnormalitySince previous tracing of same date: pacer activity seen A dual chamber pacemaker is unchanged in position. Acatheter or pacing wire is seen in the right atrium and/or right ventricle.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. po fluids. Theaortic valve leaflets are moderately thickened. PLT 280. There are probable small bilateral pleural effusions, although the extreme left costophrenic angle is not included. , RN Pt. Pt. Pt. 7p-7a Nursing note:Neuro: Pt. Overall left ventricular systolic functionis moderately depressed. No c/o cp.GI/GU: Foley in place draining adequate amts. The mitral valveleaflets are mildly thickened. Atrial fibrillation with rapid ventricular responseExtensive ST-T changes may be due to myocardial ischemiaLow QRS voltages in limb leadsSince previous tracing of same date: normal sinus rhythm absent Thereis no pericardial effusion.Compared to the previous study of , overall left ventricularcontractile function has significantly worsened, secondary to majorintercurrent anterior and anteroseptal infarct/injury. There are bibasilar patchy opacities, right side greater than left, which likely represent a combination of atelectasis and interstitial edema. plan of care. There are focal calcificationsin the aortic root.AORTIC VALVE: The number of aortic valve leaflets cannot be determined. Possible cardiac cath/ CABG or medical management. Pt on cardiac diet, tol. No resp distress noted.CV: cardiac monitor NSR without ectopy. There is bilateral perihilar haziness, consistent with pulmonary edema. Overall leftventricular systolic function is moderately depressed secondary to severehypokinesis of the anterior septum and anterior free wall; there is extensiveapical hypokinesis/akinesis. maintained on 2L NC. Will check PTT in am. A/O x 3. PTT 74.8- second theraputic value according to protocol. Abd. VSS. There is upper zone redistribution of the pulmonary vasculature and diffuse prominence of the interstitial lung markings. IMPRESSION: Findings consistent with congestive heart failure and pulmonary edema. There is no significant aorticvalve stenosis. There is no significantaortic valve stenosis. There is no significant mitral stenosis. Other lab values at - HH 30.2/10 WBC 8.7 PT 13.5CPK 100 CPK/MB 12. Baseline artifactSinus tachycardiaInferior/lateral ST-T changes suggest myocardial injury/ischemia - clinicalcorrelation is suggestedLeft atrial abnormalityBorderline intraventricular conduction delaySince previous tracing of : ST & further ST-T changes present PORTABLE AP CHEST: Comparison is made to an exam of . There is no mitral valve prolapse. BP 110-140's/60's. on 400mg po amiodarone . of clear/yellow urine. Allowing for the AP technique, the heart appears enlarged. Labs drawn at . SPO2 94-97%. very pleasant, follows and obeys commands. nursing progress note see careview for detailsneuro:awake,alert,orientedx3 pupils perl.follows commands and moves all extremities with appears equal strenght.speech clear,tongue midline.was lethargic early this am from sedation in er.resp:was on mask ventilation with full face mask,became more awake and was dcd, to open face mask then nasal prongs.breath sounds clear in upper lobes with crackles bibasilar,left side greater than right side.resp rate 15 to 20,sp02 96%.good cough efforts without production.denies sob.gi:abd soft with positive bowel sounds present.started on cardiac diet tolerated well.denies any nausea.has not had any stool today.cv:was in nsr ,went into atrial fib,rate controlled to 90 to 100 with stable bp.nito drip was dcd.amiodarone dose was increased to 400 mg tid.magnesium was repleted.bil dp pulses present by doppler.cardiac echo was done results are not known as yet.given unit of prbcs with lasix.gu:foley to cd draining large amount of clear yellow urine in response to lasix which was given earlier.access:has 2 peripheral ivs #18 ,one in right hand was dcd appeared reddened,new iv was started.social:family visited,spoke with cardiology about three options,one was medical treatment,cath lab with intervention of stent or cabg family will discuss options with patient. No changes made to heparin gtt. Am labs sent, results pending. Follow-up films, after appropriate treatment, may be helpful in excluding any underlying infectious etiology. soft, bowel sounds present.Plan:Monitor VS and signs for cardiac of resp distress.Awaiting on family for decision on pt. No aortic regurgitation is seen. Family in to see pt.Resp: Pt. on heparin gtt @ 900units/hr. | 7 | [
{
"category": "Radiology",
"chartdate": "2133-07-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 764143,
"text": " 1:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: sob, r/o chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with\n REASON FOR THIS EXAMINATION:\n sob\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath. Assess for CHF.\n\n PORTABLE AP CHEST: Comparison is made to an exam of . Allowing for the\n AP technique, the heart appears enlarged. There is upper zone redistribution\n of the pulmonary vasculature and diffuse prominence of the interstitial lung\n markings. There is bilateral perihilar haziness, consistent with pulmonary\n edema. There are probable small bilateral pleural effusions, although the\n extreme left costophrenic angle is not included. There are bibasilar patchy\n opacities, right side greater than left, which likely represent a combination\n of atelectasis and interstitial edema. A dual chamber pacemaker is unchanged\n in position.\n\n IMPRESSION: Findings consistent with congestive heart failure and pulmonary\n edema. Follow-up films, after appropriate treatment, may be helpful in\n excluding any underlying infectious etiology.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-08 00:00:00.000",
"description": "Report",
"row_id": 1338934,
"text": "7p-7a Nursing note:\n\nNeuro: Pt. A/O x 3. Pt. very pleasant, follows and obeys commands. UE/LE strength equal and bilateral. Family in to see pt.\n\nResp: Pt. maintained on 2L NC. Bs clear. SPO2 94-97%. No resp distress noted.\n\nCV: cardiac monitor NSR without ectopy. Pt. on 400mg po amiodarone . VSS. BP 110-140's/60's. Pt. on heparin gtt @ 900units/hr. Labs drawn at . PTT 74.8- second theraputic value according to protocol. No changes made to heparin gtt. Will check PTT in am. Other lab values at - HH 30.2/10 WBC 8.7 PT 13.5\nCPK 100 CPK/MB 12. PLT 280. Am labs sent, results pending. No c/o cp.\n\nGI/GU: Foley in place draining adequate amts. of clear/yellow urine. Pt on cardiac diet, tol. po fluids. Abd. soft, bowel sounds present.\n\nPlan:\nMonitor VS and signs for cardiac of resp distress.\nAwaiting on family for decision on pt. plan of care. Possible cardiac cath/ CABG or medical management.\n\n\n , RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-07 00:00:00.000",
"description": "Report",
"row_id": 1338933,
"text": "nursing progress note see careview for details\n\nneuro:awake,alert,orientedx3 pupils perl.follows commands and moves all extremities with appears equal strenght.speech clear,tongue midline.was lethargic early this am from sedation in er.\n\nresp:was on mask ventilation with full face mask,became more awake and was dcd, to open face mask then nasal prongs.breath sounds clear in upper lobes with crackles bibasilar,left side greater than right side.resp rate 15 to 20,sp02 96%.good cough efforts without production.denies sob.\n\ngi:abd soft with positive bowel sounds present.started on cardiac diet tolerated well.denies any nausea.has not had any stool today.\n\ncv:was in nsr ,went into atrial fib,rate controlled to 90 to 100 with stable bp.nito drip was dcd.amiodarone dose was increased to 400 mg tid.magnesium was repleted.bil dp pulses present by doppler.cardiac echo was done results are not known as yet.given unit of prbcs with lasix.\n\ngu:foley to cd draining large amount of clear yellow urine in response to lasix which was given earlier.\n\naccess:has 2 peripheral ivs #18 ,one in right hand was dcd appeared reddened,new iv was started.\n\nsocial:family visited,spoke with cardiology about three options,one was medical treatment,cath lab with intervention of stent or cabg family will discuss options with patient.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2133-07-07 00:00:00.000",
"description": "Report",
"row_id": 97642,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nHeight: (in) 67\nWeight (lb): 165\nBSA (m2): 1.87 m2\nBP (mm Hg): 111/68\nStatus: Inpatient\nDate/Time: at 10:53\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 mildly dilated. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis moderately depressed. There is no resting left ventricular outflow tract\nobstruction.\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.\n\nAORTIC VALVE: The number of aortic valve leaflets cannot be determined. The\naortic valve leaflets are moderately thickened. There is no significant aortic\nvalve stenosis. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is moderate mitral annular calcification. There\nis mild thickening of the mitral valve chordae. The tips of the papillary\nmuscles are calcified. There is no significant mitral stenosis. Mild (1+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Mild\ntricuspid [1+] regurgitation is seen. The estimated pulmonary artery systolic\npressure is normal.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is moderately depressed secondary to severe\nhypokinesis of the anterior septum and anterior free wall; there is extensive\napical hypokinesis/akinesis. Right ventricular chamber size and free wall\nmotion are normal. The number of aortic valve leaflets cannot be determined.\nThe aortic valve leaflets are moderately thickened. There is no significant\naortic 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 tricuspid valve leaflets are mildly\nthickened. The estimated pulmonary artery systolic pressure is normal. There\nis no pericardial effusion.\n\nCompared to the previous study of , overall left ventricular\ncontractile function has significantly worsened, secondary to major\nintercurrent anterior and anteroseptal infarct/injury.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2133-07-07 00:00:00.000",
"description": "Report",
"row_id": 268836,
"text": "Atrial fibrillation with rapid ventricular response\nExtensive ST-T changes may be due to myocardial ischemia\nLow QRS voltages in limb leads\nSince previous tracing of same date: normal sinus rhythm absent\n\n"
},
{
"category": "ECG",
"chartdate": "2133-07-07 00:00:00.000",
"description": "Report",
"row_id": 268837,
"text": "Probable atrial sensed - ventricular paced rhythm with ventricular fussion\ncomplexes\nInferolateral ST-T abnormalities - cannot exclude ischemia -= clinical\ncorrelation is suggested\nLeft atrial abnormality\nSince previous tracing of same date: pacer activity seen\n\n"
},
{
"category": "ECG",
"chartdate": "2133-07-07 00:00:00.000",
"description": "Report",
"row_id": 268838,
"text": "Baseline artifact\nSinus tachycardia\nInferior/lateral ST-T changes suggest myocardial injury/ischemia - clinical\ncorrelation is suggested\nLeft atrial abnormality\nBorderline intraventricular conduction delay\nSince previous tracing of : ST & further ST-T changes present\n\n"
}
] |
52,642 | 185,114 | 80 y/o M with history of HTN and GERD presented with chest pain, found be having STEMI. 1) STEMI-Anterior wall: Pt on presentation found be having STEMI with ST elevation in leads V1-4 and received NTG x 3, ASA 325mg, and Morphine in the ED. Troponin was elevated at 3.73. Pt was taken to cath (during which he was started on integrellin), where his LAD was found to be occluded, requiring a BMS. Cath also revealed diffuse 3-vessel disease with good collaterals. , pt was pain-free throughout entire admission and was eager to be discharged, initially not understanding the severity of his heart disease. His cardiac enzymes trended down and he was transferred from the CCU to the floors. He had some bleeding at the groin site of cath entry, with an associated 4 point drop in HCT, and thus integrellin was DCed. HCT thereafter was checked 2-3 times daily and remained stable. Pt was started on optimal medical post-MI management with Metoprolol 25mg , Lisinopril 5mg daily, Atorvastatin 80mg, ASA 325mg, and Plavix 75mg (1year). Pt had Lovenox while in house, and was recommended anticoagulation with coumadin for finding on TTE of apical, anteroseptal akinesis/hypokinesis. However, even after being clearly explained and showing understanding of risks of not anticoagulating(including stoke and death), pt refused coumadin, saying he would not comply with weekly bloodwork. Due to pt's 3 vessel disease, CABG could be considered in the future but CT surgery was not consulted in house. 2) HTN-benign essential: Per pt's report, his home blood pressure has been poorly controlled with SBPs ranging from 130s to 200s. He just recently started taking HCTZ, but now that he is post-MI his BP regimen was switched to a beta blocker and ACE inhibitor. Blood pressures were well controlled on this regimen throughout the hospital stay. Pt was asked to follow up with his PCP to recheck his BP, as well as labwork for electrolytes and renal function. | There is a trivial/physiologicpericardial effusion.IMPRESSION: Anteroseptal/anterior/apical hypokinesis/akinesis consistent withmyocardial infarction. Glycemic Control: None Lines: 18 Gauge - 08:01 PM Prophylaxis: DVT: ppx with Heparin, once patient's PCI site is stable. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Hr initially 70s sr with no vea noted. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Hr initially 70s sr with no vea noted. Integrellin gtt turned off and heparin held. Integrellin gtt turned off and heparin held. Integrellin gtt turned off and heparin held. Myocardial infarction.Height: (in) 60Weight (lb): 180BSA (m2): 1.79 m2BP (mm Hg): 160/90HR (bpm): 66Status: InpatientDate/Time: at 09:49Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: HR 70s, BP 110-130. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: HR 70s, BP 110-130. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: HR 70s, BP 110-130. Glycemic Control: None Lines: 18 Gauge - 08:01 PM Prophylaxis: DVT: ppx with lovenox. Glycemic Control: None Lines: 18 Gauge - 08:01 PM Prophylaxis: DVT: ppx with lovenox. CPK #1 1546/MB 46/MBI 3.0, troponin 3.73. CPK #1 1546/MB 46/MBI 3.0, troponin 3.73. CPK #1 1546/MB 46/MBI 3.0, troponin 3.73. CPK #1 1546/MB 46/MBI 3.0, troponin 3.73. R groin has remained d/I with hematoma outlined. R groin has remained d/I with hematoma outlined. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is elongated. Mild-moderateregional LV systolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - akinetic; basal anteroseptal - hypo; mid anteroseptal -akinetic; anterior apex - hypo; septal apex- akinetic; apex - akinetic;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Mild (1+) aortic regurgitation is seen. - Continue maximal medical mangagment . - Continue maximal medical mangagment . Cath revealed total occlusion of prox LAD, this was stented x 1. Cath revealed total occlusion of prox LAD, this was stented x 1. Trivial mitral regurgitation isseen. There is mildto moderate regional left ventricular systolic dysfunction withanteroseptal/anterior/apical hypokinesis/akinesis. There is mildsymmetric left ventricular hypertrophy with normal cavity size. Patient's troponin is 3.73. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Action: Response: Plan: Has been oob to commode Response: HR down to 60s w/ occ vea. Has been oob to commode Response: HR down to 60s w/ occ vea. Mild aortic regurgitation. 1) ACS: STEMI, EKG consistent with ST elevation in leads V1-4 consistent with involvement of anterior precordium in distribution of LAD territory. 1) ACS: STEMI, s/p PCI with BMS placement in proximal LAD. 1) ACS: STEMI, s/p PCI with BMS placement in proximal LAD. Stress ulcer: VAP: Comments: Communication: Son : Code status: Presumed full Disposition: CCU service for now After procedure he was transferred to CCU for further management Latest Vital Signs and I/O Non-invasive BP: S:121 D:78 Temperature: 99.7 Arterial BP: S: D: Respiratory rate: 23 insp/min Heart Rate: 78 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: None O2 saturation: 96% % O2 flow: 2 L/min FiO2 set: 24h total in: 750 mL 24h total out: 625 mL Pertinent Lab Results: Sodium: 136 mEq/L 10:59 AM Potassium: 4.0 mEq/L 10:59 AM Chloride: 102 mEq/L 10:59 AM CO2: 26 mEq/L 10:59 AM BUN: 26 mg/dL 10:59 AM Creatinine: 1.4 mg/dL 10:59 AM Glucose: 113 mg/dL 10:59 AM Hematocrit: 37.7 % 10:59 AM Valuables / Signature Patient valuables: Other valuables: Clothes: Transferred with patient Wallet / Money: Transferred w/ patient No money / wallet Cash Amount: $371 Credit Cards: no Cash / Credit cards sent home with: Jewelry: Transferred from: 618/ Transferred to: 310 Date & time of Transfer: 1530 After procedure he was transferred to CCU for further management Latest Vital Signs and I/O Non-invasive BP: S:121 D:78 Temperature: 99.7 Arterial BP: S: D: Respiratory rate: 23 insp/min Heart Rate: 78 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: None O2 saturation: 96% % O2 flow: 2 L/min FiO2 set: 24h total in: 750 mL 24h total out: 625 mL Pertinent Lab Results: Sodium: 136 mEq/L 10:59 AM Potassium: 4.0 mEq/L 10:59 AM Chloride: 102 mEq/L 10:59 AM CO2: 26 mEq/L 10:59 AM BUN: 26 mg/dL 10:59 AM Creatinine: 1.4 mg/dL 10:59 AM Glucose: 113 mg/dL 10:59 AM Hematocrit: 37.7 % 10:59 AM Valuables / Signature Patient valuables: Other valuables: Clothes: Transferred with patient Wallet / Money: No money / wallet Cash Amount: $371 Credit Cards: no Cash / Credit cards sent home with: Jewelry: Transferred from: Transferred to: Date & time of Transfer: | 17 | [
{
"category": "Echo",
"chartdate": "2141-09-19 00:00:00.000",
"description": "Report",
"row_id": 68689,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 60\nWeight (lb): 180\nBSA (m2): 1.79 m2\nBP (mm Hg): 160/90\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 09:49\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D or color\nDoppler. Normal IVC diameter (<2.1cm) with >55% decrease during respiration\n(estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild-moderate\nregional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - akinetic; basal anteroseptal - hypo; mid anteroseptal -\nakinetic; anterior apex - hypo; septal apex- akinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. The estimated right atrial pressure is 0-5 mmHg. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size. There is mild\nto moderate regional left ventricular systolic dysfunction with\nanteroseptal/anterior/apical hypokinesis/akinesis. No apical thrombus seen.\nRight ventricular chamber size and free wall motion are normal. The ascending\naorta is mildly dilated. The aortic valve leaflets are mildly thickened. There\nis no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Trivial mitral regurgitation is\nseen. The tricuspid valve leaflets are mildly thickened. The estimated\npulmonary artery systolic pressure is normal. There is a trivial/physiologic\npericardial effusion.\n\nIMPRESSION: Anteroseptal/anterior/apical hypokinesis/akinesis consistent with\nmyocardial infarction. Mild aortic regurgitation.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2141-09-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 541340,
"text": "80yo with 10/10 cp on , did not seek med help until . Went\n to clinic which transferred him to EW, where they noted st\n elevations anteriorly. He was treated with hep, lopressor, morphine,\n , and transferred to the cath lab. Cath revealed total\n occlusion of prox LAD, this was stented x 1. He also had OM1 80%\n stenosed and PDA 70% stenosed.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr initially 70\ns sr with no vea noted. BP slightly ^ 140\ns. R groin\n with hematoma on arrival to CCU which appeared to be enlarging.\n Action:\n Lopressor 25mg and lisinopril 5mg started. Pressure applied to groin\n and cardiac fellow called for expanding groin. Integrilin dc\nd and\n fellow removed R groin sheaths without incident. Pt remained supine\n for 6 hours to maintain groin stability then turned onto side.\n Response:\n Hr decreased to 60\ns sr and bp decreased to 110-120\ns. R groin has\n remained d/I with hematoma outlined. No change in size has been\n noted.\n Plan:\n Cont to monitor size of hematoma, follow hct. Start cardiac rehab when\n able\n"
},
{
"category": "Nursing",
"chartdate": "2141-09-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 541311,
"text": "80yo with 10/10 cp on , did not seek med help until . Went\n to clinic which transferred him to EW, where they noted st\n elevations anteriorly. He was treated with hep, lopressor, morphine,\n , and transferred to the cath lab. Cath revealed total\n occlusion of prox LAD, this was stented x 1. He also had OM1 80%\n stenosed and PDA 70% stenosed.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hr initially 70\ns sr with no vea noted. BP slightly ^ 140\ns. R groin\n with hematoma on arrival to CCU which appeared to be enlarging.\n Action:\n Lopressor 25mg and lisinopril 5mg started. Pressure applied to groin\n and cardiac fellow called for expanding groin. Integrilin dc\nd and\n fellow removed R groin sheaths without incident. Pt remained supine\n for 6 hours to maintain groin stability then turned onto side.\n Response:\n Hr decreased to 60\ns sr and bp decreased to 110-120\ns. R groin has\n remained d/I with hematoma outlined. No change in size has been\n noted.\n Plan:\n Cont to monitor size of hematoma, follow hct. Start cardiac rehab when\n able\n"
},
{
"category": "Nursing",
"chartdate": "2141-09-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541374,
"text": "81yom w/ pmh HTN and GERD presents to clinic w/ c/o epigastric/sternal\n cp w/ n&v x 1 day. EKG showing STEMI, sent directly to ED then\n cath lab. Pt w/ prox TO LAD which was stented. Pt also w/ 70% distal\n to the stent, 70% prox OM1, 40-50% Prox RCA and 80% PDA. Pt sent to\n CCU for post cath monitoring. CPK #1 1546/MB 46/MBI 3.0, troponin\n 3.73.\n CCU course complicated by r groin hematoma, requiring d/c integrillin\n and removal of sheaths at 8pm . No change in hct. Pt started and\n is tolerating lopressor, lisinopril and lovenox.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n HR 70\ns, BP 110-130. CPK\ns down to 700\ns. No c/o chest pain\n Action:\n Lopressor increased to 37.5 mg . Has been oob to commode\n Response:\n HR down to 60\ns w/ occ vea. Tolerated oob well\n Plan:\n Cont close hemodynamic monitoring, monitoring of r groin and pulses as\n well as hct this evening. Increase activity as tolerated.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n STEMI\n Code status:\n Full code\n Height:\n Admission weight:\n 83.5 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: GERD\n Surgery / Procedure and date: Cath lab revealed LAD with prox total\n occlusion which was stented x 1 with ptca. Also revealed OM1 wiht 70%\n stenosis and PDA 80% stenosis. After procedure he was transferred to\n CCU for further management\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:121\n D:78\n Temperature:\n 99.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 750 mL\n 24h total out:\n 625 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 10:59 AM\n Potassium:\n 4.0 mEq/L\n 10:59 AM\n Chloride:\n 102 mEq/L\n 10:59 AM\n CO2:\n 26 mEq/L\n 10:59 AM\n BUN:\n 26 mg/dL\n 10:59 AM\n Creatinine:\n 1.4 mg/dL\n 10:59 AM\n Glucose:\n 113 mg/dL\n 10:59 AM\n Hematocrit:\n 37.7 %\n 10:59 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash Amount: $371\n Credit Cards: no\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2141-09-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541376,
"text": "81yom w/ pmh HTN and GERD presents to clinic w/ c/o epigastric/sternal\n cp w/ n&v x 1 day. EKG showing STEMI, sent directly to ED then\n cath lab. Pt w/ prox TO LAD which was stented. Pt also w/ 70% distal\n to the stent, 70% prox OM1, 40-50% Prox RCA and 80% PDA. Pt sent to\n CCU for post cath monitoring. CPK #1 1546/MB 46/MBI 3.0, troponin\n 3.73.\n CCU course complicated by r groin hematoma, requiring d/c integrillin\n and removal of sheaths at 8pm . No change in hct. Pt started and\n is tolerating lopressor, lisinopril and lovenox.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n HR 70\ns, BP 110-130. CPK\ns down to 700\ns. No c/o chest pain\n Action:\n Lopressor increased to 37.5 mg . Has been oob to commode\n Response:\n HR down to 60\ns w/ occ vea. Tolerated oob well\n Plan:\n Cont close hemodynamic monitoring, monitoring of r groin and pulses as\n well as hct this evening. Increase activity as tolerated.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n STEMI\n Code status:\n Full code\n Height:\n Admission weight:\n 83.5 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: GERD\n Surgery / Procedure and date: Cath lab revealed LAD with prox total\n occlusion which was stented x 1 with ptca. Also revealed OM1 wiht 70%\n stenosis and PDA 80% stenosis. After procedure he was transferred to\n CCU for further management\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:121\n D:78\n Temperature:\n 99.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 750 mL\n 24h total out:\n 625 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 10:59 AM\n Potassium:\n 4.0 mEq/L\n 10:59 AM\n Chloride:\n 102 mEq/L\n 10:59 AM\n CO2:\n 26 mEq/L\n 10:59 AM\n BUN:\n 26 mg/dL\n 10:59 AM\n Creatinine:\n 1.4 mg/dL\n 10:59 AM\n Glucose:\n 113 mg/dL\n 10:59 AM\n Hematocrit:\n 37.7 %\n 10:59 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money: Transferred w/ patient\n No money / wallet\n Cash Amount: $371\n Credit Cards: no\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 618/\n Transferred to: 310\n Date & time of Transfer: 1530\n"
},
{
"category": "Physician ",
"chartdate": "2141-09-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 541368,
"text": "TITLE:\n Chief Complaint:\n 80 y/o M with history of HTN and GERD admitted the CCU after presenting\n with chest pain, found to have STEMI with complete occlusion of LAD and\n with 3v disease s/p PCI with BMS placed in LAD.\n 24 Hour Events:\n Patient with Rt groin hematoma s/p PCI. Pressure applied and patient\n supine for 6hrs. Integrellin gtt turned off and heparin held.\n Allergies:\n No Known Drug Allergies\n Medications:\n ASA 81mg\n Metoprolol 37.5mg po BID\n Lisinopril 5mg daily\n Atorvastatin 80mg daily\n Plavix 75mg daily\n Lovenox 80mg \n Changes to medical 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: 37.6\nC (99.7\n Tcurrent: 37.6\nC (99.7\n HR: 72 (61 - 80) bpm\n BP: 112/61(72) {112/61(72) - 154/85(100)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 96% 2L\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,044 mL\n 360 mL\n PO:\n 240 mL\n TF:\n IVF:\n 804 mL\n 360 mL\n Blood products:\n Total out:\n 250 mL\n 425 mL\n Urine:\n 250 mL\n 425 mL\n NG:\n Stool:\n Drains:\n Balance:\n 794 mL\n -65 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96% 2L\n ABG: ///24/\n Physical Examination\n GENERAL: WDWN NAD, oriented x 3.\n HEENT: No JVP appreciated, no carotid bruits were appreciaetd\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\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.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\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 180 K/uL\n 13.2 g/dL\n 113 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 22 mg/dL\n 102 mEq/L\n 133 mEq/L\n 35.9 %\n 8.8 K/uL\n [image002.jpg]\n 01:54 AM\n WBC\n 8.8\n Hct\n 35.9\n Plt\n 180\n Cr\n 1.2\n Glucose\n 113\n Other labs: CK / CKMB / Troponin-T:1217/37/, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 80 y/o M with history of HTN and GERD admitted the CCU after presenting\n with chest pain, found to have STEMI with complete occlusion of LAD and\n with 3v disease s/p PCI with BMS placed in LAD.\n 1) ACS: STEMI, s/p PCI with BMS placement in proximal LAD. Cath\n revealed diffuse 3v disease (discussed below).\n - Pending Echo results for possible wall motion abnormality. Depending\n on results, will determine whether patient will benefit from long term\n outpatient coagulation.\n - Start Lovenox 80mg for prophylaxis\n - Increase Metoprolol to 37.5mg \n - Continue Lisinopril 5mg daily, ASA 325mg, and Atorvastatin 80mg.\n - Continue Plavix 75mg daily.\n 2) Coronary artery disease: Cath revealed 3v disease with good\n collateralization. Will maximize medical therapy with aggressive BP\n control and lowering of lipids. Patient will benefit from maximal\n medical management with BB, ACE-I, and high dose statin, with goal LDL\n < 70.\n - Continue maximal medical mangagment\n .\n 3) HTN: BP 112/61. Improved.\n - Continue ACE-I , and increase Metoprolol to 37.5mg .\n - Will monitor and uptitrate as needed.\n .\n ICU Care\n Nutrition: Regular, heart healthy diet.\n Glycemic Control: None\n Lines:\n 18 Gauge - 08:01 PM\n Prophylaxis:\n DVT: ppx with lovenox.\n Stress ulcer:\n VAP:\n Comments:\n Communication: Son : \n Code status: Presumed full\n Disposition: To Floor\n"
},
{
"category": "Nursing",
"chartdate": "2141-09-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541370,
"text": "81yom w/ pmh HTN and GERD presents to clinic w/ c/o epigastric/sternal\n cp w/ n&v x 1 day. STEMI, sent directly to ED then cath lab. Pt\n w/ prox TO LAD which was stented. Pt also w/ 70% distal to the stent,\n 70% prox OM1, 40-50% Prox RCA and 80% PDA. Pt sent to CCU for post\n cath monitoring. CPK #1 1546/MB 46/MBI 3.0, troponin 3.73.\n CCU course complicated by r groin hematoma, requiring d/c integrillin\n and removal of sheaths at 8pm . No change in hct. Pt started and\n is tolerating lopressor, lisinopril and lovenox.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2141-09-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541371,
"text": "81yom w/ pmh HTN and GERD presents to clinic w/ c/o epigastric/sternal\n cp w/ n&v x 1 day. EKG showing STEMI, sent directly to ED then\n cath lab. Pt w/ prox TO LAD which was stented. Pt also w/ 70% distal\n to the stent, 70% prox OM1, 40-50% Prox RCA and 80% PDA. Pt sent to\n CCU for post cath monitoring. CPK #1 1546/MB 46/MBI 3.0, troponin\n 3.73.\n CCU course complicated by r groin hematoma, requiring d/c integrillin\n and removal of sheaths at 8pm . No change in hct. Pt started and\n is tolerating lopressor, lisinopril and lovenox.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n HR 70\ns, BP 110-130. CPK\ns down to 700\ns. No c/o chest pain\n Action:\n Lopressor increased to 37.5 mg .\n Response:\n HR down to 60\ns w/ occ vea.\n Plan:\n Cont close hemodynamic monitoring, monitoring of r groin and pulses as\n well as hct this evening. Increase activity as tolerated,\n"
},
{
"category": "Physician ",
"chartdate": "2141-09-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 541354,
"text": "TITLE:\n Chief Complaint:\n 80 y/o M with history of HTN and GERD admitted the CCU after presenting\n with chest pain, found to have STEMI with complete occlusion of LAD and\n with 3v disease s/p PCI with BMS placed in LAD.\n 24 Hour Events:\n Patient with Rt groin hematoma s/p PCI. Pressure applied and patient\n supine for 6hrs. Integrellin gtt turned off and heparin held.\n Allergies:\n No Known Drug Allergies\n Medications:\n ASA 81mg\n Metoprolol 25mg po BID\n Lisinopril 5mg daily\n Atorvastatin 80mg daily\n Plavix 75mg daily\n Changes to medical 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: 37.6\nC (99.7\n Tcurrent: 37.6\nC (99.7\n HR: 72 (61 - 80) bpm\n BP: 112/61(72) {112/61(72) - 154/85(100)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 96% 2L\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,044 mL\n 360 mL\n PO:\n 240 mL\n TF:\n IVF:\n 804 mL\n 360 mL\n Blood products:\n Total out:\n 250 mL\n 425 mL\n Urine:\n 250 mL\n 425 mL\n NG:\n Stool:\n Drains:\n Balance:\n 794 mL\n -65 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96% 2L\n ABG: ///24/\n Physical Examination\n GENERAL: WDWN NAD, oriented x 3.\n HEENT: No JVP appreciated, no carotid bruits were appreciaetd\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\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.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\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 180 K/uL\n 13.2 g/dL\n 113 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 22 mg/dL\n 102 mEq/L\n 133 mEq/L\n 35.9 %\n 8.8 K/uL\n [image002.jpg]\n 01:54 AM\n WBC\n 8.8\n Hct\n 35.9\n Plt\n 180\n Cr\n 1.2\n Glucose\n 113\n Other labs: CK / CKMB / Troponin-T:1217/37/, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n This is a 80 y/o M with history of HTN and GERD admitted the CCU after\n presenting with chest pain, found to have STEMI with complete occlusion\n of LAD and with 3v disease s/p PCI with BMS placed in LAD.\n .\n 1) ACS: STEMI, EKG consistent with ST elevation in leads V1-4\n consistent with involvement of anterior precordium in distribution of\n LAD territory. Patient taken for PCI, BMS placed in completely\n occluded LAD. Cath revealed diffuse 3v disease (discussed below). In\n ER, patient received NTG x 3, ASA 325mg, and Morphine. Patient started\n on integrillin during PCI. Patient's troponin is 3.73.\n - Discontinue integrellin as patient has post-intervention bleeding\n from site of sheath placement\n - Discontinue heparin\n - Will start Metoprolol 25mg , Lisinopril 5mg daily, ASA 325mg, and\n Atorvastatin 80mg.\n - Continue Plavix 75mg daily for at least 30 days for BMS.\n - Echo and TTE in AM.\n - Will perform post cath check 8hrs from PCI\n .\n 2) Coronary artery disease: Cath revealed 3v disease with good\n collateralization. Patient had complete occlusion of LAD, subseqently\n had BMS placement. Patient's main risk factor is HTN. Patient non\n smoker, no FH of CAD. Last FLP in showed LDL of 97, HDL 44.\n Patient will benefit from maximal medical management with BB, ACE-I,\n and high dose statin, with goal LDL < 70.\n Given this patient's 3v CAD, the long term question is whether this\n patient would benefit from CABG. Patient is overall a good candidate\n for sugery. Patient would likely benefit from stress testing vs\n viability study in near future once patient remains stable to determine\n if there is a need for further revascularization in this patient.\n - Will consult CT surgery in AM\n - Continue maximal medical mangagment\n .\n 3) HTN: BP 137/74. Patient's BP have not been well controlled in\n past. Will d/c home HCTZ and start BB and ACE-I as patient is post MI\n and will benefit from BP control.\n - Start BB and ACE-I, will uptitrate as needed, consider adding CCB or\n diuretic as needed.\n .\n ICU Care\n Nutrition: Regular, heart healthy diet.\n Glycemic Control: None\n Lines:\n 18 Gauge - 08:01 PM\n Prophylaxis:\n DVT: ppx with Heparin, once patient's PCI site is stable.\n Stress ulcer:\n VAP:\n Comments:\n Communication: Son : \n Code status: Presumed full\n Disposition: CCU service for now\n"
},
{
"category": "Physician ",
"chartdate": "2141-09-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 541360,
"text": "TITLE:\n Chief Complaint:\n 80 y/o M with history of HTN and GERD admitted the CCU after presenting\n with chest pain, found to have STEMI with complete occlusion of LAD and\n with 3v disease s/p PCI with BMS placed in LAD.\n 24 Hour Events:\n Patient with Rt groin hematoma s/p PCI. Pressure applied and patient\n supine for 6hrs. Integrellin gtt turned off and heparin held.\n Allergies:\n No Known Drug Allergies\n Medications:\n ASA 81mg\n Metoprolol 37.5mg po BID\n Lisinopril 5mg daily\n Atorvastatin 80mg daily\n Plavix 75mg daily\n Lovenox 80mg \n Changes to medical 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: 37.6\nC (99.7\n Tcurrent: 37.6\nC (99.7\n HR: 72 (61 - 80) bpm\n BP: 112/61(72) {112/61(72) - 154/85(100)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 96% 2L\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,044 mL\n 360 mL\n PO:\n 240 mL\n TF:\n IVF:\n 804 mL\n 360 mL\n Blood products:\n Total out:\n 250 mL\n 425 mL\n Urine:\n 250 mL\n 425 mL\n NG:\n Stool:\n Drains:\n Balance:\n 794 mL\n -65 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96% 2L\n ABG: ///24/\n Physical Examination\n GENERAL: WDWN NAD, oriented x 3.\n HEENT: No JVP appreciated, no carotid bruits were appreciaetd\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\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.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\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 180 K/uL\n 13.2 g/dL\n 113 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 22 mg/dL\n 102 mEq/L\n 133 mEq/L\n 35.9 %\n 8.8 K/uL\n [image002.jpg]\n 01:54 AM\n WBC\n 8.8\n Hct\n 35.9\n Plt\n 180\n Cr\n 1.2\n Glucose\n 113\n Other labs: CK / CKMB / Troponin-T:1217/37/, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 80 y/o M with history of HTN and GERD admitted the CCU after presenting\n with chest pain, found to have STEMI with complete occlusion of LAD and\n with 3v disease s/p PCI with BMS placed in LAD.\n 1) ACS: STEMI, s/p PCI with BMS placement in proximal LAD. Cath\n revealed diffuse 3v disease (discussed below).\n - Pending Echo results for possible wall motion abnormality. Depending\n on results, will determine whether patient will benefit from long term\n outpatient coagulation.\n - Start Lovenox 80mg for prophylaxis\n - Increase Metoprolol to 37.5mg \n - Continue Lisinopril 5mg daily, ASA 325mg, and Atorvastatin 80mg.\n - Continue Plavix 75mg daily.\n 2) Coronary artery disease: Cath revealed 3v disease with good\n collateralization. Will maximize medical therapy with aggressive BP\n control and lowering of lipids. Patient will benefit from maximal\n medical management with BB, ACE-I, and high dose statin, with goal LDL\n < 70.\n - Continue maximal medical mangagment\n .\n 3) HTN: BP 112/61. Improved.\n - Continue ACE-I , and increase Metoprolol to 37.5mg .\n - Will monitor and uptitrate as needed.\n .\n ICU Care\n Nutrition: Regular, heart healthy diet.\n Glycemic Control: None\n Lines:\n 18 Gauge - 08:01 PM\n Prophylaxis:\n DVT: ppx with lovenox.\n Stress ulcer:\n VAP:\n Comments:\n Communication: Son : \n Code status: Presumed full\n Disposition: To Floor\n"
},
{
"category": "Radiology",
"chartdate": "2141-09-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1042415,
"text": " 6:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate/edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with chest pain\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate/edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old male with chest pain, to assess for a cardiopulmonary\n process.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed. There\n is no relevant prior imaging for comparison.\n\n FINDINGS:\n\n The left costophrenic angle and left lower rib cage has not been included at\n this examination. Within these limitations, the cardiomediastinal contour is\n unremarkable. The visualized lungs are clear. There is no displaced rib\n fracture or pneumothorax.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-09-20 00:00:00.000",
"description": "Report",
"row_id": 150249,
"text": "Sinus rhythm. Q waves in the anterior leads with ST segment elevations and\nterminal T wave inversions in the anterior, anterolateral and lateral leads\nconsistent with acute or evolving infarction. Compared to the previous tracing\nno significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2141-09-20 00:00:00.000",
"description": "Report",
"row_id": 150250,
"text": "Sinus rhythm. Q waves in the anterior leads with ST segment elevations and\nterminal T wave inversions in the anterior, anterolateral and lateral leads\nconsistent with acute or evolving infarction. Compared to the previous tracing\nno significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2141-09-19 00:00:00.000",
"description": "Report",
"row_id": 150358,
"text": "Sinus rhythm. The previously mentioned multiple abnormalities recorded\non persist without diagnostic interim change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2141-09-18 00:00:00.000",
"description": "Report",
"row_id": 150359,
"text": "Sinus rhythm. The limb leads are misattached. There is low limb lead voltage.\nCompared to the previous tracing of there is variation in precordial\nlead placement. No apparent diagnostic interim change. Followup and clinical\ncorrelation are suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2141-09-18 00:00:00.000",
"description": "Report",
"row_id": 150360,
"text": "Sinus rhythm. Compared to the previous tracing of the previously\nmentioned multiple abnormalities persist without diagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2141-09-18 00:00:00.000",
"description": "Report",
"row_id": 150361,
"text": "Sinus rhythm. Recent or ongoing anteroseptal myocardial infarction with\ncontinued ST segment elevation and biphasic to inverted T waves in\nleads V1-V5. Followup and clinical correlation are suggested. No previous\ntracing available for comparison.\n\n"
}
] |
1,042 | 130,732 | Taken to OR for orthotopic (piggyback)deceased donor liver transplant pv-pv, cbd-cbd, no t-tube. He received 3,300 of crystalloid, 3units FFP, 2units of RBC, 2 units of plts and 1 cryo. EBL was 300. See operative report. Given induction immunosuppression (Simulect, Cellcept, and Solumedrol). A duplex of the liver demonstrated "Unremarkable post-transplant liver ultrasound and Doppler." He was transferred to SICU postop intubated and stable. On POD 1 sedation was decreased with goal to extubate. Lungs were clear. Hct was 25.4. He was transfused with 4 units of PRBC and 1 unit of plts. JP 1 drained 385 and JP # 2 110cc. Solumedrol m and Cellcept 1gram were given. On POD 2, temperature was 101.7. Blood and urine cultures were done and subsequently negative. JP 1 drained 1245 and #2 55. He was extubated. Prograf was initiated in addition to cellcept and a daily solumedrol tapering dose for immunosuppression. Liver duplex was normal. Pain was managed with dilaudid prn. Alt 222, ast 191, alk phos 98 and t.bili 3.7. LFTs trended down until POD 4 when alk phos started to increase to 368. On POD 4, he received Simulect 20mg IV. The lateral JP and NG were removed and diet was advanced to sips of clears. He became dyspneic and dropped 02 sat to 88% on RA. A 70% face mask was applied with O2 sat that increased to 98%. Wheezing and decreased breath sounds were noted on the right. ABGs,CXR and EKG were done. He was given albuterol neb treatment with improvement of O2 sat. ABG was 7.32/48/75/26/-1. CXR revealed small bilateral pleural effusions that were stable. EKG was stable. He was treated with IV lasix 40 for volume overload. O2 remained at 92% on 5L face tent.He continued to receive albuterol neb treatments every 2-4 hours. He diuresed, but PAO2 continued at 68 and PC02 53. Diamox was added. He diuresed 4290cc with repeat ABG of 7.35/54/83/31/12 and decreased wheezing. He required hand restraints for some confusion and pulling off O2. On POD 5, alk phos increased to 572 and t.bili to 3.1. A duplex of the liver demonstrated " interval development of a new fluid collection just deep to the left lobe of the liver extending into the left porta. The collection contains fluid and solid components, with septations. It measures 5.9 x 5.7 x 3.2 cm. Aside from this collection, the left lobe parenchyma is normal in appearance. There is no intrahepatic biliary ductal dilatation. In addition, there is a second collection found in the right subhepatic region. This collection contains fluid and some echogenic material that may represent clot. This collection measures 7.5 x 3.0 x 4.7 cm. The parenchyma of the right lobe is normal in appearance, without biliary ductal dilatation. A right pleural effusion with associated atelectasis is noted." Arterial/venous flow and resistive indices were normal. Prograf level was 19.4 and prograf was held x 4 doses. Repeat prograf level was 7.8 and prograf was resumed at 1mg on POD7. He was given 2 bags of platelets for a plt count of 68. A HIT antibody was sent. Medial JP was removed. On POD 7, he was coughing and raising thick, green sputum. He remained in the SICU for close management of respiratory and mental status. He had episodes of somnolence and confusion. At times, he appeared to be hallucinating. Pain medication was decreased. On POD 8, he was transferred to the transplant unit. Diet was advanced and PT continued to work with him. He required a 1:1 sitter as he was agitated, and pulling at IV lines and removing O2 tubing. Foley was removed. Percocet was decreased for sedation. On POD 9, he received Pamidronate x1. Calcium and vitamin D were started. Alk phos increased to 566. A repeat duplex revealed ". Patent portal vein, with most probably slight narrowing in the anastomotic site, demonstrating velocity gradient of uncertain significance. 2. Unchanged subhepatic and left intrahepatic small fluid collections." Prograf was increased for a level of 10.4. ON POD 11 (), a liver biopsy was performed. This demonstrated "Features indeterminate for acute cellular rejection. Focal minimal lobular inflammation, nonspecific. Focal poorly formed histiocytic aggregate, suggestive of granuloma". Prograf was decreased to 1.5mg for a level of 13.5. Prednisone remained at 20mg and cellcept at 1gram . A consult was obtained for elevated glucoses. These were treated with sliding scale insulin. recommendations, Prandin 1mg prior to meals was started. On POD 13, he was alert and ambulatory. O2 sats were in the high 90's on room air. Lungs were clear. He was tolerating a regular diet and vital signs were stable. Hct trended down to 25.1. AST was 24, alt 40, alk phos 340 and t.bili 1.5. VNA ( Home Care) was set up to assist with medication and insulin/glucose management as well as PT for strengthening and safety training. A rolling walker was provided for unsteady gait. His mother arranged for time off from work in order to provide 24 hour supervision as he did display poor safety awareness and judgement. Incision was clean and dry. There was extensive ecchymosis on right side of abdomen and flank. He was discharged home with scheduled f/u appointments at the Transplant office. | FINDINGS: The heart, mediastinal and hilar contours are within normal limits. Stable right lower lobe atelectasis/consolidation and right pleural effusion. FINDINGS: There is a right IJ central line with the tip in the lower SVC. medial jp remains and it is draing serosanguinous.neuro: pt complains alot. LESS FEBRILE-99.7- AFTER BATH.ABDOMINAL INCISION WITH ORIGINAL OR DRESSING INTACT. A right pleural effusion with associated atelectasis is noted. FEBRILE TO 101.7-DR AND DR. Generalized edema noted. There is again noted a right pleural effusion and alveolar process. Percocet given with + effect.CV: SR, No ectopy noted. LIVER DOPPLER: The hepatic veins are patent with the appropriate direction of flow. Normal hepatic vasculature. Prograf levels sent. Lasix gtt d/c'd this am. FINDINGS: Again are demonstrated small right subhepatic and deep left lobe intrahepatic fluid collections, unchanged in size or appearance. Pt has been afebrile. wheezes I/E present bilateral. The right internal jugular central venous catheter has been pulled back such that the tip is now at the level of the upper superior vena cava. LIVER DOPPLER ULTRASOUND: There is normal hepatic artery flow with resistive indices ranging from 0.47 to 0.61. positive bowel sounds.integumentary: y incision clean and dry..open to air. Plan is to transfer to floor when respiratory status is stable. bp stable see careview. C/O INCISIONAL PAIN WHICH IS RELIEVED WITH PRN DILAUDID.LUNGS CLEAR BILAT. The portal vein is patent with hepatopetal flow. IMPRESSION: Normal liver Doppler ultrasound. Normal flow and direction are demonstrated in the right and left intrahepatic branches of the portal vein. Abdominal drains are in place consistent with recent surgical history. Productive cough noted.CV: NSR without ectopy. POSITIVE BOWEL SOUNDS. The osseous structures are within normal limits. Portable AP semi upright chest radiograph shows obscuration of the left hemidiaphragm, progress compared to one day ago and also associated with some consolidation in the left retrocardiac region. lateral jp drain removed.s/p jp site is draining serosanguinous. Abd incision site open to air, JPX1 intact with dsg to old JP site.GI/GU: Abd soft, + BS. COMPARISON: Immediate postop ultrasound of . IMPRESSION: Right IJ central line catheter tip over right atrium. + pulses to ext. Unchanged subhepatic and left intrahepatic small fluid collections. There is a right IJ central line with tip over the right atrium. The right, mid, and left hepatic veins and the IVC are patent with good flow. COMPARISON: FINDINGS: The tip of the Swan-Ganz catheter is only minimally changed still seen centrally in the mediastinum. Staples intact on abdomen. There is normal hepatic arterial flow, with resistive indices ranging from 0.76 through 0.82, with normal waveforms. SEROSANG DRAINAGE FROM AROUND MEDIAL JP INSERT SITE. Comparison is made to the prior chest x-ray dated . R lower lobe pleural effusion & atelectasis by cxr today, encourage IS, cpt, oob to chair, sputum c&s Persistent right-sided pleural effusion. Color Doppler imaging demonstrates fully patent portal vein, demonstrating good hepatopetal flow. dilutional vs bldg-> ho aware. Incision C/D/I. NGT to LWCS with bilious drainage.ENDO: RISS as ordered.GU: foley, c/y/u. Pt has been afebrile. Pt has been afebrile. 2uprbc infused for same. diuresed with diamox.Resp: Pt continues on 4L 02 via n/c. JP #1 with moderate serosang output. Percocet given with + effect. ABG's drawn ph 7.31,C02 46, Pa02 177, HC03 24. 1x medium, guiac - stool during the noc. LUNGS CLEAR/DIMINISHED AT THE BASES. ABG's drawn PH 7.44/C02 39/ Pa02 222/HC03 27. Transfuse one unit pRBC. Continue dilaudid and haldol as needed. Continue to diures. CONT DIEURESIS. Generalized edema. PERRL.CV: SR. Rare pvc's noted. ABG done with improved PaO2. + PULSES TO EXT. Bbs coarse to cl, diminsh at bases.Gi status: ngt to lws w bilious drng. Area where jp drain d/c'd still draining moderate of serosang drainage. Plan for extubation this AM. MINIMAL EDEMA TO EXT. HR 70S, BP STABLE, AFEBRILE. Will wean PS as tolerated. Pt receiving 4L 02 via nc. Monitot hempdynamics, assist with OOB activity. Tolerating well. Condition Update. NG d/c. Pt admitted to flr from OR. Temp of blood 37.1. BS. REVIEW AM ABG. Lungs are diminished bil at bases.GI: BS are present, soft, tender x4, Medial JP with copious amounts of sero/sang drainage. + BS. O2 was weaned down from nasal cannula and face tent to just nasal cannula. R IJ MULTILUMEN CATHETER.GI/GU: ABD ROUND SOFT, + BS. , RRT PRODUCTIVE COUGH NOTED. Pt. MEDICATED FOR PAIN X1. RESP REGULAR DENIES SOB. Sinus rhythm. JP's with small amounts serosang. Sa02 99%.Abdomen soft and distended with pos. AM ABG ORDERED.CV: NSR WITHOUT ECTOPY. See carevue for specifics.Pt. RESPIRATORY CARE NOTEPt remains intubated and ventilated on PS settings as of 0500. ABD INCISION WITH STAPLES INTACT/OPEN TO AIR. SMALL DSG TO OLD JP SITE CHANGED. UPdateO:See carevue flowsheet for specifics CV status: sr no ectopy. rlq jp drains to bulb suct w ss drng around drsg reinforced.Protonix for gi prophylax.Gu status: negligable urine outpt-> Ho aware.Tacrolimus to be held this a.m. for same.Neuro status: arousable off prop-> mae spont not to commands.Perl 3-2mm. Short QTc interval. sbp stable. Lateral JP site draining scant amounts of serosang fluid. placed.Plan: Continue with current plan of care per sicu/ tranplant teams. Abd soft distended no active bowel snds.Abd dsg d/i. Condition UpdateD: See carevue flowsheet for specifics. Lateral JP with small amounts of sang drainage. Afebrile, 98.6 via blood.Respir: CMV, Vt 650, FiO2 .40, Peep 5. ?psych eval. Will cont to ventilate on CMV and re-eval in am. After sleeping for ~1hr abg was drawn and PaO2 77. Easily reoriented. LASIX X 1 DOSE GIVEN IN PM. MAES. CCO swan and trauma line d/c and quad lumen guide-wired. O2 sat 98-100%.GI: BS are absent x4, NGT to LWCS with bilious drainage, Abd medial JP with sero/sang drainage. ABG, EKG and chest x-ray obatained. Transfused with several units platelets today.Lungs CTA. SBP 130-150, PAP 30-40/20. | 38 | [
{
"category": "Radiology",
"chartdate": "2166-07-01 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 871709,
"text": " 2:32 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: duplex u/s s/p transplant, please eval portal vein for stric\n Admitting Diagnosis: LIVER CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man with s/p liver trasnplant s/p post op bleed\n\n REASON FOR THIS EXAMINATION:\n duplex u/s s/p transplant, please eval portal vein for stricture/patency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient post-liver transplantation, for evaluation of portal\n vein.\n\n COMPARISON: .\n\n FINDINGS: Again are demonstrated small right subhepatic and deep left lobe\n intrahepatic fluid collections, unchanged in size or appearance. The liver is\n otherwise normal in contour and echogenicity. There is no intrahepatic or\n extrahepatic biliary dilatation.\n\n Color Doppler imaging demonstrates fully patent portal vein, demonstrating\n good hepatopetal flow. Focal aliasing is demonstrated at the anastomotic\n site, with a velocity gradient, the portal velocity flow is 75 prior to the\n anastomosis, 200 in the anastomotic site, and approximately 30 cc per second\n in the intrahepatic portal vein. Normal flow and direction are demonstrated\n in the right and left intrahepatic branches of the portal vein. The hepatic\n artery and its right and left branches are patent, demonstrating good\n waveforms. The right, mid, and left hepatic veins and the IVC are patent with\n good flow.\n\n IMPRESSION:\n 1. Patent portal vein, with most probably slight narrowing in the anastomotic\n site, demonstrating velocity gradient of uncertain significance.\n 2. Unchanged subhepatic and left intrahepatic small fluid collections.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-07-02 00:00:00.000",
"description": "BX-NEEDLE LIVER BY RADIOLOGIST",
"row_id": 871792,
"text": " 8:28 AM\n BX-NEEDLE LIVER BY RADIOLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: ? rejection-please do the biopsy by 9AM so that path can be\n Admitting Diagnosis: LIVER CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with s/p OLT on now with elevated LFTs\n REASON FOR THIS EXAMINATION:\n ? rejection-please do the biopsy by 9AM so that path can be rushed for same day\n -Call beeper for specimen pick-up or and questions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ultrasound guided liver biopsy for a patient post-liver\n transplantation, question of rejection.\n\n PROCEDURE: After the risks and benefits of the procedure were discussed with\n the patient, informed consent was obtained. A pre-procedure time-out was\n obtained to confirm the identity of the patient and the procedure which he\n has to undergo.\n\n The patient's skin was prepped and draped in the usual sterile fashion and 1%\n Lidocaine was used for local anesthesia.\n\n Under direct ultrasound guidance, using an 18 gauge automatic core biopsy\n system, 1 pass was obtained from the right lobe of the liver.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n Dr. , attending radiologist, was present and supervising the entire\n procedure.\n\n IMPRESSION: Technically successful core needle biopsy of the liver.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-06-23 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 870712,
"text": " 1:56 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: asses CVL position\n Admitting Diagnosis: LIVER CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man s/p liver transplant with advancement of Pa cath.\n\n REASON FOR THIS EXAMINATION:\n asses CVL position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Liver transplant advancement of PA catheter.\n\n Chest, single AP semi upright portable view obtained at 2:10 p.m.\n\n Lordotic positioning. The superior mediastinal silhouette is prominent, but\n likely accentuated by lordotic positioning. There are probable small\n bilateral pleural effusions, with underlying subsegmental atelectasis. Doubt\n CHF. There is a right IJ central line with tip over the right atrium.\n Compared with , the Swan-Ganz catheter, ET tube, and NG tube have\n been removed. Again seen are two drains over the upper abdomen, with multiple\n abdominal staples. No pneumothorax is identified.\n\n IMPRESSION: Right IJ central line catheter tip over right atrium. Clinical\n correlation requested, as this lies relatively low. New small bilateral\n pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-06-21 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 870479,
"text": " 12:57 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: LIVER CIRRHOSIS\n Admitting Diagnosis: LIVER CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36M with ESLD, awaiting transplant, also with bilateral PNA on previous CXR,\n now s/p 1 week vanco/zosyn, continues to have mild O2 requirement.\n REASON FOR THIS EXAMINATION:\n Pre-op for liver tx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage liver disease, awaiting transplant.\n\n Comparison is made to the prior chest x-ray dated .\n\n FINDINGS: The heart, mediastinal and hilar contours are within normal limits.\n The lungs are clear without effusion, consolidation or pneumothorax. The\n osseous structures are within normal limits.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-06-26 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 871057,
"text": " 10:57 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: LIVER TRANSPLANT, INCREASING LFT'S\n Admitting Diagnosis: LIVER CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man with s/p liver trasnplant s/p post op bleed\n\n REASON FOR THIS EXAMINATION:\n increasing LFTs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant with increasing LFTs.\n\n COMPARISON: Immediate postop ultrasound of .\n\n LIVER TRANSPLANT ULTRASOUND: There has been interval development of a new\n fluid collection just deep to the left lobe of the liver extending into the\n left porta. The collection contains fluid and solid components, with\n septations. It measures 5.9 x 5.7 x 3.2 cm. Aside from this collection, the\n left lobe parenchyma is normal in appearance. There is no intrahepatic\n biliary ductal dilatation. In addition, there is a second collection found in\n the right subhepatic region. This collection contains fluid and some\n echogenic material that may represent clot. This collection measures 7.5 x\n 3.0 x 4.7 cm. The parenchyma of the right lobe is normal in appearance,\n without biliary ductal dilatation. A right pleural effusion with associated\n atelectasis is noted.\n\n LIVER DOPPLER: The hepatic veins are patent with the appropriate direction of\n flow. The portal veins are also patent, with the appropriate direction of\n flow. There is normal hepatic arterial flow, with resistive indices ranging\n from 0.76 through 0.82, with normal waveforms.\n\n IMPRESSION:\n 1. Interval development of indeterminate fluid collections, which may contain\n bile or hematoma.\n 2. Normal hepatic vasculature.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-06-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 871048,
"text": " 9:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? EXTENT OF PLEURAL EFFUSION\n Admitting Diagnosis: LIVER CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man s/p liver transplant with acute SOB.\n\n REASON FOR THIS EXAMINATION:\n ? EXTENT OF PLEURAL EFFUSION\n ______________________________________________________________________________\n FINAL REPORT\n 36-year-old man, post-liver transplant with acute shortness of breath.\n\n AP portable film compared to the previous film of shows interval\n worsening of the multiple pulmonary opacities with persistent right-sided\n pleural effusion. This could represent worsening pulmonary edema and/or\n multifocal pneumonia.\n\n CONCLUSION: Worsening of multiple pulmonary opacities, either representing\n progression of pulmonary edema or multifocal pneumonia since the previous film\n of . Persistent right-sided pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-06-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 870615,
"text": " 2:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: advancement of PA cath\n Admitting Diagnosis: LIVER CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man s/p liver transplant with advancement of Pa cath.\n\n REASON FOR THIS EXAMINATION:\n advancement of PA cath\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Advancement of PA catheter.\n\n COMPARISON: \n\n FINDINGS:\n\n The tip of the Swan-Ganz catheter is only minimally changed still seen\n centrally in the mediastinum. There is no pneumothorax. ETT and NGT remain\n in place. There are no new infiltrates and no evidence for worsening fluid\n status.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-06-21 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 870548,
"text": " 5:24 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: S/P LIVER TX TODAY, EVAL AND DUPLEX\n Admitting Diagnosis: LIVER CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man with s/p liver trasnplant\n REASON FOR THIS EXAMINATION:\n liver trasnplant ultrasound and duplex\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 36-year-old man status post orthotopic liver transplant.\n Evaluate.\n\n Liver ultrasound with Doppler. The lower liver is normal in echotexture\n without focal nodules or masses. All hepatic veins appear patent with normal\n flow. The portal vein is patent with hepatopetal flow. All arteries\n demonstrate normal waveforms with resistive indices ranging from 0.46 through\n 0.49.\n\n IMPRESSION: Unremarkable post-transplant liver ultrasound and Doppler.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-06-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 870537,
"text": " 2:59 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: lione placement\n Admitting Diagnosis: LIVER CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man s/p liver transplant\n REASON FOR THIS EXAMINATION:\n lione placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 19:26.\n\n INDICATION: Line placement.\n\n FINDINGS:\n\n There is an ETT with its tip 4.6 cm above the carina. The right Swan-Ganz\n catheter is introduced via a sheath on the right and its tip is located in the\n region of the right main pulmonary artery. There is no PTX. The lungs are\n clear of consolidations or effusions and the pulmonary vascular markings are\n normal.\n\n Abdominal drains are in place consistent with recent surgical history.\n\n IMPRESSION: Lines and tubes as described above with no evidence for CHF or\n pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-06-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 870829,
"text": " 11:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval acute SOB/hypoxia. R/o pneumonia, atalectasis, pneumot\n Admitting Diagnosis: LIVER CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man s/p liver transplant with acute SOB.\n\n REASON FOR THIS EXAMINATION:\n eval acute SOB/hypoxia. R/o pneumonia, atalectasis, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate shortness of breath and hypoxia in a patient status post\n liver transplant.\n\n Portable AP semi upright chest radiograph shows obscuration of the left\n hemidiaphragm, progress compared to one day ago and also associated with some\n consolidation in the left retrocardiac region. This obscuration may be\n related to some subsegmental atelectasis or pneumonia, and in view of the\n slightly full perihilarasculature and some peribronchial cuffing, may also be\n related to edema. No pneumothorax is seen. The right internal jugular\n central venous catheter has been pulled back such that the tip is now at the\n level of the upper superior vena cava. Surgical drains are seen over the\n right upper quadrant in this patient with a skin staples in a Chevron\n incision.\n\n CONCLUSION: Slight pulmonary vascular congestion, possibly exaggerated\n because semi upright positioning. Obscuration at the bases, with progression\n on the right compared to yesterday may be related to atelectasis or\n consolidation from pneumonia or edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-06-22 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 870611,
"text": " 1:31 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: ? HEMATOMA FLOW POST TX\n Admitting Diagnosis: LIVER CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man with s/p liver trasnplant s/p post op bleed\n\n REASON FOR THIS EXAMINATION:\n ?hematoma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 36-year-old man status post liver transplant. Evaluate for\n hematoma.\n\n COMPARISON: .\n\n LIVER ULTRASOUND: The liver is of normal echogenicity without evidence of\n focal lesions or fluid collection to suggest the presence of hemorrhage.\n\n LIVER DOPPLER ULTRASOUND: There is normal hepatic artery flow with resistive\n indices ranging from 0.47 to 0.61. The flow in the hepatic and portal veins\n is normal.\n\n IMPRESSION: Normal liver Doppler ultrasound. No evidence of hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-06-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 870941,
"text": " 11:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?sob\n Admitting Diagnosis: LIVER CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man s/p liver transplant with acute SOB.\n\n REASON FOR THIS EXAMINATION:\n ?sob\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 36-year-old male status post liver transplant, now presenting\n with acute shortness of breath.\n\n COMPARISONS: Comparison is made to .\n\n TECHNIQUE: AP semi-upright single view of the chest.\n\n FINDINGS: There is a right IJ central line with the tip in the lower SVC. The\n cardiac and mediastinal contours are unchanged when compared to prior study.\n There is again noted a right pleural effusion and alveolar process. This is\n unchanged when compared to the prior study. There is also a slight worsening\n of left lower lobe, retrocardiac opacity, which could represent atelectasis or\n consolidation. There are new perihilar ill-defined opacities that could\n represent pulmonary edema. Continued follow up recommended.\n\n IMPRESSION:\n 1. Stable right lower lobe atelectasis/consolidation and right pleural\n effusion.\n 2. Slight worsening of left lower lobe patchy opacity that could represent\n atelectasis or consolidation.\n 3. Left perihilar ill-defined patchy opacity is new when compared to prior\n study and could be secondary to pulmonary edema. Follow up recommended.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-26 00:00:00.000",
"description": "Report",
"row_id": 1275646,
"text": "1900-0700\n\nNeuro: Pt awake, alert, oriented with intermit periods of confusion. Follows commands well. MAEs. Movement purposeful. ? periods of lethargy noted.\n\nResp: Increased face tent to 70% with 5 NC. O2sat remain>93%. Resp easy and regular, denies SOB. Pt desats quickly without O2: very dependent. Lungs clear with scattered crackles at the bases. Productive cough noted.\n\nCV: NSR without ectopy. HR 60-80, SBP 120-130, max temp 97.8. Lasix drip started with minimal effect-transplant team aware. + pulses to ext. Generalized edema noted. Abd incision site open to air, JPX1 intact with dsg to old JP site.\n\nGI/GU: Abd soft, + BS. Tolerating clear liquids. No N/V. Foley to BSD draining clear yellow urine.\n\nPlan: Supportive care. Resp support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-26 00:00:00.000",
"description": "Report",
"row_id": 1275647,
"text": "Condition Update\nPlease see carevue for specifics.\n\nNeuro: Pt is alert and oriented x3. Becomes confused at times, and is easily reoriented. Attempted to get oob x2. OOB with P.T. Pt pivots well, able to get up with 1x assist. Moves all extremities. Follows commands inconsistently. C/o abdominal pain this am. Percocet given with + effect.\n\nCV: SR, No ectopy noted. Pt has been afebrile. cvp 19-29. HIT panel sent today. Prograf levels sent. SBP 120's-130's. 1 episode of ?SVT/Vtach. MD notified.\n\nResp: Pt continues on 6L 02 via n/c + %02 via face tent. 02 sats 87-93% Pt c/o sob at all times. MD's are aware. Pt has a productive cough, but is unable to expectorate in a cup to send off a sample. CXR done today. Pulm toilet done, and pt is using IS at the bedside.\n\nGI/GU: Foley is patent and draining adequate of clear, yellow urine. Lasix gtt d/c'd this am. Pt to start just getting intermittent IV lasix doses. -2 liters is goal. Pt is tolerating clear liquid diet well. Liver US done today d/t increased alkphos levels.\n\nEndo: Pt has a regular insulin sliding scale for bs coverage.\n\nInteg: S/p liver transplant. Staples intact on abdomen. No drainage, reddness noted. JP drain d/c'd this am. placed at site. Small amt of sero sang drainage noted.\n\nplan: Continue with current plan of care per sicu team. Closely monitor resp status. Aggressive pulm toilet, IS.Intermittent Lasix for diuresis. Goal 2 liters negative. Pain mgmt. Follow up on Liver us / CXR / HIT panel results. Pt to remain in the ICU until resp status stabilized.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-24 00:00:00.000",
"description": "Report",
"row_id": 1275642,
"text": "Respiratory Care Note\nPt became dyspneic and dropped his 02 sats to the upper 80's. Pt placed on face tent and given alb treatments X2. Plan is to transfer to floor when respiratory status is stable. See careview for additional info.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-25 00:00:00.000",
"description": "Report",
"row_id": 1275643,
"text": "at beginning of shift pt was agitated. c/o pain and sob. wheezes I/E present bilateral. lasix 80 mg iv given at and dilaudid 1 mg iv. pt diuresed and much more comfortable and cooperative.\n\ncv: hr nsr no ectopy. bp stable see careview. aline d.c'd at ~2400 because unable to draw and unable to get trace. dr the a.m. abg at 0100. see careview for the result.abg stable pt was on .50 %. pt did have and episode of sob ~ 2400. he had wheezes bilateral and receiived albuterol tx with good effect. albuterol repeated again at 0400 pt only slightly wheezy at 0400.\n\ngu: foley draining clear yellow urine. received lasix 80 mg iv at . with good response.\n\ngi: npo. positive bowel sounds.\n\nintegumentary: y incision clean and dry..open to air. staples intact. lateral jp drain removed.s/p jp site is draining serosanguinous. dressing changed times 2 for moderate amounts of serosanguinous. medial jp remains and it is draing serosanguinous.\n\nneuro: pt complains alot. he is alert and oriented.mae .follows commands. c/o pain and got good relief from dilaudid 1 mg iv. later he received 2 percocet with good relief. pt took a few long naps.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-25 00:00:00.000",
"description": "Report",
"row_id": 1275644,
"text": "7a-7p\nneuro: AAOx3, follows commands, moving all extremites, pt restless @ times, picks @ tubes\n\ncv: hr nsr, no ectopy, sbp stable(116-135)\n\nresp: on 5 l np & 50% ofm, pt desats quickly to 85-88 if o2 off, neb tx by R.T. q 2-4 hrs, bs+ all lobes, diminished to R base, ins/exp wheezes @ times, otherwise course bs, is encouraged, coughing productively, sm thick green sputum, cpt to R base\n\ngi: diet advanced to cl lix, tol well, no stool, iv protonix\n\ngu: foley patent, clear yellow urine, good uo, iv lasix , extra dose iv lasix x 1 today, good diuresis\n\nskin: abd jp draining lg around tube, abd dsg saturated with serosang drainage, dsg changed x 1\n\nother: oob to chair with 2 assists, tol well, medicated with 2 percs @ 1700 for incisional pain, tx with 2 u plts this am\n\nplan: monitor resp status, ? R lower lobe pleural effusion & atelectasis by cxr today, encourage IS, cpt, oob to chair, sputum c&s\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-25 00:00:00.000",
"description": "Report",
"row_id": 1275645,
"text": "Respiratory Care Note\nPt remains on supplementary oxygen and has been recieving nebulized albuterol Q2-4 hrs for wheezes. Plan is to move pt to the floors once his respiratory status has stabalized. See careview for additional info.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-23 00:00:00.000",
"description": "Report",
"row_id": 1275638,
"text": "STATUS UPDATE\nDATA:\nSEE CAREVUE FLOWSHEET FOR DETAILS.\n\nPT ALERT AND ORIENTED X3. FIDGETY AND MOVING ALL OVER IN BED. FOLLOWS ALL COMMANDS AND ASSISTS WITH TURNING. C/O INCISIONAL PAIN WHICH IS RELIEVED WITH PRN DILAUDID.\n\nLUNGS CLEAR BILAT. CONTINUES ON COOL NEB FACE MASK AT 35% WITH SATS 95-100%. FEBRILE TO 101.7-DR AND DR. AWARE. BLOOD CULTURES SENT FROM R IJ CVL. UNABLE TO DRAW PERIPHERAL CULTURES. DR. AWARE. URINE CULTURE SENT. LESS FEBRILE-99.7- AFTER BATH.\n\nABDOMINAL INCISION WITH ORIGINAL OR DRESSING INTACT. NO DRAINAGE. MEDIAL JP WITH LARGE AMOUNTS SEROSANG OUTPUT. LATERAL JP WITH SCANT DRAINAGE. JP'S STRIPPED Q1-2HRS. SEROSANG DRAINAGE FROM AROUND MEDIAL JP INSERT SITE. ABDOMEN SOFT, DISTENDED AND TENDER TO THE TOUCH. POSITIVE BOWEL SOUNDS. NGT TO LCS WITH BILIOUS OUTPUT.\n\nURINE OUTPUT MINIMAL AT TIMES. ALBUMIN X2.\n\nPLAN:\nPOSSIBLE SWAN CHANGE TO CVL. CONTINUE CURRENT PLAN OF CARE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-23 00:00:00.000",
"description": "Report",
"row_id": 1275639,
"text": "Nursing\nSee flowsheet for details.\n\nVSS. Temp of blood 37.1. CCO swan and trauma line d/c and quad lumen guide-wired. Transfused with several units platelets today.\n\nLungs CTA. On 3L NC. Sa02 99%.\n\nAbdomen soft and distended with pos. BS. NG d/c. Taking sips. Abdominal incision intact. JP #1 with moderate serosang output. JP#2 with minimal drainage. Foley with good output.\n\nPt. affect irritable and inappropriate at times. Very needy. Becomes more emotional and cries when mother in room.\n\nPlan to cont. to monitor HCT and platelets and get pt OOB and up to chair today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-24 00:00:00.000",
"description": "Report",
"row_id": 1275640,
"text": "See carevue for specifics.\n\nNeuro: Alert and oriented times two (place and name) quickly reoriented to date/time. Agitated, pulling at CL, aline, foley, jp's. aware, pt received 3mg Haldol with effect. 1mg Dilaudid for abd pain with fair relief.\n\nCardio: NSR, no ectopy, SBP 130-150's. No edema. CVP 20-22. Received one unit of platelets for PLT count of 90, repeat count was 123.\n\nRespir: LS diminished right bases, productive cough of thick whitish yellow sputum. O2 sat 93-98% on 3L NC.\n\nGI: +BSx4, -flatus, tender x4, NPO, abd lateral and medial JP with sero/sang drainage.\n\nENDO: RISS as ordered.\n\nGU: foley, c/y/u.\n\nSKIN: Abd incision with old staining noted on original surgical dressing. JP site draining small amounts of sero/sang fluid. No breakdown noted.\n\nPOC: Transfer to floor today. ?psych eval. Monitot hempdynamics, assist with OOB activity. Continue dilaudid and haldol as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-24 00:00:00.000",
"description": "Report",
"row_id": 1275641,
"text": "Nursing\nSee flowsheet for details.\n\nPt. A&Ox2-3. MAEE. Very anxious and agitated. Becomes more needy with family present. OOB and up to chair.\n\nBecame dyspnic around 1100 and dropped sats to 88% on RA. Placed on 70% face mask and sats increased to 95%. Lungs were slightly wheezey; much improved after breathing treatment. ABG, EKG and chest x-ray obatained. Pt. restrained due to removing of oxygen.\n\nAbdomen soft with pos bs. Incision C/D/I. JP's with small amounts serosang. drainage. Foley with clear amber urine.\n\nPlan to transfer to floor if resp. status stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-22 00:00:00.000",
"description": "Report",
"row_id": 1275635,
"text": "UPdate\nO:See carevue flowsheet for specifics\n CV status: sr no ectopy. sbp stable. co/ci 6-7liters 7 SVO2-40's to 70's after recal-until am volume-> now svo2 80's. co 8liters.Feet cool distal pulses +.\n\nResp status: cmv to simv to cpap w ps @ 12(attempt to wean ps unsuccessful at present).. Pt poorly tol being off propfol and req low dose prop for vent wean.Dr here and observed pt level of agitation \"ordered\" propfol @ 10 mcg/kg. Bbs coarse to cl, diminsh at bases.\n\nGi status: ngt to lws w bilious drng. Abd soft distended no active bowel snds.Abd dsg d/i. rlq jp drains to bulb suct w ss drng around drsg reinforced.Protonix for gi prophylax.\n\nGu status: negligable urine outpt-> Ho aware.Tacrolimus to be held this a.m. for same.\n\nNeuro status: arousable off prop-> mae spont not to commands.Perl 3-2mm. On low dose prpfol as noted above.Med x 2 for presumed pain w dilaudid(pt grimace w movement).\n\nHeme/Id: hct drop this am-> ? dilutional vs bldg-> ho aware. 2uprbc infused for same. 2ffp for inr 1.7\n\nA/P: check abg, inr,hct after ffp completed.Wean to extub whn fully awake.HOld a.m. dose tacrolimus per ho.Cont w ICU care & support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-22 00:00:00.000",
"description": "Report",
"row_id": 1275636,
"text": "Pt placed on Spontaneous trial. PSV 5, 40%. Vt's 500-600's, RR 10-18, 02 sats in high 90's. ABG's drawn ph 7.31,C02 46, Pa02 177, HC03 24. Pt extubated and placed on 35% face tent humidified. Sx lg of thick white secretions via Yankeur. Pt resting comfortably and in no resp distress.\n"
},
{
"category": "ECG",
"chartdate": "2166-06-24 00:00:00.000",
"description": "Report",
"row_id": 184890,
"text": "Sinus arrhythmia\nNormal ECG\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2166-06-24 00:00:00.000",
"description": "Report",
"row_id": 185131,
"text": "Sinus arrhythmia\nWithin normal limits\nSince previous tracing of , the rate has decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2166-06-21 00:00:00.000",
"description": "Report",
"row_id": 185132,
"text": "Sinus rhythm. Short QTc interval. Compared to the previous tracing of \nthere is no diagnostic change.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-22 00:00:00.000",
"description": "Report",
"row_id": 1275637,
"text": "Neuro: Alert and oriented times three, PERL. Follows commands, MAE, hydromorphone prn for pain.\n\nCardio: NSR with rare PVC's. SBP 130-150, PAP 30-40/20. CVP 10-18, CO , SVR 800-1100, Wedge at 23, PVR 105. SVO2 70-80's. PA cath refloated this afternoon after pt became agitated and tried to get OOB requiring five nurses and a resp therapy to hold pt down.\n\nRespir: Extubated. O2 sat 100% on FiO2 .35 FM. Productive cough of thick blood tinged to white secretions. Lungs are diminished bil at bases.\n\nGI: BS are present, soft, tender x4, Medial JP with copious amounts of sero/sang drainage. Lateral JP with small amounts of sang drainage. NGT to LWCS with bilious drainage.\n\nENDO: RISS as ordered.\n\nGU: foley, c/y/u. 5-60cc amounts hourly. 40mg IV lasis adm without diuresis.\n\nSKIN: Abd incision with small staining noted on dressing. Medial JP site draining large amounts of sero/sang drainage. Despite additional stitch placed at medial JP site, site continues to drain large amounts of sero/sang. Dressing changed throughout day. Lateral JP site draining scant amounts of serosang fluid. No skin breadown noted.\n\nPOC: Continue pulm toilet, monitor hemodynamics, monitor u/o, ?transfer to floor or .\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-26 00:00:00.000",
"description": "Report",
"row_id": 1275648,
"text": "Condition Update\n.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-27 00:00:00.000",
"description": "Report",
"row_id": 1275649,
"text": "1900-0700\n\nNEURO: PT RESTLESS, ATTEMPTING TO REMOVE CENTRAL LINE, REMOVING O2 ETC.. SOFT WRIST RESTRAINTS APPLIED AS NEEDED. PT X WITH CONFUSION INTERM. MAES. PUPILS EQUAL AND BRISK. MOTHER AT BEDSIDE IN PM WHICH KEPT PT CALMER.\n\nRESP: 5LNC/70% FACE TENT, PT REMAINS VERY DEPENDENT UPON O2. O2 SAT 90-95%. RESP REGULAR DENIES SOB. PRODUCTIVE COUGH NOTED. LUNGS CLEAR/DIMINISHED AT THE BASES. AM ABG ORDERED.\n\nCV: NSR WITHOUT ECTOPY. HR 70S, BP STABLE, AFEBRILE. LASIX X 1 DOSE GIVEN IN PM. + PULSES TO EXT. SKIN INTACT. ABD INCISION WITH STAPLES INTACT/OPEN TO AIR. SMALL DSG TO OLD JP SITE CHANGED. MEDICATED FOR PAIN X1. MINIMAL EDEMA TO EXT. R IJ MULTILUMEN CATHETER.\n\nGI/GU: ABD ROUND SOFT, + BS. NO BM. CLEAR LIQUIDS TOLERATED WELL. NO N.V. FOLEY TO BSD DRAINING CLEAR YELLOW URINE.\n\nPLAN: CONT RESP SUPPORT. REVIEW AM ABG. ? CONT DIEURESIS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-21 00:00:00.000",
"description": "Report",
"row_id": 1275631,
"text": "Pt initially placed on 50% not 60% FI02.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-21 00:00:00.000",
"description": "Report",
"row_id": 1275632,
"text": "Pt admitted to flr from OR. Intubated with #8 endotracheal tube, 20@lip. BS: Decreased, ess clear, no sx needed at this time. 02 sats in high 90's. Pt placed on CMV 12/650/60%/5peep. ABG's drawn PH 7.44/C02 39/ Pa02 222/HC03 27. Decreased FI02 to 35%. Will cont to ventilate on CMV and re-eval in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-21 00:00:00.000",
"description": "Report",
"row_id": 1275633,
"text": "See carevue for specifics.\nPt. received from OR at 1600 after liver transplant.\nNeuro: Pt sedated and not yet reversed from OR. PERL, Propofol at 50mcg/kg/min.\n\nCardio: Sinus tach 100-115, SBP 130-150. Generalized edema. CVP 13-15, CCO . Afebrile, 98.6 via blood.\n\nRespir: CMV, Vt 650, FiO2 .40, Peep 5. Lungs are clear bil throughout. O2 sat 98-100%.\n\nGI: BS are absent x4, NGT to LWCS with bilious drainage, Abd medial JP with sero/sang drainage. Abd lateral JP with Sang drainage.\n\nGU: foley, c/y/u.\n\nENDO: RISS per sliding scale.\n\nSKIN: upper abd incision with DSD covering, CDI.\n\nPOC: COntinue to monitor hemodynamics, labs every eight hours, monitor skin integrity, JP outputs, emotional support to family. Continue propofol and fentanyl as needed. Transfuse one unit pRBC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-22 00:00:00.000",
"description": "Report",
"row_id": 1275634,
"text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and ventilated on PS settings as of 0500. Tolerating well. Vt=550-600, Ve=6.5, RR=10. When sedation off completely pt agitated and attempting to pull out ETT. Will wean PS as tolerated. Plan for extubation this AM.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-27 00:00:00.000",
"description": "Report",
"row_id": 1275650,
"text": "Condition Update\nD: See carevue flowsheet for specifics\nPatient lethargic all morning-starting to wake up more this afternoon. Slept in chair for most of the day. O2 was weaned down from nasal cannula and face tent to just nasal cannula. ABG done @10am unchanged from earlier with PaO2 68 and PCO2 53. Lasix 80mg iv given with large amt of diuresis-lungs still have crackles throghout.\nOtherwise stable throughout the day. Full set of labs checked in the afternoon with stable results.\nPLAN:\n Cont to diurese\n Monitor for change in mental status\n Notify H.o. with any changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-28 00:00:00.000",
"description": "Report",
"row_id": 1275651,
"text": "Condition Update\nPlease see carevue for specifics.\n\nNeuro: Pt is alert and x3. Becomes confused at times and hallucinating. Easily reoriented. C/o abdominal pain. Percocet given with + effect. Moves all extremities with equal strength. PERRL.\n\nCV: SR. Rare pvc's noted. Pt has been afebrile. No hemodynamic issues.\n\nResp: LS are clear, with crackles. Pt expectorating thick yellow sputum. Pt receiving 4L 02 via nc. 02 sats 94-99%\n\nGI/GU: foley is patent and draining adequate of clear urine. Abdomen is soft, non distended. + BS. Pt had 1 medium soft stool during the noc using the bedpan.\n\nEndo: Pt has a regular insulin sliding scale for bs coverage. Has not needed any insulin this shift.\n\nInteg: s/p liver transplant. Abdominal staples intact. No drainage noted. Reddened at some areas. Pt caught picking at some of the staples. Area where jp drain d/c'd still draining moderate of serosang drainage. placed.\n\nPlan: Continue with current plan of care per sicu/ tranplant teams. continue aggressive pulmonary toilet. Pain mgmt. ? xfer to 10.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-28 00:00:00.000",
"description": "Report",
"row_id": 1275652,
"text": "Condition Update\nD: See carevue flowsheet for specifics.\n AM uneventful. Patient remained sommulent-arousable but not easily. ABG done with improved PaO2. Patient was transferred out to the floor and was sent back to the SICU within 30min after transplant service decided to keep pt in SICU for closer monitoring of oxygenation and mental status for one more night. Pt was very alert and conversing appropriately for a few hours, sat up in the chair and ambulated with 1 assist around the unit, but then went back to bed and fell asleep. After sleeping for ~1hr abg was drawn and PaO2 77. O2 sat 99% on 4L NC and lungs sound clear. Cough and raising thick yellow sputum.\nPLAN:\n Cont to monitor neuro status\n Ammonia level checked this am\n ?place aline if team wants to cont to check ABG's\n Notify H.O. with any changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-06-29 00:00:00.000",
"description": "Report",
"row_id": 1275653,
"text": "Condition Update\nPlease see carevue for specifics.\n\nNeuro: Pt waxes and wanes between alert and x3 to confused and hallucinating at times. Following commands inconsistently by continuously picking at the bld pressure cuff and wounds, taking his abdominal dressing off x3 etc.\n\nCV: NSR no ectopy noted. Pt has been afebrile. diuresed with diamox.\n\nResp: Pt continues on 4L 02 via n/c. Pt desats to the 80's on RA. LS are clear. Pt able to expectorate brown to bld tinged sputum.\n\nGI/GU: Foley is patent and draining adequate of clear urine. Abd is soft. Pt c/o upset/ sour stomach. Pt also requesting tums to settle his stomach. Sicu team to consult transplant before order is written. 1x medium, guiac - stool during the noc. Pt able to use the bedpan. Pt written for a regular diet. Tolerated liquids during the noc.\n\nEndo: Pt has a regular insulin sliding scale for bs coverage. No insulin given this shift.\n\nInteg: S/p liver transplant. Staples are intact and open to air. No drainage noted. Copious of serosang drainage from d/c'd jp drains site. 's changed d/t saturation approx q 1-3 hours.\n\nPlan: Continue with current plan of care per sicu/ transplant teams. Closely monitor respiratory status. ? xfer to 10 when bed available. Continue to diures.\n"
}
] |
30,265 | 164,752 | 83M admitted s/p fall due to syncopal episode in driveway after exiting his car. He was found to have two areas of intraparenchymal hemorrhage/ hemorrhagic contusions within the frontal lobes bilaterally. Bilateral anterior frontal subdural hematomas. Small left temporal subdural hematoma. Scattered areas of subarachnoid hemorrhage, predominantly within the frontal lobes, left temporal lobe. No significant associated mass effect. Subdural hemorrhage noted along the tentorium on the left. Dilatation of the left lateral ventricle and to minimal extent, the third ventricle. Pt did not have any focal deficits, did have difficulties with EOM in L eye and left pupil was fixed and dilated, however this was his baseline due to prior stroke after CEA surgery. Pt was admited to the ICU for 24h observation and had Head CT on which showed evolving bifrontal hemorrhagic contusions. More evident bihemispheric subarachnoid hemorrhage. New intraventricular blood, layering in the lateral ventricular atria without change in the ventricular size. Slightly enlarged left and stable right subdural hematomas, without mass effect. Pt did remain stable. On the the Head CT was again repeated showing no interval change compared to the previous scan. He was then transferred to the floor given his stable radgiographic examination. His diet was advanced as tolerated and he was evaluated by physical therapy. They recommend rehab for continued strengthening and conditioning. While in the ICU, geriatric service was consulted for concerns relating to his syncopal episode. Their recommendations were negative in result during this hospital stay (no arrhythmia noted on telemetry, now EKG changes, and patient was maintained euvolemic). The did additionally recommend following up with a cardiologist for possible consideration of holter monitor as an outpatient. | Slightly enlarged left and stable right subdural hematomas, without mass effect. A small amount of high-attenuation material is noted within the left sylvian fissure, consistent with subarachnoid hemorrhage. Unchanged bilateral frontal hemorrhagic contusions. COMPARISON: Non-contrast head CTs performed between and . Within the anterior right frontal lobe, there is a second hyperdense area measuring 2.0 x 1.9 cm with surrounding low attenuation consistent with edema. Unchanged subarachnoid hemorrhage. Unchanged subarachnoid hemorrhage. Unchanged subarachnoid hemorrhage. There are atherosclerotic calcifications in the cavernous and supraclinoid segments of the right internal carotid artery, without evidence of a hemodynamically significant stenosis. 2) Dilatation of the left lateral ventricle and to minimal extent, the third ventricle. Mild irregularity in the P1 segment of the right posterior cerebral artery and in the M1 segment of the right middle cerebral artery. Mild irregularity in the P1 segment of the right posterior cerebral artery and in the M1 segment of the right middle cerebral artery. FINDINGS: NON-CONTRAST HEAD CT: Bilateral frontal hemorrhagic contusions and subarachnoid blood products in the hemispheric sulci are unchanged compared to . Small left temporal subdural hematoma. There is mild irregularity in the P1 segment of the right posterior cerebral artery and in the M1 segment of the right middle cerebral artery. FINDINGS: Within the left frontal lobe, there is a hyperdense focus measuring 2.0 x 1.9 cm with surrounding low-attenuation area consistent with edema. Unchanged hemorrhagic contusions in the frontal lobes. Unchanged hemorrhagic contusions in the frontal lobes. TECHNIQUE: Non-contrast head CT. 7 mm calcification vs bleed in right basal ganglia. FINAL REPORT INDICATION: Intracranial hemorrhage and questionable posterior communicating artery aneurysm. Dilatation of the left lateral ventricle compared to the right lateral ventricle is present. Multifocal bihemispheric subarachnoid hemorrhage appears stable compared to the previous scan. Normal caliber of the left middle cerebral artery, which may be supplied through the large left posterior communicating artery. Bilateral anterior frontal subdural hematomas. Moderate degenerative changes are seen involving both hips with subchondral sclerosis and osteophyte formation. Small A1 segment of the left anterior cerebral artery, which may be related to hypoplasia or stenosis. communicating aneurysm. communicating aneurysm. communicating aneurysm. communicating aneurysm. communicating aneurysm. communicating aneurysm. Hyperdensities overlying the frontal lobes bilaterally are consistent with subdural hemorrhage. The left subdural hematoma extends slightly more posteriorly over the left frontal convexity, while the right frontal subdural hematoma is unchanged. DENIES HEADACHECV: AFEBRILE. The A1 segment of the left anterior cerebral artery is small in caliber, either due to hypoplasia or stenosis. The A1 segment of the left anterior cerebral artery is small in caliber, either due to hypoplasia or stenosis. There is near-complete occlusion of the petrous, cavernous, and supraclinoid segments of the left internal carotid artery. The left subdural hematoma and the frontal right subdural hematoma appear stable compared to the previous scan. Vasculitis or fibromuscular dysplasia involving the left posterior cerebral artery, and to a lesser extent the right posterior cerebral and the right middle cerebral arteries. Comparison made to CT head without contrast on . Slight increase in the left subdural hematoma. Slight increase in the left subdural hematoma. More evident bihemispheric subarachnoid hemorrhage. A 2-mm area of high attenuation overlies the left temporal lobe and is consistent with a small subdural hemorrhage. Occlusion of the left internal carotid artery, as described above. FINDINGS: There are bilateral frontal lobes hematomas that appear stable compared to prior scans. COMPARISON: CT head without contrast, . The left internal carotid artery demonstrates complete occlusion in its distal cervical segment and near near-complete occlusion in its petrous, cavernous, and supraclinoid segments. The left internal carotid artery demonstrates complete occlusion in its distal cervical segment and near near-complete occlusion in its petrous, cavernous, and supraclinoid segments. communicating artery aneurysm. communicating artery aneurysm. The A1 segment of the left anterior cerebral artery is small, which may be due to hypoplasia or stenosis. FINAL REPORT STUDY: CT of the head without contrast. There is diffuse irregularity and beading throughout the left posterior cerebral artery. PT STARTED ON PO LOPRESSOR TID.RESP: BS CLEAR BUT DIMINSHED IN BASES. There is an area of hyperdensity adjacent to the third ventricle on the left side which could represent clot or aneurysm. There is an area of hyperdensity adjacent to the third ventricle on the left side which could represent clot or aneurysm. There is a 9 x 5 x 4 mm aneurysm in the proximal P1 segment of the left posterior cerebral artery, which projects superiorly. Bilateral small anterior frontal SDH. Small chronic lacunar infarctions are again seen in the heads of the caudate nuclei. Adjacent to the third ventricle on the left side on sequence 2, image 13, there is a 4-mm area of hyperdensity which could represent subarachnoid clot. There are multifocal bihemispheric subarachnoid hemorrhages which also appear stable compared to prior studies. PA and lateral upright chest radiograph was compared to . IMPRESSION: 1) Two areas of intraparenchymal hemorrhage/ hemorrhagic contusions within the frontal lobes bilaterally, each measuring 2 cm and surrounded by a small amount of edema. The left middle cerebral artery is normal in caliber. The third ventricle appears minimally dilated. Admitting Diagnosis: INTRACRANIAL HEMORRHAGE FINAL REPORT (Cont) mucosal thickening in the left sphenoid sinus. No significant associated mass effect.S Subdural hemorrhage noted along the tentorium on the left. Admitting Diagnosis: INTRACRANIAL HEMORRHAGE FINAL REPORT (Cont) 5. No interval change in multifocal subarachnoid hemorrhages and subdural hematomas. | 19 | [
{
"category": "Radiology",
"chartdate": "2163-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026365,
"text": " 7:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulmonary process\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with head bleed and increased o2 requirement\n REASON FOR THIS EXAMINATION:\n ? pulmonary process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:19 PM\n No significant interval change. Slightly increased bibasilar atelectasis but\n no pneumonia, effusion or pneumothorax. No evidence for congestive failure.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage and now with increasing oxygen requirement.\n\n COMPARISON: .\n\n FINDINGS: There has been slight increase in bibasilar atelectasis. There is\n no focal pneumonia or appreciable effusion. No pneumothorax. The hilar and\n cardiomediastinal contours remain normal. There is no evidence for vascular\n congestion to suggest overhydration or congestive failure. Degenerative\n changes with osteophytic spurring are again noted in the spine.\n\n IMPRESSION: Lung volumes are low with slight increase in bibasilar\n atelectasis. No acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026366,
"text": ", M. NSURG SICU-A 7:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulmonary process\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with head bleed and increased o2 requirement\n REASON FOR THIS EXAMINATION:\n ? pulmonary process\n ______________________________________________________________________________\n PFI REPORT\n No significant interval change. Slightly increased bibasilar atelectasis but\n no pneumonia, effusion or pneumothorax. No evidence for congestive failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-08-16 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1026076,
"text": " 6:34 PM\n CHEST (PA & LAT) Clip # \n Reason: ? Heart size\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with Syncope\n REASON FOR THIS EXAMINATION:\n ? Heart size\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Syncope.\n\n COMPARISON: None.\n\n PA AND LATERAL VIEWS OF THE CHEST: The heart is normal in size. The aorta is\n mildly unfolded. Hilar contours are normal. Pulmonary vascularity is normal.\n Low lung volumes are present, but no focal consolidations are seen. No\n pleural effusions or pneumothorax is demonstrated. Degenerative changes are\n seen within the thoracic spine.\n\n IMPRESSION: Low lung volumes. Normal heart size. No acute cardiopulmonary\n abnormality.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2163-08-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1026391,
"text": " 9:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Follow up resolution of blood\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with frontal contusions\n REASON FOR THIS EXAMINATION:\n Follow up resolution of blood\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf 12:32 PM\n No interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n HISTORY: 83-year-old man with frontal contusions. Follow up resolution of\n blood.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n COMPARISON: CT head without contrast, .\n\n FINDINGS: The bilateral hematomas in the frontal lobes appear stable compared\n to the previous scan. Multifocal bihemispheric subarachnoid hemorrhage\n appears stable compared to the previous scan. The left subdural hematoma and\n the frontal right subdural hematoma appear stable compared to the previous\n scan. There is no shift of normally placed midline structures. Layering of\n intraventricular blood is stable compared to the previous scan. There is no\n change of size in ventricles compared to the previous scan. No fractures are\n identified.\n\n IMPRESSION: No interval change compared to the previous scan.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-08-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1026082,
"text": " 7:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: H/O SDH, ? INTERVAL CHANGE.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with SDH\n REASON FOR THIS EXAMINATION:\n interval change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj TUE 8:10 PM\n Bilateral 2 cm hyperdense frontal lobe foci c/w intraparenchymal hemorrhage\n and mild surrounding edema.\n Bilateral small anterior frontal SDH. Small left temporal and tentorial SDH.\n Scattered foci of SAH mostly in the left frontal and temporal lobes.\n No fracture.\n No significant mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the head without contrast.\n\n INDICATION: 83-year-old male with intracranial hemorrhage. Assess interval\n change.\n\n COMPARISONS: Outside hospital CT study.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Within the left frontal lobe, there is a hyperdense focus measuring\n 2.0 x 1.9 cm with surrounding low-attenuation area consistent with edema.\n Within the anterior right frontal lobe, there is a second hyperdense area\n measuring 2.0 x 1.9 cm with surrounding low attenuation consistent with edema.\n Hyperdensities overlying the frontal lobes bilaterally are consistent with\n subdural hemorrhage. There are several small linear areas in the frontal\n lobes bilaterally in the sulci, suspicious for subarachnoid hemorrhage as\n well. A small amount of high-attenuation material is noted within the left\n sylvian fissure, consistent with subarachnoid hemorrhage. A 2-mm area of high\n attenuation overlies the left temporal lobe and is consistent with a small\n subdural hemorrhage. There are several areas of linear attenuation within the\n left temporal lobe consistent with subarachnoid hemorrhage. Layering high-\n attenuation material is noted along the tentorium, particularly on the left\n and is also consistent with subdural hematoma. There is no significant\n associated mass effect. Dilatation of the left lateral ventricle compared to\n the right lateral ventricle is present. The third ventricle appears minimally\n dilated. The fourth ventricle is unremarkable. The visualized paranasal\n sinuses and mastoid air cells are clear. The soft tissues and osseous\n structures appear unremarkable.\n\n IMPRESSION:\n 1) Two areas of intraparenchymal hemorrhage/ hemorrhagic contusions within the\n frontal lobes bilaterally, each measuring 2 cm and surrounded by a small\n amount of edema. Bilateral anterior frontal subdural hematomas. Small left\n temporal subdural hematoma. Scattered areas of subarachnoid hemorrhage,\n (Over)\n\n 7:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: H/O SDH, ? INTERVAL CHANGE.\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n predominantly within the frontal lobes, left temporal lobe. No significant\n associated mass effect.S Subdural hemorrhage noted along the tentorium on the\n left. 7 mm calcification vs bleed in right basal ganglia.\n 2) Dilatation of the left lateral ventricle and to minimal extent, the third\n ventricle.\n\n\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-08-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1027037,
"text": " 9:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 83yo with increased confusion, dysarthria and dysphagia\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with increased confusion, dysarthria and dysphagia\n REASON FOR THIS EXAMINATION:\n 83yo with increased confusion, dysarthria and dysphagia\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 7:48 PM\n Multiple hemorrhagic contusions, stable from prior examinations, with no\n evidence of new hemorrhage. There is an area of hyperdensity adjacent to the\n third ventricle on the left side which could represent clot or aneurysm.\n Would recommend MRI or CTA to further evaluate this focus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old man with increasing confusion, dysarthria, and\n dysphasia.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain, no\n contrast was administered.\n\n COMPARISONS: Head CTs dating back to , the most recent from\n .\n\n FINDINGS: There are bilateral frontal lobes hematomas that appear stable\n compared to prior scans. There are multifocal bihemispheric subarachnoid\n hemorrhages which also appear stable compared to prior studies. The left\n subdural hematoma and right-sided frontal subdural hematoma also appear stable\n compared with prior examination. There is no shift of normally midline\n structures and the ventricles appear stable compared to prior scans. The\n osseous structures are normal and there are no fractures identified.\n\n Adjacent to the third ventricle on the left side on sequence 2, image 13,\n there is a 4-mm area of hyperdensity which could represent subarachnoid clot.\n However, it has not evolved over the series of CT studies available, and we\n cannot exclused the possibility of an aneurysm of the posterior cerebral\n artery. To further evaluate the etiology of this structure, would recommend an\n CTA or MRA.\n\n The layering of intraventricular blood seen on prior examinations is no longer\n seen on this study.\n\n IMPRESSION:\n\n 1. No interval change in multifocal subarachnoid hemorrhages and subdural\n hematomas.\n\n 2. Hyperdensity adjacent to the third ventricle which could represent clot or\n aneurysm of the posterior circulation. Would recommend CTA or MRA to further\n evaluate this.\n (Over)\n\n 9:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 83yo with increased confusion, dysarthria and dysphagia\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Resolution of intraventricular blood.\n\n The results of this study were communicated with Dr. at approximately\n 5:20 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-08-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1027038,
"text": ", M. NSURG FA11 9:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 83yo with increased confusion, dysarthria and dysphagia\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with increased confusion, dysarthria and dysphagia\n REASON FOR THIS EXAMINATION:\n 83yo with increased confusion, dysarthria and dysphagia\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Multiple hemorrhagic contusions, stable from prior examinations, with no\n evidence of new hemorrhage. There is an area of hyperdensity adjacent to the\n third ventricle on the left side which could represent clot or aneurysm.\n Would recommend MRI or CTA to further evaluate this focus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-08-16 00:00:00.000",
"description": "PELVIS (AP ONLY)",
"row_id": 1026077,
"text": " 6:34 PM\n PELVIS (AP ONLY) Clip # \n Reason: Fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with Syncope\n REASON FOR THIS EXAMINATION:\n Fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Syncope. Evaluate for fracture.\n\n COMPARISON: None.\n\n AP VIEW OF THE PELVIS: No fracture or dislocation is identified. Moderate\n degenerative changes are seen involving both hips with subchondral sclerosis\n and osteophyte formation. Sacroiliac joints are preserved. No focal lytic or\n sclerotic osseous abnormality is present. Stool is demonstrated within the\n colon and rectum.\n\n IMPRESSION: No fracture or dislocation.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2163-08-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1026166,
"text": " 8:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for progression of bleed**Please do at 8 AM**\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with head trauma\n REASON FOR THIS EXAMINATION:\n evaluate for progression of bleed**Please do at 8 AM**\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg WED 7:19 PM\n Expected further evolution of bilateral frontal intraparenchymal hemorrhages.\n Multifocal bihemispheric subarachnoid hemorrhage more extensive today. Slight\n increase in the left subdural hematoma. No evidence of mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n INDICATION: 83-year-old male with head trauma. Evaluate for progression of\n bleeding.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered. Comparison made to CT head without contrast on\n .\n\n FINDINGS: The bilateral hematomas in the frontal lobes are slightly decreased\n in size with a slight increase in the surrounding edema, consistent with\n expected further evolution. Multifocal bihemispheric subarachnoid hemorrhage\n is more evident than on the prior study. The left subdural hematoma extends\n slightly more posteriorly over the left frontal convexity, while the right\n frontal subdural hematoma is unchanged. There is no shift of the normally\n midline structures. Layering blood is evident in the atria of the lateral\n ventricles tracking into the trigones. There is no change in ventricular size\n compared to prior. No fractures are identified.\n\n IMPRESSION:\n 1. Evolving bifrontal hemorrhagic contusions.\n 2. More evident bihemispheric subarachnoid hemorrhage.\n 3. New intraventricular blood, layering in the lateral ventricular atria\n without change in the ventricular size.\n 4. Slightly enlarged left and stable right subdural hematomas, without mass\n effect.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-08-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1026167,
"text": ", M. NSURG SICU-A 8:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for progression of bleed**Please do at 8 AM**\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with head trauma\n REASON FOR THIS EXAMINATION:\n evaluate for progression of bleed**Please do at 8 AM**\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Expected further evolution of bilateral frontal intraparenchymal hemorrhages.\n Multifocal bihemispheric subarachnoid hemorrhage more extensive today. Slight\n increase in the left subdural hematoma. No evidence of mass effect.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-08-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1027067,
"text": ", M. NSURG FA11 11:00 AM\n CHEST (PA & LAT) Clip # \n Reason: 83 yo Male ?aspiration phneumonia\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 yo Male ?aspiration pneumonia\n REASON FOR THIS EXAMINATION:\n 83 yo Male ?aspiration phneumonia\n ______________________________________________________________________________\n PFI REPORT\n No evidence of aspiration pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-08-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1026392,
"text": ", M. NSURG SICU-A 9:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Follow up resolution of blood\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with frontal contusions\n REASON FOR THIS EXAMINATION:\n Follow up resolution of blood\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-08-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1027066,
"text": " 11:00 AM\n CHEST (PA & LAT) Clip # \n Reason: 83 yo Male ?aspiration phneumonia\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 yo Male ?aspiration pneumonia\n REASON FOR THIS EXAMINATION:\n 83 yo Male ?aspiration phneumonia\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 12:57 PM\n No evidence of aspiration pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Suspected aspiration pneumonia.\n\n PA and lateral upright chest radiograph was compared to .\n\n The heart size is normal. Mediastinal position, contour and width are\n unremarkable except for tortuous aorta, unchanged since the prior study with\n no evidence of focal dilatation on PA and lateral views. The lungs are\n essentially clear with minimal linear opacity in the right base consistent\n with atelectasis but no evidence of aspiration pneumonia is present. There is\n no pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-08-23 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1027275,
"text": " 10:47 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Question of post. communicating aneurysm. Results to Dr. \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with questionable post. communicating artery aneurysm.\n REASON FOR THIS EXAMINATION:\n Question of post. communicating aneurysm. Results to Dr. .\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DFDkq TUE 7:19 PM\n PFI:\n\n 1. Unchanged hemorrhagic contusions in the frontal lobes. Unchanged\n subarachnoid hemorrhage.\n\n 2. The left internal carotid artery demonstrates complete occlusion in its\n distal cervical segment and near near-complete occlusion in its petrous,\n cavernous, and supraclinoid segments. The left middle cerebral artery is well\n opacified, probably via the large left posterior communicating artery. The A1\n segment of the left anterior cerebral artery is small in caliber, either due\n to hypoplasia or stenosis.\n\n 3. 9-mm aneurysm in the proximal P1 segment of the left posterior cerebral\n artery, with a small daughter aneurysm pointing anteriorly. 4-mm aneurysm in\n the distal P1 segment of the left posterior cerebral artery. 6-mm aneurysm at\n the origin of the left posterior communicating artery. Questionable 3-mm\n broad-based aneurysm in the cavernous right internal carotid artery.\n\n 4. Extensive beading in the left posterior cerebral artery. Mild\n irregularity in the P1 segment of the right posterior cerebral artery and in\n the M1 segment of the right middle cerebral artery. These findings may be\n related to vasculitis or fibromuscular dysplasia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage and questionable posterior communicating\n artery aneurysm.\n\n COMPARISON: Non-contrast head CTs performed between and .\n\n TECHNIQUE: Following a non-contrast head CT, axial multidetector CT images of\n the head were obtained during intravenous contrast administration, per CTA\n protocol. Multiplanar two-dimensional reformatted images and volume-rendered\n three-dimensional reformatted images were generated.\n\n FINDINGS:\n\n NON-CONTRAST HEAD CT: Bilateral frontal hemorrhagic contusions and\n subarachnoid blood products in the hemispheric sulci are unchanged compared to\n . There is no evidence of new hemorrhage. Small chronic lacunar\n infarctions are again seen in the heads of the caudate nuclei. There is\n (Over)\n\n 10:47 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Question of post. communicating aneurysm. Results to Dr. \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mucosal thickening in the left sphenoid sinus.\n\n HEAD CTA: There is complete occlusion of the distal cervical segment of the\n left internal carotid artery. There is near-complete occlusion of the\n petrous, cavernous, and supraclinoid segments of the left internal carotid\n artery. The left middle cerebral artery is normal in caliber. The A1 segment\n of the left anterior cerebral artery is small, which may be due to hypoplasia\n or stenosis. There are atherosclerotic calcifications in the cavernous and\n supraclinoid segments of the right internal carotid artery, without evidence\n of a hemodynamically significant stenosis.\n\n There is a 9 x 5 x 4 mm aneurysm in the proximal P1 segment of the left\n posterior cerebral artery, which projects superiorly. There is a small\n daughter aneurysm in the anterior aspect of this aneurysm.\n\n There is a 4 x 2 x 2 mm aneurysm in the distal P1 segment of the left\n posterior cerebral artery, which projects posteriorly.\n\n There is a 6 x 5 mm aneurysm at the origin of the left posterior communicating\n artery, which projects posterolaterally.\n\n There is a probable 3 mm broad-necked aneurysm in the medial aspect of the\n cavernous right internal carotid artery (series 3, image 59).\n\n There is diffuse irregularity and beading throughout the left posterior\n cerebral artery. There is mild irregularity in the P1 segment of the right\n posterior cerebral artery and in the M1 segment of the right middle cerebral\n artery. These findings may be related to vasculitis or fibromuscular\n dysplasia.\n\n IMPRESSION:\n\n 1. Unchanged bilateral frontal hemorrhagic contusions. Unchanged\n subarachnoid hemorrhage.\n\n 2. Occlusion of the left internal carotid artery, as described above. Normal\n caliber of the left middle cerebral artery, which may be supplied through the\n large left posterior communicating artery. Small A1 segment of the left\n anterior cerebral artery, which may be related to hypoplasia or stenosis.\n\n 3. 9 mm aneurysm in the proximal P1 segment of the left posterior cerebral\n artery, with a small daughter aneurysm projecting anteriorly.\n\n 4. 4 mm aneurysm in the distal P1 segment of the left posterior cerebral\n artery.\n\n (Over)\n\n 10:47 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Question of post. communicating aneurysm. Results to Dr. \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 5. 6 mm aneurysm at the origin of the left posterior communicating artery.\n\n 6. Probable 3 mm broad-necked aneurysm in the cavernous right internal\n carotid artery.\n\n 7. Vasculitis or fibromuscular dysplasia involving the left posterior\n cerebral artery, and to a lesser extent the right posterior cerebral and the\n right middle cerebral arteries.\n\n Findings were discussed with physician assistant in the\n afternoon of .\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-08-23 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1027276,
"text": ", M. NSURG FA11 10:47 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Question of post. communicating aneurysm. Results to Dr. \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with questionable post. communicating artery aneurysm.\n REASON FOR THIS EXAMINATION:\n Question of post. communicating aneurysm. Results to Dr. .\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Unchanged hemorrhagic contusions in the frontal lobes. Unchanged\n subarachnoid hemorrhage.\n\n 2. The left internal carotid artery demonstrates complete occlusion in its\n distal cervical segment and near near-complete occlusion in its petrous,\n cavernous, and supraclinoid segments. The left middle cerebral artery is well\n opacified, probably via the large left posterior communicating artery. The A1\n segment of the left anterior cerebral artery is small in caliber, either due\n to hypoplasia or stenosis.\n\n 3. 9-mm aneurysm in the proximal P1 segment of the left posterior cerebral\n artery, with a small daughter aneurysm pointing anteriorly. 4-mm aneurysm in\n the distal P1 segment of the left posterior cerebral artery. 6-mm aneurysm at\n the origin of the left posterior communicating artery. Questionable 3-mm\n broad-based aneurysm in the cavernous right internal carotid artery.\n\n 4. Extensive beading in the left posterior cerebral artery. Mild\n irregularity in the P1 segment of the right posterior cerebral artery and in\n the M1 segment of the right middle cerebral artery. These findings may be\n related to vasculitis or fibromuscular dysplasia.\n DFDkq\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-08-17 00:00:00.000",
"description": "Report",
"row_id": 1652263,
"text": "SICU Nursing Note: See flowsheet for details\nPlease see admission history note and chart for more detailed data. In brief, 83 y/o man admitted to from OSH s/p fall possibly secondary to syncope resulting in brief LOC and SAH/SDH in ant frontal lobe, small L temporal SDH and scattered foci SAH, mostly frontal lobe. Admitted to SICU from emergency department at 2345. A&OX3 - though having difficulty remembering name of , he knows he's in hospital. Also oriented to his name, my role as a nurse and date. Good historian. Very calm and cooperative with care. Denies pain, HA, nausea, dizziness, other neuro symptoms. MAEs with 5+ strength. Follows commands consistently. L pupil at baseline is fixed and dilated due to stroke 50 years ago. R pupil 3-4 mm and briskly reactive to light.\n\nLS clear, slightly diminished at bases, on shovel mask and sats 95-96%, de-sats to 90-91% on room air as well as nasal cannula as he is observed to be breathing through his mouth when asleep. Sinus tach 100-110 without noted ectopy. BP 120-140s/70s. Abd soft distended with positive bowel sounds in all 4 quadrants. Took water and pills without incident swallowing. Skin intact, has small hematomas in areas where IVs/blood draws attempted.\n\nLives with Godchild. Has a daughter in .\n\nPLAN: Neuro checks Q1; continue dilantin; SBP 90-160.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-08-17 00:00:00.000",
"description": "Report",
"row_id": 1652264,
"text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: REPEAT HEAD CT DONE. PT TO STAY IN SICU FOR 1 MORE DAY FOR NEURO CHECKS PER TEAM. LEFT PUPIL NON-REACTIVE, RIGHT PUPIL 3-4MM WITH BRISK REACTION. ORIENTED X3, FOLLOWING COMMANDS. MAE WITH EQUAL STRENGTH. PT \" SHAKY\" WITH ANY MOVEMENT- STATES HE IS ALWAYS LIKE THAT. DENIES HEADACHE\nCV: AFEBRILE. HR 90-110. SBP 130-170. PT STARTED ON PO LOPRESSOR TID.\nRESP: BS CLEAR BUT DIMINSHED IN BASES. NC AT 5 LITERS WITH SATS 93-96%\nGI: ABD SOFT, STARTED ON REGULAR DIET= TOL WELL\nGU: VOIDING QS\nENDO: BS 126-140'S= TX'D WITH 2 UNITS HUMALOG X2\nSOCIAL: SPOKE WITH DAUGHTER WHO LIVES IN - UPDATE GIVEN, WHO PT LIVES WITH CAME IN TO VISIT.\nA/P: CONT TO MONITOR HEMODYNAMNICS AND NEURO STATUS, ADVANCE DIET AS TOLERATED,\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-08-18 00:00:00.000",
"description": "Report",
"row_id": 1652265,
"text": "NEURO: Pt alert, responds approp to verbal commands, had episode of confusion/agitation, re-oriented per staff, appears more calm/approp, R 4mm/brisk, L pupil 7mm/nonreactive, slight L facial droop from previous CVA, MAE, denies pain/headaches, on PO Dilantin 100mg, plan for repeat CT scan today\n\nRESP: Sats 91-92% when asleep on 5L NC, as high as 95-96% when awake, lung sounds dim at bases\n\nCV: NSR without ectopy, HR 70-80s, SBP 120-150s, on PO Lopressor, pulses palpable bilaterally, afebrile, new PIV placed on wrist after Pt discontinued twice\n\nGI/GU: Pt tolerating clears/PO meds, abd soft/nontender, +BS, no BM; Pt incontinent of urine, adult briefs on, Pt did request for urinal but does consistently understand how to use call light\n\nENDO: Pt on own SSRI\n\nSOCIAL: No phone call or visit from family overnight\n\nPLAN: Repeat CT scan today, continue to monitor neuro, ?need for sitter, possible transfer today\n"
},
{
"category": "ECG",
"chartdate": "2163-08-19 00:00:00.000",
"description": "Report",
"row_id": 222112,
"text": "Sinus rhythm. No previous tracing available for comparison.\n\n"
}
] |
94,719 | 166,273 | 63 year old F with DM, afib on coumadin who p/w symptomatic anemia, elevated IRN, melena c/w GIB who is currently HD stable. . # GIB: The patient had a dramatic drop in her Hct from a baseline of 33 down to 18 on admission. Even though the patient's vital signs were stable on admission, she was on a beta blocker, thus was admitted initially to the ICU for concern for hypovolemia. The GI bleed was thought to be precipitated by being significantly supratherapeutic with her INR. In the ICU, the patient was placed on protonix IV BID, received 2 units FFP and 2 units pRBC's. As she was HD stable, she was monitored overnight in the MICU on telemetry but was did not receive endocsopy immediately then transferred to the floor. The patient's ASA and warfarin as well as diuretics and anti-hypertensives were held. The patient had a colonoscopy and EGD during admission, which showed evidence of gastritis and multiple polyps, likely the source of bleeding in supratherapeutic INR. Will need capsule endoscopy as an outpatient as may have a small bowel lesion contributing to bleed. She will follow up with Dr. as an outpatient. . # Troponin leak: As the patient had atypical chest pain cardiac enzymes were drawn. Two sets showed no increasing trend, most likely at the patient's baseline. The patient's cardiac medications were held given GI bleed including aspirin, carvedilol, but restarted prior to discharge. . # Type 2 DM: While the patient was NPO she received only dose of patient's home NPH which is 20 (gets 45 and 40 at home). Continued insulin sliding scale, QIDACHS FS BG. . # A fib: The patient was in sinus bradycardia during her hospitalization thus far. CHADS score high 2+. Continued amiodarone as it was likely maintaining normal sinus rhythm because of antiarrhythmic properties. No need for beta blockers at this time, but restarted low dose on discharge. Held warfarin as was supratherapeutic on admission and has GI bleed, but restarted on discharge. Monitored on telemetry. . # HTN: As above, the patient had borderline blood pressures during admission in the setting of GI bleed. Held multiple antihypertensives including carvedilol, isosorbide dinitrate, torsemide, metolazone, hydralazine and candesartan during admission, but restarted carvedilol and candesartan prior to discharge. . # Diastolic Dysfunction: Echo in had EF 60% and mild diastolic dysfunction with inc E/E'. The patient was euvolemic on admission and during hospitalization. . # Hyperlipidemia: Continued atorvastatin. . # ESRD: Secondary to diabetic nephropathy. Not currently on HD. Restarted calcitriol. Monitored daily. . # Glaucoma: Switched bimatorpost to latanoprost as home med non-forumlary. Continued dorzolamide. Continued timolol . # Sleep apnea: CPAP at night . Prophylaxis: PPI , sc heparin . FEN: clears, replete lytes PRN . Access: PIVs (2) . Code Status: Full . | Yesterday, had INR checked at , and was called to lower coumadin dose. Yesterday, had INR checked at , and was called to lower coumadin dose. Yesterday, had INR checked at , and was called to lower coumadin dose. # ESRD: not on HD, Cr baseline - cont calcitriol when taking PO's . # ESRD: not on HD, Cr baseline - cont calcitriol when taking PO's . Seriel Hct last Hct @ 1230.27.3 MP SB no ectopy HR 40-58 BP 120-165/55-60 No off HTN meds. # Glaucoma: - switch bimatorpost to latanoprost as home med non-forumlary - cont dorzolamide - cont timolol . # Glaucoma: - switch bimatorpost to latanoprost as home med non-forumlary - cont dorzolamide - cont timolol . Seriel Hct last Hct @ 1230 MP SB no ectopy HR 40-58 BP 120-165/55-60 No off HTN meds. Seriel Hct last Hct @ 1230 MP SB no ectopy HR 40-58 BP 120-165/55-60 No off HTN meds. She was transferred to the micu for further care Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB) Assessment: Awake alert oriented x3 No c/o CP SOB No N/V. She was transferred to the micu for further care Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB) Assessment: Awake alert oriented x3 No c/o CP SOB No N/V. She was transferred to the micu for further care Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB) Assessment: Awake alert oriented x3 No c/o CP SOB No N/V. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Had some atypical CP which has now resolved. Had some atypical CP which has now resolved. She reported an intermittent sharp "poke" in right chest just below her present, which has now resoved; no SOb, no N/V, no sweating. She reported an intermittent sharp "poke" in right chest just below her present, which has now resoved; no SOb, no N/V, no sweating. She reported an intermittent sharp "poke" in right chest just below her present, which has now resoved; no SOb, no N/V, no sweating. She reported an intermittent sharp "poke" in right chest just below her present, which has now resoved; no SOb, no N/V, no sweating. She reported an intermittent sharp "poke" in right chest just below her present, which has now resoved; no SOb, no N/V, no sweating. Received amiodarone per routine. HR 56-58 SB rare PVC, BP 110-145/54-63 MAPS>65, RR 18-20 02 3l/min NC Lungs clear. # ESRD: not on HD, Cr baseline - cont calcitriol when taking PO's . # ESRD: not on HD, Cr baseline - cont calcitriol when taking PO's . acute process FINAL REPORT CHEST PORTABLE AP. ECG: sinus bradycardia, biphasic twaves in V4-V6 and I, AVl - unchanged from prior Assessment and Plan GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB) 63 year old F with DM, afib on coumadin who p/w symptomatic anemia, elevated IRN, c/w GIB who is currently HD stable. NPO Fluid resuscitation Transfuse for Hct <30 Vit K Monitor FSBS, start IV dextrose for low BS. # GIB: Baseline HCT 33, now 18. # GIB: Baseline HCT 33, now 18. # Glaucoma: - switch bimatorpost to latanoprost as home med non-forumlary - cont dorzolamide - cont timolol . # Glaucoma: - switch bimatorpost to latanoprost as home med non-forumlary - cont dorzolamide - cont timolol . - monitor on tele - protonix - appreciate GI consult - keep NPO - q 6hrs HCT - hold asa and warfarin . Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. F/u Hcts q6h for now. F/u Hcts q6h for now. F/u Hcts q6h for now. HPI: 63F with ESRD, DM, CHF, Afib on coumadin. HPI: 63F with ESRD, DM, CHF, Afib on coumadin. HPI: 63F with ESRD, DM, CHF, Afib on coumadin. HPI: 63F with ESRD, DM, CHF, Afib on coumadin. Plan: Serial hct q6hrs, next Hct 2hrs post transfusion. # Troponin leak: Trop 0.06, CK 297. # Troponin leak: Trop 0.06, CK 297. Had some atypical CP which has now resolved. Had some atypical CP which has now resolved. Labs / Radiology 179 294 2.6 119 26 99 3.7 137 18 11.6 [image002.jpg] CE: Troponin 0.06 MB 4 CK 297 NEBH labs: - HCT 33 - BUN 74 Imaging: CXR; Stable cardiomegaly without focal consolidation. | 27 | [
{
"category": "Physician ",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 458238,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 47 (46 - 85) bpm\n BP: 123/54(72) {116/42(61) - 148/69(115)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 2,100 mL\n 135 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 1,100 mL\n 135 mL\n Total out:\n 1,300 mL\n 1,100 mL\n Urine:\n 1,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 800 mL\n -965 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.6 g/dL\n 136 K/uL\n 101 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 100 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.0 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 PM\n 03:57 AM\n WBC\n 10.6\n Hct\n 21.7\n 27.0\n Plt\n 136\n Cr\n 2.5\n TropT\n 0.06\n Glucose\n 101\n Other labs: PT / PTT / INR:15.4/21.2/1.4, CK / CKMB /\n Troponin-T:276/4/0.06, Ca++:8.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 458242,
"text": "Chief Complaint: melena\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 is known to me from clinic. Two weeks ago was told to increase\n coumadin dose. Yesterday, had INR checked at , and was called to\n lower coumadin dose. She had some dizziness yesterday (but attributed\n to missing lunch). This morning saw black stools. Checked her BP at\n home - 95/40. Decided to come into ED.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 47 (46 - 85) bpm\n BP: 123/54(72) {116/42(61) - 148/69(115)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 2,100 mL\n 135 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 1,100 mL\n 135 mL\n Total out:\n 1,300 mL\n 1,100 mL\n Urine:\n 1,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 800 mL\n -965 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.6 g/dL\n 136 K/uL\n 101 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 100 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.0 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 PM\n 03:57 AM\n WBC\n 10.6\n Hct\n 21.7\n 27.0\n Plt\n 136\n Cr\n 2.5\n TropT\n 0.06\n Glucose\n 101\n Other labs: PT / PTT / INR:15.4/21.2/1.4, CK / CKMB /\n Troponin-T:276/4/0.06, Ca++:8.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 63 yr old woman with multiple medical problems, 15 point Hct drop since\n last checked ~3 weeks ago in the context of increased coumadin dose,\n INR 6.7 and black stools this AM.\n - GI bleed with acute blood loss anemia: suspect lower GI but upper\n possible. Received vitamin K 10 mg IV, FFP and receiving 2 units PRBC.\n Has 2 large bore IVs. PPI IV drip. F/u Hcts q6h for now. Coumadin and\n ASA on hold. GI aware and seeing patient. Will await their recs.\n - OSA, would resume CPAP at 10 cm H2O at night.\n - DM, renal failure, watch for CHF, HTN, most of outpatient meds being\n held. Agree with continuing amio.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 458223,
"text": "Chief Complaint: none\n 24 Hour Events:\n - got three units pRBC's\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 47 (46 - 85) bpm\n BP: 123/54(72) {116/42(61) - 148/69(115)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 2,100 mL\n 135 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 1,100 mL\n 135 mL\n Total out:\n 1,300 mL\n 1,100 mL\n Urine:\n 1,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 800 mL\n -965 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 136 K/uL\n 9.6 g/dL\n 101 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 100 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.0 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 PM\n 03:57 AM\n WBC\n 10.6\n Hct\n 21.7\n 27.0\n Plt\n 136\n Cr\n 2.5\n TropT\n 0.06\n Glucose\n 101\n Other labs: PT / PTT / INR:15.4/21.2/1.4, CK / CKMB /\n Troponin-T:276/4/0.06, Ca++:8.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:14 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 458228,
"text": "Chief Complaint: none\n 24 Hour Events:\n - got three units pRBC's\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 47 (46 - 85) bpm\n BP: 123/54(72) {116/42(61) - 148/69(115)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 2,100 mL\n 135 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 1,100 mL\n 135 mL\n Total out:\n 1,300 mL\n 1,100 mL\n Urine:\n 1,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 800 mL\n -965 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n General: Awake, alert, NAD.\n HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted,\n MMM, no lesions noted in OP\n Neck: supple, no JVD or carotid bruits appreciated\n Pulmonary: Lungs CTA bilaterally\n Cardiac: RRR, nl. S1S2, no M/R/G noted\n Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or\n organomegaly noted.\n Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l.\n Lymphatics: No cervical, supraclavicular, axillary or inguinal\n lymphadenopathy noted.\n Skin: no rashes or lesions noted.\n Neurologic:\n -mental status: Alert, oriented x 3. Able to relate history without\n difficulty.\n Labs / Radiology\n 136 K/uL\n 9.6 g/dL\n 101 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 100 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.0 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 PM\n 03:57 AM\n WBC\n 10.6\n Hct\n 21.7\n 27.0\n Plt\n 136\n Cr\n 2.5\n TropT\n 0.06\n Glucose\n 101\n Other labs: PT / PTT / INR:15.4/21.2/1.4, CK / CKMB /\n Troponin-T:276/4/0.06, Ca++:8.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n 63 year old F with DM, afib on coumadin who p/w symptomatic anemia,\n elevated IRN, melena c/w GIB who is currently HD stable.\n .\n # GIB: Baseline HCT 33, now 18. Vitals signs continue to be stable and\n she is not tachycardic. GIB likely precipitated by elevated INR\n although she may have underlying GI pathology. Has received FFP, vit K\n and is now receiving blood.\n - monitor on tele\n - protonix \n - appreciate GI consult\n - advance to clears\n - q 6hrs HCT\n - hold asa and warfarin\n .\n # Troponin leak: Trop 0.06, CK 297. MB 4. Had some atypical CP which\n has now resolved. Likely to elevated creatinine and impair\n clearance. CE stable\n - will not give ASA or BB\n .\n # DM:\n - 1/2 dose NPH: 20 (gets 45 and 40 at home)\n - SSI\n .\n # Afib: currently sinus bradycardia, CHADS score high 2+\n - cont amiodarone\n - hold warfarin\n .\n # HTN: Holding anti-HTn while GIb. Will need to watch O2 sat as is on a\n lot of afterload reduction and diuretics. Echo in had EF 60% and\n only a suggestion of mild diastolic dysfunction with inc E/E'.\n - hold carvedilol, isosorbide dinitrate, torsemide, metolazone and\n hydralazine, candesartan\n .\n # High cholesterol\n - restart atorvastatin when taking PO\n .\n # ESRD: not on HD, Cr baseline\n - cont calcitriol when taking PO's\n .\n # Glaucoma:\n - switch bimatorpost to latanoprost as home med non-forumlary\n - cont dorzolamide\n - cont timolol\n .\n # Sleep apnea\n - CPAP at night\n .\n #) Prophylaxis: PPI gtt, sc heparin, bowel regimen\n .\n #) FEN: p.o. diet as tolerated\n .\n #) Access: PIVs\n .\n #) Code Status: Full\n .\n #) Dispo: pending further work-up and treatment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:14 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2173-06-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 458100,
"text": "63 yr old woman with multiple medical problems. presented to ED today\n with c/o of general malaise and weaknes note black stools over past\n couple of days. ED found to have Hct 18 , INR 6.7(15 point Hct drop\n since last checked ~3 weeks ago in the context of increased coumadin\n dose. Adm MICU for GI bleed with acute blood loss anemia: suspect\n lower GI but upper possible. Received vitamin K 10 mg IV, FFP and\n receiving 2 units PRBC. GI aware and seeing patient. Will await their\n recs.\n 63 yr old woman with multiple medical problems, 15 point Hct drop since\n last checked ~3 weeks ago in the context of increased coumadin dose,\n INR 6.7 and black stools this AM.\n - GI bleed with acute blood loss anemia: suspect lower GI but upper\n possible. Received vitamin K 10 mg IV, FFP and receiving 2 units PRBC.\n Has 2 large bore IVs. PPI IV drip. F/u Hcts q6h for now. Coumadin and\n ASA on hold. GI aware and seeing patient. Will await their recs.\n - OSA, would resume CPAP at 10 cm H2O at night.\n - DM, renal failure, watch for CHF, HTN, most of outpatient meds being\n held. Agree with continuing amio.\n Rest of plan as per Dr \ns note.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Serial hct q6hrs,\n NPO\n Fluid resuscitation\n Tansfuse forHct <30\n Vit K\n"
},
{
"category": "Nursing",
"chartdate": "2173-06-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 458103,
"text": "63 yr old woman with multiple medical problems. presented to ED today\n with c/o of general malaise and weaknes note black stools over past\n couple of days. ED found to have Hct 18 , INR 6.7(15 point Hct drop\n since last checked ~3 weeks ago in the context of increased coumadin\n dose. Adm MICU for GI bleed with acute blood loss anemia: suspect\n lower GI but upper possible. Received vitamin K 10 mg IV, FFP and\n receiving 2 units PRBC. GI aware and seeing patient. Will await their\n recs.\n PMH: DM , renal failure, CHF, HTN, afib, OSA Has BIPAP infreq use\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Serial hct q6hrs,\n NPO\n Fluid resuscitation\n Tansfuse forHct <30\n Vit K\n"
},
{
"category": "Nursing",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 458304,
"text": "Pt is a 63 year old F with DM, afib on coumadin who p/w dizziness and\n low BP. She reports that she was in her usual state of health until\n yesterday. Yesterday, she went to her doctor's office to have her INR\n checked. She reports that she missed lunch. Later on in the day she\n began feeling lightheaded and dizzy, but attributed this to missing a\n meal. Her doctor subsequently called and told her not to take her\n coumadin. She awoke this morning around 6am and noticed dark black,\n sticky stool. She took her BP at home: 95/40. She denies any diarrhea,\n no hematemasis. She reported an intermittent sharp \"poke\" in right\n chest just below her present, which has now resoved; no SOb, no N/V, no\n sweating.\n .\n In the ED: In the ED, she did not tolerate NG lavage, but there was no\n overt blood. She was noted to have dark marroon stool but no melena.\n Her HCT was 18; INR 6.4. Two 18 guage IV's were placed. She was given\n vitK 10mg and protonix. She was transferred to the micu for further\n care\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Awake alert oriented x3 No c/o CP SOB No N/V. Diet adv to Clear liq tol\n well. Abd soft + BS. OOB to commode passing mod amt black melena\n stool + guiac. Seriel Hct last Hct @ 1230\n MP SB no ectopy HR 40-58 BP 120-165/55-60 No off HTN meds. Denies\n dizziness. Not orthostatic. No s+s of bleeding.\n Action:\n Serial Hct . Received amiodarone per routine. FSBC QID coverage per\n sliding scale.\n Response:\n Hemodynamically stable. OOB to commode no lightheaded/dizziness.\n Plan:\n Assess for s+s of bleeding.\n FSBS QID Insulin per sliding scale\n GI consult plan EGD/colonoscopy \n Start Golytly @ 1600\n Cont seriel Q6hr Hct\n NPO after Midnight\n"
},
{
"category": "Nursing",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 458306,
"text": "Pt is a 63 year old F with DM, afib on coumadin who p/w dizziness and\n low BP. She reports that she was in her usual state of health until\n yesterday. Yesterday, she went to her doctor's office to have her INR\n checked. She reports that she missed lunch. Later on in the day she\n began feeling lightheaded and dizzy, but attributed this to missing a\n meal. Her doctor subsequently called and told her not to take her\n coumadin. She awoke this morning around 6am and noticed dark black,\n sticky stool. She took her BP at home: 95/40. She denies any diarrhea,\n no hematemasis. She reported an intermittent sharp \"poke\" in right\n chest just below her present, which has now resoved; no SOb, no N/V, no\n sweating.\n .\n In the ED: In the ED, she did not tolerate NG lavage, but there was no\n overt blood. She was noted to have dark marroon stool but no melena.\n Her HCT was 18; INR 6.4. Two 18 guage IV's were placed. She was given\n vitK 10mg and protonix. She was transferred to the micu for further\n care\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Awake alert oriented x3 No c/o CP SOB No N/V. Diet adv to Clear liq tol\n well. Abd soft + BS. OOB to commode passing mod amt black melena\n stool + guiac. Seriel Hct last Hct @ 1230\n.27.3\n MP SB no ectopy HR 40-58 BP 120-165/55-60 No off HTN meds. Denies\n dizziness. Not orthostatic. No s+s of bleeding.\n Action:\n Serial Hct . Received amiodarone per routine. FSBC QID coverage per\n sliding scale.\n Response:\n Hemodynamically stable. OOB to commode no lightheaded/dizziness.\n Plan:\n Assess for s+s of bleeding.\n FSBS QID Insulin per sliding scale\n GI consult plan EGD/colonoscopy \n Start Golytly @ 1600\n Cont seriel Q6hr Hct\n NPO after Midnight\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n LOWER GASTROINTESTINAL BLEED\n Code status:\n Full code\n Height:\n 61 Inch\n Admission weight:\n 81.7 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin, GI Bleed, HEMO or PD\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: ESRD, gout, glaucoma\n diabetes mellitus, complicated by nephropathy, neuropathy, and\n retinopathy.\n atrial fibrillation on chronic Coumadin, hypertension, pulmonary\n hypertension, hypercholesterolemia,resected breast cancer for which\n she received chemo and radiation therapy in , depression, and\n end-stage kidney disease\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:165\n D:60\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 46 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 495 mL\n 24h total out:\n 1,950 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 03:57 AM\n Potassium:\n 3.8 mEq/L\n 03:57 AM\n Chloride:\n 105 mEq/L\n 03:57 AM\n CO2:\n 25 mEq/L\n 03:57 AM\n BUN:\n 100 mg/dL\n 03:57 AM\n Creatinine:\n 2.5 mg/dL\n 03:57 AM\n Glucose:\n 101 mg/dL\n 03:57 AM\n Hematocrit:\n 27.3 %\n 11:33 AM\n Finger Stick Glucose:\n 246\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: \n Transferred from: MICU7\n Transferred to: CC715\n Date & time of Transfer: 1500\n"
},
{
"category": "Nursing",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 458298,
"text": "Pt is a 63 year old F with DM, afib on coumadin who p/w dizziness and\n low BP. She reports that she was in her usual state of health until\n yesterday. Yesterday, she went to her doctor's office to have her INR\n checked. She reports that she missed lunch. Later on in the day she\n began feeling lightheaded and dizzy, but attributed this to missing a\n meal. Her doctor subsequently called and told her not to take her\n coumadin. She awoke this morning around 6am and noticed dark black,\n sticky stool. She took her BP at home: 95/40. She denies any diarrhea,\n no hematemasis. She reported an intermittent sharp \"poke\" in right\n chest just below her present, which has now resoved; no SOb, no N/V, no\n sweating.\n .\n In the ED: In the ED, she did not tolerate NG lavage, but there was no\n overt blood. She was noted to have dark marroon stool but no melena.\n Her HCT was 18; INR 6.4. Two 18 guage IV's were placed. She was given\n vitK 10mg and protonix. She was transferred to the micu for further\n care\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Awake alert oriented x3 No c/o CP SOB No N/V. Diet adv to Clear liq tol\n well. Abd soft + BS. OOB to commode passing mod amt black melena\n stool + guiac. Seriel Hct last Hct @ 1230\n MP SB no ectopy HR 40-58 BP 120-165/55-60 No off HTN meds. Denies\n dizziness. Not orthostatic. No s+s of bleeding.\n Action:\n Serial Hct . Received amiodarone per routine. FSBC QID coverage per\n sliding scale.\n Response:\n Hemodynamically stable. OOB to commode no lightheaded/dizziness.\n Plan:\n Assess for s+s of bleeding.\n FSBS QID Insulin per sliding scale\n GI consult plan EGD/colonoscopy \n Start Golytly @ 1600\n Cont seriel Q6hr Hct\n NPO after Midnight\n"
},
{
"category": "Physician ",
"chartdate": "2173-06-12 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 458090,
"text": "Chief Complaint: melena\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 is known to me from clinic. Two weeks ago was told to increase\n coumadin dose. Yesterday, had INR checked at , and was called to\n lower coumadin dose. She had some dizziness yesterday (but attributed\n to missing lunch). This morning saw black stools. Checked her BP at\n home - 95/40. Decided to come into ED.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions: Protonix\n Other ICU medications:\n Other medications:\n reviewed - including coumadin\n Past medical history:\n Family history:\n Social History:\n 63-year-old woman with diabetes mellitus, complicated by nephropathy,\n neuropathy, and retinopathy. She\n also has a history of atrial fibrillation on chronic Coumadin,\n hypertension, pulmonary hypertension, hypercholesterolemia,resected\n breast cancer for which she received chemo and radiation therapy in\n , depression, and end-stage kidney disease attributed to her\n diabetes.\n There is no\n history of cancer in the family.\n Occupation:\n Drugs: none\n Tobacco: never smoker\n Alcohol: rare wine\n Other: from - here 25 yrs\n Review of systems:\n Flowsheet Data as of 04:55 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.6\nC (97.8\n HR: 53 (53 - 58) bpm\n BP: 132/55(76) {119/46(67) - 135/61(76)} mmHg\n RR: 19 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 476 mL\n PO:\n TF:\n IVF:\n Blood products:\n 476 mL\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 226 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, No(t)\n Anxious\n Eyes / Conjunctiva: PERRL, Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 179\n 18.7\n 294\n 2.8\n 119\n 11.63\n [image002.jpg]\n Other labs: PTT 30.5/ INR 6.4, Trop 0.06\n Fluid analysis / Other labs: U/a neg\n Last labs on Hct 33, INR 1.5, BUN 74, creat 2.6 on .\n Assessment and Plan\n 63 yr old woman with multiple medical problems, 15 point Hct drop since\n last checked ~3 weeks ago in the context of increased coumadin dose,\n INR 6.7 and black stools this AM.\n - GI bleed with acute blood loss anemia: suspect lower GI but upper\n possible. Received vitamin K 10 mg IV, FFP and receiving 2 units PRBC.\n Has 2 large bore IVs. PPI IV drip. F/u Hcts q6h for now. Coumadin and\n ASA on hold. GI aware and seeing patient. Will await their recs.\n - OSA, would resume CPAP at 10 cm H2O at night.\n - DM, renal failure, watch for CHF, HTN, most of outpatient meds being\n held. Agree with continuing amio.\n Rest of plan as per Dr \ns note.\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 03:14 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 458151,
"text": "Pt is a 63 year old F with DM, afib on coumadin who p/w dizziness and\n low BP. She reports that she was in her usual state of health until\n yesterday. Yesterday, she went to her doctor's office to have her INR\n checked. She reports that she missed lunch. Later on in the day she\n began feeling lightheaded and dizzy, but attributed this to missing a\n meal. Her doctor subsequently called and told her not to take her\n coumadin. She awoke this morning around 6am and noticed dark black,\n sticky stool. She took her BP at home: 95/40. She denies any diarrhea,\n no hematemasis. She reported an intermittent sharp \"poke\" in right\n chest just below her present, which has now resoved; no SOb, no N/V, no\n sweating.\n .\n In the ED: In the ED, she did not tolerate NG lavage, but there was no\n overt blood. She was noted to have dark marroon stool but no melena.\n Her HCT was 18; INR 6.4. Two 18 guage IV's were placed. She was given\n vitK 10mg and protonix. She was transferred to the micu for further\n care\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Post transfusion hct 21. hr into 40\ns throughout night. Bp stable\n >120. denies dizziness. Not orthostatic. No s+s of bleeding. No stool\n o/n.\n Action:\n Second unit of blood given overnight\n Response:\n Tolerated well. Am labs pending\n Plan:\n Assess for s+s of bleeding. Continue with plan of care\n"
},
{
"category": "Nursing",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 458297,
"text": "Pt is a 63 year old F with DM, afib on coumadin who p/w dizziness and\n low BP. She reports that she was in her usual state of health until\n yesterday. Yesterday, she went to her doctor's office to have her INR\n checked. She reports that she missed lunch. Later on in the day she\n began feeling lightheaded and dizzy, but attributed this to missing a\n meal. Her doctor subsequently called and told her not to take her\n coumadin. She awoke this morning around 6am and noticed dark black,\n sticky stool. She took her BP at home: 95/40. She denies any diarrhea,\n no hematemasis. She reported an intermittent sharp \"poke\" in right\n chest just below her present, which has now resoved; no SOb, no N/V, no\n sweating.\n .\n In the ED: In the ED, she did not tolerate NG lavage, but there was no\n overt blood. She was noted to have dark marroon stool but no melena.\n Her HCT was 18; INR 6.4. Two 18 guage IV's were placed. She was given\n vitK 10mg and protonix. She was transferred to the micu for further\n care\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Post transfusion hct 21. hr into 40\ns throughout night. Bp stable\n >120. denies dizziness. Not orthostatic. No s+s of bleeding. No stool\n o/n.\n Action:\n Second unit of blood given overnight\n Response:\n Tolerated well. Am labs pending\n Plan:\n Assess for s+s of bleeding. Continue with plan of care\n"
},
{
"category": "Physician ",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 458240,
"text": "Chief Complaint: melena\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 is known to me from clinic. Two weeks ago was told to increase\n coumadin dose. Yesterday, had INR checked at , and was called to\n lower coumadin dose. She had some dizziness yesterday (but attributed\n to missing lunch). This morning saw black stools. Checked her BP at\n home - 95/40. Decided to come into ED.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 47 (46 - 85) bpm\n BP: 123/54(72) {116/42(61) - 148/69(115)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 2,100 mL\n 135 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 1,100 mL\n 135 mL\n Total out:\n 1,300 mL\n 1,100 mL\n Urine:\n 1,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 800 mL\n -965 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.6 g/dL\n 136 K/uL\n 101 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 100 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.0 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 PM\n 03:57 AM\n WBC\n 10.6\n Hct\n 21.7\n 27.0\n Plt\n 136\n Cr\n 2.5\n TropT\n 0.06\n Glucose\n 101\n Other labs: PT / PTT / INR:15.4/21.2/1.4, CK / CKMB /\n Troponin-T:276/4/0.06, Ca++:8.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 458277,
"text": "Chief Complaint: none\n 24 Hour Events:\n - got three units pRBC's\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 47 (46 - 85) bpm\n BP: 123/54(72) {116/42(61) - 148/69(115)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 2,100 mL\n 135 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 1,100 mL\n 135 mL\n Total out:\n 1,300 mL\n 1,100 mL\n Urine:\n 1,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 800 mL\n -965 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n General: Awake, alert, NAD.\n HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted,\n MMM, no lesions noted in OP\n Neck: supple, no JVD or carotid bruits appreciated\n Pulmonary: Lungs CTA bilaterally\n Cardiac: RRR, nl. S1S2, no M/R/G noted\n Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or\n organomegaly noted.\n Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l.\n Lymphatics: No cervical, supraclavicular, axillary or inguinal\n lymphadenopathy noted.\n Skin: no rashes or lesions noted.\n Neurologic:\n -mental status: Alert, oriented x 3. Able to relate history without\n difficulty.\n Labs / Radiology\n 136 K/uL\n 9.6 g/dL\n 101 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 100 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.0 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 PM\n 03:57 AM\n WBC\n 10.6\n Hct\n 21.7\n 27.0\n Plt\n 136\n Cr\n 2.5\n TropT\n 0.06\n Glucose\n 101\n Other labs: PT / PTT / INR:15.4/21.2/1.4, CK / CKMB /\n Troponin-T:276/4/0.06, Ca++:8.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n 63 year old F with DM, afib on coumadin who p/w symptomatic anemia,\n elevated IRN, melena c/w GIB who is currently HD stable.\n .\n # GIB: Baseline HCT 33, now 18. Vitals signs continue to be stable and\n she is not tachycardic. GIB likely precipitated by elevated INR\n although she may have underlying GI pathology. Has received FFP, vit K\n and is now receiving blood. She has bumped her HCT appropriately.\n - monitor on tele\n - protonix \n - appreciate GI consult: EGD/Colonoscopy tomorrow\n - advance to clears, NPO after MN\n - q 6hrs HCT\n - hold asa and warfarin\n .\n # Troponin leak: Trop 0.06, CK 297. MB 4. Had some atypical CP which\n has now resolved. Likely to elevated creatinine and impair\n clearance. CE stable\n - will not give ASA or BB\n .\n # DM:\n - 1/2 dose NPH: 20 (gets 45 and 40 at home)\n - SSI\n .\n # Afib: currently sinus bradycardia, CHADS score high 2+\n - cont amiodarone\n - hold warfarin\n .\n # HTN: Holding anti-HTn while GIb. Will need to watch O2 sat as is on a\n lot of afterload reduction and diuretics. Echo in had EF 60% and\n only a suggestion of mild diastolic dysfunction with inc E/E'.\n - hold carvedilol, isosorbide dinitrate, torsemide, metolazone and\n hydralazine, candesartan\n .\n # High cholesterol\n - restart atorvastatin when taking PO\n .\n # ESRD: not on HD, Cr baseline\n - cont calcitriol when taking PO's\n .\n # Glaucoma:\n - switch bimatorpost to latanoprost as home med non-forumlary\n - cont dorzolamide\n - cont timolol\n .\n # Sleep apnea\n - CPAP at night\n .\n #) Prophylaxis: PPI gtt, sc heparin, bowel regimen\n .\n #) FEN: p.o. diet as tolerated\n .\n #) Access: PIVs\n .\n #) Code Status: Full\n .\n #) Dispo: pending further work-up and treatment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:14 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 458278,
"text": "Chief Complaint: melena\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 63F with ESRD, DM, CHF, Afib on coumadin. A/W melena and HCT=18 in the\n setting of INR=6.\n 24 Hour Events:\n Now s/p ffp, vit k, 3 U PRBC. HCT 18->21->27. This AM formed normal\n stool. GI consult- for EGD/scope tomorrow.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Amio 200 qd\n Protonix\n RISS\n Pneumoboots\n Zocor\n HELD:\n Coreg, metolazone, torsemide, asa.\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 47 (46 - 85) bpm\n BP: 123/54(72) {116/42(61) - 148/69(115)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 2,100 mL\n 135 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 1,100 mL\n 135 mL\n Total out:\n 1,300 mL\n 1,100 mL\n Urine:\n 1,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 800 mL\n -965 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.6 g/dL\n 136 K/uL\n 101 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 100 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.0 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 PM\n 03:57 AM\n WBC\n 10.6\n Hct\n 21.7\n 27.0\n Plt\n 136\n Cr\n 2.5\n TropT\n 0.06\n Glucose\n 101\n Other labs: PT / PTT / INR:15.4/21.2/1.4, CK / CKMB /\n Troponin-T:276/4/0.06, Ca++:8.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n Clinically improved with stable HCT. Melena resolved. Plan is for\n EGD/scope tomorrow. Stable for transfer to floor. + tropninin noted\n but not changing over time.\n - GI bleed with acute blood loss anemia: suspect lower GI but upper\n possible. Received vitamin K 10 mg IV, FFP and receiving 2 units PRBC.\n Has 2 large bore IVs. PPI IV drip. F/u Hcts q6h for now. Coumadin and\n ASA on hold. GI aware and seeing patient. Will await their recs.\n - OSA, would resume CPAP at 10 cm H2O at night.\n - DM, renal failure, watch for CHF, HTN, most of outpatient meds being\n held. Agree with continuing amio.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 458279,
"text": "Chief Complaint: melena\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 63F with ESRD, DM, CHF, Afib on coumadin. A/W melena and HCT=18 in the\n setting of INR=6.\n 24 Hour Events:\n Now s/p ffp, vit k, 3 U PRBC. HCT 18->21->27. This AM formed normal\n stool. GI consult- for EGD/scope tomorrow.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Amio 200 qd\n Protonix\n RISS\n Pneumoboots\n Zocor\n HELD:\n Coreg, metolazone, torsemide, asa.\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 47 (46 - 85) bpm\n BP: 123/54(72) {116/42(61) - 148/69(115)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 2,100 mL\n 135 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 1,100 mL\n 135 mL\n Total out:\n 1,300 mL\n 1,100 mL\n Urine:\n 1,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 800 mL\n -965 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.6 g/dL\n 136 K/uL\n 101 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 100 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.0 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 PM\n 03:57 AM\n WBC\n 10.6\n Hct\n 21.7\n 27.0\n Plt\n 136\n Cr\n 2.5\n TropT\n 0.06\n Glucose\n 101\n Other labs: PT / PTT / INR:15.4/21.2/1.4, CK / CKMB /\n Troponin-T:276/4/0.06, Ca++:8.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n Clinically improved with stable HCT. Melena resolved. Plan is for\n EGD/scope tomorrow. Stable for transfer to floor with q8 cbcs. +\n tropninin noted but not changing over time.\n - GI bleed with acute blood loss anemia: suspect lower GI but upper\n possible. Received vitamin K 10 mg IV, FFP and receiving 2 units PRBC.\n Has 2 large bore IVs. PPI IV drip. F/u Hcts q6h for now. Coumadin and\n ASA on hold. GI aware and seeing patient. Will await their recs.\n - OSA, would resume CPAP at 10 cm H2O at night.\n - DM, renal failure, watch for CHF, HTN, most of outpatient meds being\n held. Agree with continuing amio.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 458280,
"text": "Chief Complaint: none\n 24 Hour Events:\n - got three units pRBC's\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 47 (46 - 85) bpm\n BP: 123/54(72) {116/42(61) - 148/69(115)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 2,100 mL\n 135 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 1,100 mL\n 135 mL\n Total out:\n 1,300 mL\n 1,100 mL\n Urine:\n 1,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 800 mL\n -965 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n General: Awake, alert, NAD.\n HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted,\n MMM, no lesions noted in OP\n Neck: supple, no JVD or carotid bruits appreciated\n Pulmonary: Lungs CTA bilaterally\n Cardiac: RRR, nl. S1S2, no M/R/G noted\n Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or\n organomegaly noted.\n Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l.\n Lymphatics: No cervical, supraclavicular, axillary or inguinal\n lymphadenopathy noted.\n Skin: no rashes or lesions noted.\n Neurologic:\n -mental status: Alert, oriented x 3. Able to relate history without\n difficulty.\n Labs / Radiology\n 136 K/uL\n 9.6 g/dL\n 101 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 100 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.0 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 PM\n 03:57 AM\n WBC\n 10.6\n Hct\n 21.7\n 27.0\n Plt\n 136\n Cr\n 2.5\n TropT\n 0.06\n Glucose\n 101\n Other labs: PT / PTT / INR:15.4/21.2/1.4, CK / CKMB /\n Troponin-T:276/4/0.06, Ca++:8.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n 63 year old F with DM, afib on coumadin who p/w symptomatic anemia,\n elevated IRN, melena c/w GIB who is currently HD stable.\n .\n # GIB: Baseline HCT 33, now 18. Vitals signs continue to be stable and\n she is not tachycardic. GIB likely precipitated by elevated INR\n although she may have underlying GI pathology. Has received FFP, vit K\n and is now receiving blood. She has bumped her HCT appropriately.\n - monitor on tele\n - protonix \n - appreciate GI consult: EGD/Colonoscopy tomorrow\n - advance to clears, NPO after MN\n - q 6hrs HCT\n - hold asa and warfarin\n .\n # Troponin leak: Trop 0.06, CK 297. MB 4. Had some atypical CP which\n has now resolved. Likely to elevated creatinine and impair\n clearance. CE stable\n - will not give ASA or BB\n .\n # DM:\n - 1/2 dose NPH: 20 (gets 45 and 40 at home)\n - SSI\n .\n # Afib: currently sinus bradycardia, CHADS score high 2+\n - cont amiodarone\n - hold warfarin\n .\n # HTN: Holding anti-HTn while GIb. Will need to watch O2 sat as is on a\n lot of afterload reduction and diuretics. Echo in had EF 60% and\n only a suggestion of mild diastolic dysfunction with inc E/E'.\n - hold carvedilol, isosorbide dinitrate, torsemide, metolazone and\n hydralazine, candesartan\n .\n # High cholesterol\n - restart atorvastatin when taking PO\n .\n # ESRD: not on HD, Cr baseline\n - cont calcitriol when taking PO's\n .\n # Glaucoma:\n - switch bimatorpost to latanoprost as home med non-forumlary\n - cont dorzolamide\n - cont timolol\n .\n # Sleep apnea\n - CPAP at night\n .\n #) Prophylaxis: PPI gtt, sc heparin, bowel regimen\n .\n #) FEN: p.o. diet as tolerated\n .\n #) Access: PIVs\n .\n #) Code Status: Full\n .\n #) Dispo: pending further work-up and treatment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:14 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n ------ Protected Section ------\n On PPI , not on heparin sc- on pneumoboots, taking clears\n ------ Protected Section Addendum Entered By: , MD\n on: 10:39 ------\n"
},
{
"category": "Nursing",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 458284,
"text": "Pt is a 63 year old F with DM, afib on coumadin who p/w dizziness and\n low BP. She reports that she was in her usual state of health until\n yesterday. Yesterday, she went to her doctor's office to have her INR\n checked. She reports that she missed lunch. Later on in the day she\n began feeling lightheaded and dizzy, but attributed this to missing a\n meal. Her doctor subsequently called and told her not to take her\n coumadin. She awoke this morning around 6am and noticed dark black,\n sticky stool. She took her BP at home: 95/40. She denies any diarrhea,\n no hematemasis. She reported an intermittent sharp \"poke\" in right\n chest just below her present, which has now resoved; no SOb, no N/V, no\n sweating.\n .\n In the ED: In the ED, she did not tolerate NG lavage, but there was no\n overt blood. She was noted to have dark marroon stool but no melena.\n Her HCT was 18; INR 6.4. Two 18 guage IV's were placed. She was given\n vitK 10mg and protonix. She was transferred to the micu for further\n care\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Post transfusion hct 21. hr into 40\ns throughout night. Bp stable\n >120. denies dizziness. Not orthostatic. No s+s of bleeding. No stool\n o/n.\n Action:\n Second unit of blood given overnight\n Response:\n Tolerated well. Am labs pending\n Plan:\n Assess for s+s of bleeding. Continue with plan of care\n"
},
{
"category": "Physician ",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 458225,
"text": "Chief Complaint: none\n 24 Hour Events:\n - got three units pRBC's\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 47 (46 - 85) bpm\n BP: 123/54(72) {116/42(61) - 148/69(115)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 2,100 mL\n 135 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 1,100 mL\n 135 mL\n Total out:\n 1,300 mL\n 1,100 mL\n Urine:\n 1,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 800 mL\n -965 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n General: Awake, alert, NAD.\n HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted,\n MMM, no lesions noted in OP\n Neck: supple, no JVD or carotid bruits appreciated\n Pulmonary: Lungs CTA bilaterally\n Cardiac: RRR, nl. S1S2, no M/R/G noted\n Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or\n organomegaly noted.\n Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l.\n Lymphatics: No cervical, supraclavicular, axillary or inguinal\n lymphadenopathy noted.\n Skin: no rashes or lesions noted.\n Neurologic:\n -mental status: Alert, oriented x 3. Able to relate history without\n difficulty.\n Labs / Radiology\n 136 K/uL\n 9.6 g/dL\n 101 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 100 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.0 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 PM\n 03:57 AM\n WBC\n 10.6\n Hct\n 21.7\n 27.0\n Plt\n 136\n Cr\n 2.5\n TropT\n 0.06\n Glucose\n 101\n Other labs: PT / PTT / INR:15.4/21.2/1.4, CK / CKMB /\n Troponin-T:276/4/0.06, Ca++:8.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:14 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2173-06-12 00:00:00.000",
"description": "Resident Admission Note",
"row_id": 458128,
"text": "Chief Complaint: dizziness and black stool\n HPI:\n This is a 63 year old F with DM, afib on coumadin who p/w dizziness and\n low BP. She reports that she was in her usual state of health until\n yesterday. Yesterday, she whent to her doctor's office to have her INR\n checked. She reports that she missed lunch. Later on in the day she\n began feeling lightheaded and dizzy, but attributed this to missing a\n meal. Her doctor subsequently called and told her not to take her\n coumadin. She awoke this morning around 6am and noticed dark black,\n sticky stool. She took her BP at home: 95/40. She denies any diarrhea,\n no hematemasis. She reported an intermittent sharp \"poke\" in right\n chest just below her present, which has now resoved; no SOb, no N/V, no\n sweating.\n .\n In the ED: In the ED, she did not tolerate NG lavage, but there was no\n overt blood. She was noted to have dark marroon stool but no .\n Her HCT was 18; INR 6.4. Two 18 guage IV's were placed. She was given\n vitK 10mg and protonix. She was started on fluids and ordered 2 units\n FFP and 2 units pRBC's but did not receive it yet.\n Vitals on arrival: Temp 98.3 HR67 BP130/53 RR18 100%RA\n Vitals on transfer: HR 51 (BB) 110/40->95/36\n .\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 Home Medications:\n AMIODARONE 200 mg Tablet - 1 Tablet(s) by mouth once a day\n ATORVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth once a day\n BIMATOPROST - 0.03 % Drops - 1 drop both eyes at bedtime\n CALCITRIOL 0.25 mcg Capsule - 1 Capsule(s) by mouth once a day\n CANDESARTAN 32 mg Tablet - 1 Tablet(s) by mouth once a day\n CARVEDILOL - 3.125 mg Tablet - 1 Tablet(s) by mouth once a day\n DORZOLAMIDE-TIMOLOL 0.5 %-2 % Drops - 1 drop both eyes twice a day\n HYDRALAZINE - 50 mg Tablet - 1 1/2 tabs Tablet(s) by mouth twice a day\n ISOSORBIDE DINITRATE - 40 mg Tablet - 20 Tablet(s) by mouth once a day\n LATANOPROST - 0.005 % Drops - 1 gtt OU at bedtime\n METOLAZONE - - 5 mg Tablet - 1 Tablet(s) by mouth q Thursday\n TORSEMIDE - - 20 mg Tablet - 3 tabs Tablet(s) by mouth twice a day\n WARFARIN - 5 mg Tablet - 1 Tablet(s) by mouth once a day\n ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a day\n INSULIN NPH & REGULAR HUMAN [NOVOLIN 70/30] - 100 unit/mL (70-30)\n Suspension - 45 in the AM and 40 in the PM twice a day\n Past medical history:\n Family history:\n Social History:\n type II diabetes complicated by retinopathy, neuropathy, nephropathy,\n atrial fibrillation on chronic Coumadin therapy\n hypertension,\n hypercholesterolemia\n breast cancer four years ago which was resected; She also had lymph\n node resection, received chemo and radiotherapy in , no recurrence\n She also had three C-sections\n AV fistula surgery\n therapy for her retinopathy.\n n/c\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient emigrated from approximately\n 25 years ago. She has 4 children and lives with 2 of them here in\n . She has been a widow for 2 years and suffered some\n depression after her late husband's death. She is a never\n smoker, drinks rare wine, and denies drug use.\n Review of systems:\n Flowsheet Data as of 07:48 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.6\nC (97.8\n HR: 59 (52 - 67) bpm\n BP: 135/60(79) {119/46(67) - 148/69(87)} mmHg\n RR: 22 (14 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 1,859 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 859 mL\n Total out:\n 0 mL\n 900 mL\n Urine:\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 959 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General: Awake, alert, NAD.\n HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted,\n MMM, no lesions noted in OP\n Neck: supple, no JVD or carotid bruits appreciated\n Pulmonary: Lungs CTA bilaterally\n Cardiac: RRR, nl. S1S2, no M/R/G noted\n Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or\n organomegaly noted.\n Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l.\n Lymphatics: No cervical, supraclavicular, axillary or inguinal\n lymphadenopathy noted.\n Skin: no rashes or lesions noted.\n Neurologic:\n -mental status: Alert, oriented x 3. Able to relate history without\n difficulty.\n Labs / Radiology\n 179\n 294\n 2.6\n 119\n 26\n 99\n 3.7\n 137\n 18\n 11.6\n [image002.jpg]\n CE:\n Troponin 0.06\n MB 4\n CK 297\n NEBH labs: \n - HCT 33\n - BUN 74\n Imaging: CXR; Stable cardiomegaly without focal consolidation.\n ECG: sinus bradycardia, biphasic twaves in V4-V6 and I, AVl - unchanged\n from prior\n Assessment and Plan\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)\n 63 year old F with DM, afib on coumadin who p/w symptomatic anemia,\n elevated IRN, c/w GIB who is currently HD stable.\n .\n # GIB: Baseline HCT 33, now 18. Vitals signs are stable and she is not\n tachycardic (but on BB) suggesting that this is not a rapid, acute GIB\n although she had some symptoms of hypovolemia. GIB likely precipitated\n by elevated INR although she may have underlying problem. \n suggests upper GIB although she had maroon stools which makes upper vs\n lower GIB equivocal. BUN elevated which could indicate upper GIB with\n reabsobtion but BUN has high in the past, but 74 in . She may\n have gastritis, ulcer or even lower GIB- diverticulitar bleed, AVM's.\n Has received FFP, vit K and is now receiving blood.\n - monitor on tele\n - protonix \n - appreciate GI consult\n - keep NPO\n - q 6hrs HCT\n - hold asa and warfarin\n .\n # Troponin leak: Trop 0.06, CK 297. MB 4. Had some atypical CP which\n has now resolved.\n - trend enzymes\n - will not give ASA or BB\n - pRBC's and volume rescucitation\n .\n # DM:\n - 1/2 dose NPH: 20 (gets 45 and 40 at home)\n - SSI\n .\n # Afib: currently sinus bradycardia, CHADS score high 2+\n - cont amiodarone\n - hold warfarin\n - afib\n .\n # HTN: Holding anti-HTn while GIb. Will need to watch O2 sat as is on a\n lot of afterload reduction and diuretics. Echo in had EF 60% and\n only a suggestion of mild diastolic dysfunction with inc E/E'.\n - hold carvedilol, isosorbide dinitrate, torsemide, metolazone and\n hydralazine, candesartan\n .\n # High cholesterol\n - restart atorvastatin when taking PO\n .\n # ESRD: not on HD, Cr baseline\n - cont calcitriol when taking PO's\n .\n # Glaucoma:\n - switch bimatorpost to latanoprost as home med non-forumlary\n - cont dorzolamide\n - cont timolol\n .\n # Sleep apnea\n - CPAP at night\n .\n #) Prophylaxis: PPI gtt, sc heparin, bowel regimen\n .\n #) FEN: p.o. diet as tolerated\n .\n #) Access: PIVs\n .\n #) Code Status: Full\n .\n #) Dispo: pending further work-up and treatment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:14 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2173-06-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 458113,
"text": "63 yr old woman with multiple medical problems. presented to ED today\n with c/o of general malaise and weaknes note black stools over past\n couple of days. ED found to have Hct 18 , INR 6.7(15 point Hct drop\n since last checked ~3 weeks ago in the context of increased coumadin\n dose. Adm MICU for GI bleed with acute blood loss anemia: suspect\n lower GI but upper possible. Received vitamin K 10 mg IV, FFP and\n receiving 2 units PRBC. GI aware and seeing patient. Will await their\n recs.\n PMH: DM , renal failure, CHF, HTN, afib, OSA Has BIPAP infreq use\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Arrived from @ 1530 awake alert oriented x3 follows commands MAE\n random denies pin. . HR 56-58 SB rare PVC, BP 110-145/54-63 MAPS>65,\n RR 18-20 02 3l/min NC Lungs clear. Abd soft nontender to palpation.\n No stool. GI team to eval rectal exam +guiac. IV access 2PIV received\n 2Units FFP, 2Units PRBC. OOB to commode vdg clear urine. Fluid Bolus\n 1Liter. Pt is NPO received\n dose NPH @ 1830 per Resident.\n Action:\n Transfusion and fluid resiusitation. Started protonix.\n Response:\n No active bleed, hemodynamically stable.\n Plan:\n Serial hct q6hrs, next Hct 2hrs post transfusion.\n NPO\n Fluid resuscitation\n Transfuse for Hct <30\n Vit K\n Monitor FSBS, start IV dextrose for low BS.\n"
},
{
"category": "Physician ",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 458321,
"text": "Chief Complaint: melena\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 63F with ESRD, DM, CHF, Afib on coumadin. A/W melena and HCT=18 in the\n setting of INR=6.\n 24 Hour Events:\n Now s/p ffp, vit k, 3 U PRBC. HCT 18->21->27. This AM formed normal\n stool. GI consult- for EGD/scope .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Amiodarone 200 qd\n Protonix\n RISS\n Pneumoboots\n Zocor\n HELD:\n Coreg, metolazone, torsemide, asa.\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 47 (46 - 85) bpm\n BP: 123/54(72) {116/42(61) - 148/69(115)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 2,100 mL\n 135 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 1,100 mL\n 135 mL\n Total out:\n 1,300 mL\n 1,100 mL\n Urine:\n 1,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 800 mL\n -965 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n GEN NAD\n CV S1 S2 regular. No m/r/g\n LUNG CTA bl. No crackles\n ABD NT/ND\n EXT No c/c/e\n SKIN No r/p/e\n Labs / Radiology\n 9.6 g/dL\n 136 K/uL\n 101 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 100 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.0 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 PM\n 03:57 AM\n WBC\n 10.6\n Hct\n 21.7\n 27.0\n Plt\n 136\n Cr\n 2.5\n TropT\n 0.06\n Glucose\n 101\n Other labs: PT / PTT / INR:15.4/21.2/1.4, CK / CKMB /\n Troponin-T:276/4/0.06, Ca++:8.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n Clinically improved with stable HCT. Melena resolved. Plan is for\n EGD/scope tomorrow. Stable for transfer to floor with q8 cbcs. +\n tropninin noted but not changing over time.\n -For OSA, would resume CPAP at 10 cm H2O at night.\n - DM, renal failure, watch for CHF, HTN, most of outpatient meds being\n held in the setting of large GIB, with the exception of amiodarone.\n These can be reinstated after stable HCT documented.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 458336,
"text": "Chief Complaint: melena\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 63F with ESRD, DM, CHF, Afib on coumadin. A/W melena and HCT=18 in the\n setting of INR=6.\n 24 Hour Events:\n Now s/p ffp, vit k, 3 U PRBC. HCT 18->21->27. This AM formed normal\n stool. GI consult- for EGD/scope .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Amiodarone 200 qd\n Protonix\n RISS\n Pneumoboots\n Zocor\n HELD:\n Coreg, metolazone, torsemide, asa.\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 47 (46 - 85) bpm\n BP: 123/54(72) {116/42(61) - 148/69(115)} mmHg\n RR: 16 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n Total In:\n 2,100 mL\n 135 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n 1,100 mL\n 135 mL\n Total out:\n 1,300 mL\n 1,100 mL\n Urine:\n 1,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 800 mL\n -965 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n GEN NAD\n CV S1 S2 regular. No m/r/g\n LUNG CTA bl. No crackles\n ABD NT/ND\n EXT No c/c/e\n SKIN No r/p/e\n Labs / Radiology\n 9.6 g/dL\n 136 K/uL\n 101 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 100 mg/dL\n 105 mEq/L\n 142 mEq/L\n 27.0 %\n 10.6 K/uL\n [image002.jpg]\n 09:34 PM\n 03:57 AM\n WBC\n 10.6\n Hct\n 21.7\n 27.0\n Plt\n 136\n Cr\n 2.5\n TropT\n 0.06\n Glucose\n 101\n Other labs: PT / PTT / INR:15.4/21.2/1.4, CK / CKMB /\n Troponin-T:276/4/0.06, Ca++:8.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n GIB\n -Clinically improved with stable HCT\n -Melena resolved.\n -Plan is for EGD/scope tomorrow\n -Stable for transfer to floor with q8 cbcs.\n CV\n -positive troponin noted but not changing over time.\n OSA\n -resume CPAP at 10 cm H2O at night.\n DM\n -FSG/SSRI\n CHF\n -meds being held in the setting of large GIB\n HTN\n -meds being held in the setting of large GIB\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:14 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2173-06-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 458096,
"text": "63 yr old woman with multiple medical problems, 15 point Hct drop since\n last checked ~3 weeks ago in the context of increased coumadin dose,\n INR 6.7 and black stools this AM.\n - GI bleed with acute blood loss anemia: suspect lower GI but upper\n possible. Received vitamin K 10 mg IV, FFP and receiving 2 units PRBC.\n Has 2 large bore IVs. PPI IV drip. F/u Hcts q6h for now. Coumadin and\n ASA on hold. GI aware and seeing patient. Will await their recs.\n - OSA, would resume CPAP at 10 cm H2O at night.\n - DM, renal failure, watch for CHF, HTN, most of outpatient meds being\n held. Agree with continuing amio.\n Rest of plan as per Dr \ns note.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2173-06-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 458158,
"text": "Demographics\n Ideal body weight: 47.6 None\n Ideal tidal volume: 190.4 / 285.6 / 380.8 mL/kg\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 :\n Ventilation Assessment\n Non-invasive ventilation assessment: Tolerated well\n Plan\n Next 24-48 hours: Continue with cpap at night, then nasal cannula\n during day @ 2 lpm 02\n"
},
{
"category": "Radiology",
"chartdate": "2173-06-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1077599,
"text": " 12:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with lgib, cp\n REASON FOR THIS EXAMINATION:\n ? acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP.\n\n COMPARISON: .\n\n HISTORY: Lower GI bleed and chest pain.\n\n FINDINGS: The cardiac silhouette is enlarged, stable. Linear atelectasis is\n noted within the left mid lung field. There is no focal consolidation,\n effusion or pneumothorax. There is a tortuous aorta. Clips in the right axilla\n are noted.\n\n IMPRESSION: Stable cardiomegaly without focal consolidation.\n DFDdp\n\n"
},
{
"category": "ECG",
"chartdate": "2173-06-12 00:00:00.000",
"description": "Report",
"row_id": 274413,
"text": "Sinus bradycardia. Prolonged Q-T interval. Intraventricular conduction delay.\nNon-specific ST-T wave changes. Compared to the previous tracing of \nno definite change.\n\n"
}
] |
9,637 | 110,835 | This is a 61 year old female with a history of tobacco use who was admitted from an outside hospital with an acute inferior ST elevation myocardial infarction. She was immediately taken to the cardiac catheterization laboratory and was found to have two vessel coronary artery disease with the right coronary artery with a 90% lesion and an acutely occluded 90% proximal left circumflex artery. The left circumflex lesion was successfully stented and the patient was transferred to the Coronary Care Unit for further observation. | Sinus rhythmLateral ST changes are nonspecificsmall inferior Q's consider inferior myocardial infarctionSince last ECG, right bundle branch block resolved Noaortic regurgitation is seen. Updated on pts condition by RN.A&P: Hemo dynamically stable after R/I IMI with stent to LCX. There is moderate regional left ventricular systolicdysfunction.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal inferior - akinetic; mid inferior - akinetic;basal inferolateral - akinetic; mid inferolateral - akinetic; basalanterolateral - hypokinetic; mid anterolateral - hypokinetic; inferior apex -hypokinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets appear structurally normal with goodleaflet excursion. pulses by doppler.ck 3700, +mb, troponin>50.resp: cta, no sob. There is mild symmetric left ventricularhypertrophy with normal cavity size. Attempt to titrate doses as tolerated. CCU NPNneuro: A&O x3, pleasant, cooperative, calmcv: hr 60-80's sr no vea, bp 88-106/50-60, tolerating lopressor and captopril, pain free, r groin d/i, distal pulses dopplerable. Elevated PCWP-> effective diuresis 2.5L +. rec'd tylenol, serax, protonix and cp resolved. Myocardial infarction.Height: (in) 62Weight (lb): 140BSA (m2): 1.64 m2BP (mm Hg): 98/54HR (bpm): 71Status: InpatientDate/Time: at 14:37Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. There is mildmitral annular calcification. Distal pulses palpable(weak) but confirmed by doppler. Mild (1+) mitral regurgitation is seen.TRICUSPID VALVE: The pulmonary artery systolic pressure could not bedetermined.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Distal pulses present by doppler.Resp: Lungs clear. Inferior ST segments changes on EKG. ivf to complete after 1l of 1/2ns.id: afeb. Mild mitral regurgitation.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). Sinus rhythmGeneralized low QRS voltagesConsider inferoposterolateral myocardial infarction - may be acute - clinicalcorrelation is suggestedSince previous tracing of : further ST-T wave changes are seen Tx w/ ASA, Nitro gtt, Hep bolus & gtt, Integrellin gtt & IV Lopressor c/b hypotension (SBP 70s) following start of Nitro. There is no pericardial effusion.IMPRESSION: Symmetric left ventricular hypertrophy with regional systolicdysfunction c/w CAD. will need eval for rca lesion...?poss intervention this stay. H/H remains stable.Resp: Lung sounds CTA. Post cath hydration complete.Neuro: Pt is alert and oriented x's 3. The mitral valve leaflets are mildly thickened.Mild (1+) mitral regurgitation is seen. will be premed for tomorrow's cath.cv: hr 60s sr, no pvc. There is moderate regional leftventricular systolic dysfunction with focal near akinesis of the basal 2/3rdsof the inferior and inferolateral wall. Sinus rhythmLow QRS voltages in limb leadsModest nonspecific low amplitude lateral T wavesNo previous tracing for comparison Sinus rhythmLow QRS voltagesInferior Q waves and prominent R wave in lead V2 are nondiagnostic but clinicalcorrelation is suggested for possible inferposterior myocardial infarctionModest nonspecific lateral T wave changesSince previous tracing of : inferior QRS changes are seen Left ventricular function. NBP 85-104/47-53. Pt remains hemodynamically stable s/p IMI. ccu nursing progress notes: i feel kind of tired todayo: pls see carevue flowsheet for complete vs/data/eventsid: tmax 99.1. no abx.pt cont w dissuse raised rash, pt w mild discomfort. R groin is C&D without evidence of hematoma. No aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Based on AHA endocarditis prophylaxis recommendations, the echo findings indicatea moderate risk (prophylaxis recommended). rec'd lopressor 12.5, captopril 6.25. pt briefly dropped her bp after dose to high 80s, no complaints. wbc 16.8. no abx.social: pt widowed. Recath scheduled for ? +BS. There islipomatous hypertrophy of the interatrial septum.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy withnormal cavity size. 3420cc.ID: Afebrile. Right groin site CDI. Sinus rhythmConsider inferoposterolateral myocardial infarction - may be acute - clinicalcorrelation is suggestedLow QRS voltages in limb leadsSince previous tracing of the same date: further QRS and ST-T wave changes arepresent good uop.ms: ox3. NO COMPLAINTS CP/SOBO. no stool.gu: good diuresis from lasix in cath lab. recovered without interventionresp: ra sat 97%.gi: tol diet, no stool.gu: cont w foley. S/P stent to LCX only. Transparent dsg applied. Clinical decisions regarding theneed for prophylaxis should be based on clinical and echocardiographic data.Conclusions:The left atrium is normal in size. Denies chest pain or shortness of breath. k and mg repleted. PO temp 98.8. No c/o pain. BP returned to upper 90s shortly there after without any nsg intervention. no further cp.hr 60-70s sr, no vea. ccu nursing progress notes: i have a little paino: pls see carevue flowsheet for complete vs/data/eventssee fhpa for details of admitneuro: a/o x3. Continue support for smoking cessation. Currently not on abx regimen. Given Lopressor 12.5 mg. SBP 80's-100's not given Captopril d/t SBP in high 80's. cardiac rehab/teaching. Slept comfortably overnoc w/ minimal interruption.CV: HR 60-75. CCU NURSING PROGRESS NOTE 7P-11PS. Sinus rhythmConduction defect of RBBB typeQ waves in leads lll, aVF consider inferior myocardial infarctionRight bundle branch block new from ECG of O2 sat 95-98% on 2l NP.GU/GI: Tolerating liquids well. Output gradually decreasing overnoc but output remains adequate. Abd soft. Integrilin continues at 2mcgs/kg/min. Tx w/ Benadryl and Zantac prior shift. monitor response to cv meds, ? ck's trending down.resp: lungs cta, sats 98% on RAgu: foley draining cl yel urine 100-175cc/hr, currently ~ 2500cc neg.gi: good appitite, no stoolid: afebrileskin: intactactivity: oob to chair for several hours tolerated well.A: hemodynamically stable s/p mi, stent to lcx.P: c/o, ^ activity. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATAVSS, LOPRESSOR 12.5 MG GIVEN AT 10 PM, OOB TO CHAIR - TOLERATED WELL;TO COMMODE W/MOD BM GUIAC NEGATIVE7:45 PM PT C/O ITCHING ON NECK - REDDENED BLOTCHY RASH ON FRONT AND BACK OF NECK W/1 LARGE HIVE NOTED, MD INFORMED, LUNGS CLEAR, NO SOB, SATS 97-98%, BENADRYL 25MG PO, ZANTAC 150MG PO GIVEN, NO FURTHER COMPLAINTS;A/P. site stable. The remaining segments contract well.Right ventricular chamber size and free wall motion are normal. | 13 | [
{
"category": "Echo",
"chartdate": "2146-03-29 00:00:00.000",
"description": "Report",
"row_id": 74947,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Myocardial infarction.\nHeight: (in) 62\nWeight (lb): 140\nBSA (m2): 1.64 m2\nBP (mm Hg): 98/54\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 14:37\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. There is\nlipomatous hypertrophy of the interatrial septum.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy with\nnormal cavity size. There is moderate regional left ventricular systolic\ndysfunction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferior - akinetic; mid inferior - akinetic;\nbasal inferolateral - akinetic; mid inferolateral - akinetic; basal\nanterolateral - hypokinetic; mid anterolateral - hypokinetic; inferior apex -\nhypokinetic;\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 appear structurally normal with good\nleaflet excursion. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The pulmonary artery systolic pressure could not be\ndetermined.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Based on\n AHA endocarditis prophylaxis recommendations, the echo findings indicate\na moderate risk (prophylaxis recommended). Clinical decisions regarding the\nneed for prophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is moderate regional left\nventricular systolic dysfunction with focal near akinesis of the basal 2/3rds\nof the inferior and inferolateral wall. The remaining segments contract well.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets appear structurally normal with good leaflet excursion. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure\ncould not be estimated. There is no pericardial effusion.\n\nIMPRESSION: Symmetric left ventricular hypertrophy with regional systolic\ndysfunction c/w CAD. Mild mitral regurgitation.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-03-29 00:00:00.000",
"description": "Report",
"row_id": 1389307,
"text": "ccu nursing progress note\ns: i have a little pain\no: pls see carevue flowsheet for complete vs/data/events\nsee fhpa for details of admit\nneuro: a/o x3. mae w purpose.\ncv: had brief episode of cp around 1pm. no ekg changes. rec'd tylenol, serax, protonix and cp resolved. no further cp.\nhr 60-70s sr, no vea. k and mg repleted. bp 95-105/60. tol 1st dose captopril at 6.25.\nr fem sheaths dc'd at 11am. site stable. pulses by doppler.\nck 3700, +mb, troponin>50.\nresp: cta, no sob. sat 95-100% on 2l nc.\ngi: tol diet this eve. no stool.\ngu: good diuresis from lasix in cath lab. now down to 40-50cc/hr. ivf to complete after 1l of 1/2ns.\nid: afeb. wbc 16.8. no abx.\nsocial: pt widowed. active, lives alone has 3 grown children who live in the area.\na: s/p mi, stent to lcx.\np: follow for cp/chf/bleeding complications. will need eval for rca lesion...?poss intervention this stay. cardiac rehab/teaching. support to pt and family.\n"
},
{
"category": "ECG",
"chartdate": "2146-03-29 00:00:00.000",
"description": "Report",
"row_id": 169657,
"text": "Sinus rhythm\nLow QRS voltages\nInferior Q waves and prominent R wave in lead V2 are nondiagnostic but clinical\ncorrelation is suggested for possible inferposterior myocardial infarction\nModest nonspecific lateral T wave changes\nSince previous tracing of : inferior QRS changes are seen\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-29 00:00:00.000",
"description": "Report",
"row_id": 169658,
"text": "Sinus rhythm\nLow QRS voltages in limb leads\nModest nonspecific low amplitude lateral T waves\nNo previous tracing for comparison\n\n"
},
{
"category": "ECG",
"chartdate": "2146-04-01 00:00:00.000",
"description": "Report",
"row_id": 169653,
"text": "Sinus rhythm\nConduction defect of RBBB type\nQ waves in leads lll, aVF consider inferior myocardial infarction\nRight bundle branch block new from ECG of \n\n"
},
{
"category": "ECG",
"chartdate": "2146-04-02 00:00:00.000",
"description": "Report",
"row_id": 169654,
"text": "Sinus rhythm\nLateral ST changes are nonspecific\nsmall inferior Q's consider inferior myocardial infarction\nSince last ECG, right bundle branch block resolved\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-30 00:00:00.000",
"description": "Report",
"row_id": 169655,
"text": "Sinus rhythm\nGeneralized low QRS voltages\nConsider inferoposterolateral myocardial infarction - may be acute - clinical\ncorrelation is suggested\nSince previous tracing of : further ST-T wave changes are seen\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-29 00:00:00.000",
"description": "Report",
"row_id": 169656,
"text": "Sinus rhythm\nConsider inferoposterolateral myocardial infarction - may be acute - clinical\ncorrelation is suggested\nLow QRS voltages in limb leads\nSince previous tracing of the same date: further QRS and ST-T wave changes are\npresent\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-03-30 00:00:00.000",
"description": "Report",
"row_id": 1389308,
"text": "CCU Nursing Progress Note 7p-7a\nS/P IMI with Stent to LCX\n\nO: CV: See flow sheet for vital signs. Remains in sinus rhythm. Given Lopressor 12.5 mg. SBP 80's-100's not given Captopril d/t SBP in high 80's. Integrilin continues at 2mcgs/kg/min. To be dc'd at 6am. K 3.4. Recieved 40meq's. Ck's starting to trend down. Denies chest pain or shortness of breath. R groin is C&D without evidence of hematoma. Distal pulses present by doppler.\n\nResp: Lungs clear. O2 sat 95-98% on 2l NP.\n\nGU/GI: Tolerating liquids well. No c/o nausea or vomiting. Abd is soft with bowel sounds present. Foley draining good amts of clear yellow urine. Post cath hydration complete.\n\nNeuro: Pt is alert and oriented x's 3. Able to move all extremities without difficulty.\n\nSocial: Children in to visit. Updated on pts condition by RN.\n\nA&P: Hemo dynamically stable after R/I IMI with stent to LCX. Integrilin to be dc'd at 6am. Check am labs. Possible transfer to floor later today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-03-30 00:00:00.000",
"description": "Report",
"row_id": 1389309,
"text": "CCU NPN\nneuro: A&O x3, pleasant, cooperative, calm\ncv: hr 60-80's sr no vea, bp 88-106/50-60, tolerating lopressor and captopril, pain free, r groin d/i, distal pulses dopplerable. ck's trending down.\nresp: lungs cta, sats 98% on RA\ngu: foley draining cl yel urine 100-175cc/hr, currently ~ 2500cc neg.\ngi: good appitite, no stool\nid: afebrile\nskin: intact\nactivity: oob to chair for several hours tolerated well.\nA: hemodynamically stable s/p mi, stent to lcx.\nP: c/o, ^ activity. monitor response to cv meds, ? RCA intervention \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-03-30 00:00:00.000",
"description": "Report",
"row_id": 1389310,
"text": "CCU NURSING PROGRESS NOTE 7P-11P\nS. NO COMPLAINTS CP/SOB\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nVSS, LOPRESSOR 12.5 MG GIVEN AT 10 PM, OOB TO CHAIR - TOLERATED WELL;\nTO COMMODE W/MOD BM GUIAC NEGATIVE\n7:45 PM PT C/O ITCHING ON NECK - REDDENED BLOTCHY RASH ON FRONT AND BACK OF NECK W/1 LARGE HIVE NOTED, MD INFORMED, LUNGS CLEAR, NO SOB, SATS 97-98%, BENADRYL 25MG PO, ZANTAC 150MG PO GIVEN, NO FURTHER COMPLAINTS;\n\nA/P. PT CALLED OUT AND AWAITING BED ON ; AWAITING CATH ON FRIDAY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-03-31 00:00:00.000",
"description": "Report",
"row_id": 1389311,
"text": "CCU Nursing Progress Note 11p-7a\nS: \" I feel much better than I did the other day\"\n\nO: Please see careview for complete VS/ additional objective data\n\nNeuro: Extremely pleasant. AAOX3. MAE. Following commands and cooperative with care. Pt is moving independently in bed. No c/o pain. Slept comfortably overnoc w/ minimal interruption.\n\nCV: HR 60-75. NSR no ectopy noted. NBP 85-104/47-53. SBP to 80s following midnight dose of Captopril 6.25mg. BP returned to upper 90s shortly there after without any nsg intervention. Pt continues to deny CP/SOB. Right groin site CDI. No evidence of hematoma or ooze. Transparent dsg applied. Distal pulses palpable(weak) but confirmed by doppler. H/H remains stable.\n\nResp: Lung sounds CTA. RR 14-18. O2 sats 95-97% without supplemental O2.\n\nGI/GU: Appetite advancing tolerating dinner without N/V. Taking po meds without difficulty. Abd soft. +BS. Guiac negative BM prior shift.\nFoley catheter patent draining clear-light yellow urine. HUO 90-300cc q 1-2 hrs. Output gradually decreasing overnoc but output remains adequate. 3420cc.\n\nID: Afebrile. PO temp 98.8. Currently not on abx regimen. ?Allergic rx prior shift-> new presentation of itchy, reddened neck w/ blothchy rash and hives. Tx w/ Benadryl and Zantac prior shift. HO changed Pravastatin to Atorvastatin. No further incidence overnoc.\n\nAccess: 2 PIVS\n\nDispo: Full code\n\nSocial: No visitors or calls overnoc.\n\nA/P: 61 yo pleasant female w/ no significant PMH except tobacco use. S/P L arm pain @ rest radiation to SSCP assoc w/ SOB. Inferior ST segments changes on EKG. Tx w/ ASA, Nitro gtt, Hep bolus & gtt, Integrellin gtt & IV Lopressor c/b hypotension (SBP 70s) following start of Nitro. Pressure responded well to IVF x 2L and dc of Nitro. To for cath revealing 2VD. 90% occluded LCX & RCA. S/P stent to LCX only. Elevated PCWP-> effective diuresis 2.5L +. Significant IMI cks peaked @ 3745.\n Pt remains hemodynamically stable s/p IMI. Continue to monitor response to BB and ACE-I. (At times becomes slightly hypotensive on low doses.) Attempt to titrate doses as tolerated. Continue support for smoking cessation. OOB to chair without difficulty. Pt is called out to floor awaiting available bed. Recath scheduled for ? Thursday or Friday for intervention of 90% diseased RCA prior to discharge.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-03-31 00:00:00.000",
"description": "Report",
"row_id": 1389312,
"text": "ccu nursing progress note\ns: i feel kind of tired today\no: pls see carevue flowsheet for complete vs/data/events\nid: tmax 99.1. no abx.\npt cont w dissuse raised rash, pt w mild discomfort. will be premed for tomorrow's cath.\ncv: hr 60s sr, no pvc. rec'd lopressor 12.5, captopril 6.25. pt briefly dropped her bp after dose to high 80s, no complaints. recovered without intervention\nresp: ra sat 97%.\ngi: tol diet, no stool.\ngu: cont w foley. good uop.\nms: ox3. cooperative. oob to ch, amb w pt.\nsocial: famimly in touch by phone\na: stable awaiting bed on floor.\np: cont to monitor for ischemia/chf. activity as tol. cardiac teaching. cath for rca intervention tomorrow.\n"
}
] |
7,517 | 174,684 | Abnormal septal motion/position.AORTA: Normal aortic root diameter. RR REGULARE AND UNLABORED. PT IS AFEBRILE.C/V: HR 80'S AND SINUS. No AS.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV inflow patternc/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets. SOME GENERALIZED DEPENDENT EDEMA NOTED. Prior inferior myocardialinfarction. ABLE TO MAE.RESP: LS DIMINSHED BILAT. DENIES CP/SOB/PALP.RESP: LS DIMINSHED BILAT. There is left ventricular enlargement. +BS NO BM. +BS NO BM. Lungs CTA, diminished at bases. Normal aortic arch diameter. LAST PTT 93.4. Left anterior fascicular block. The left ventricular inflow pattern suggests impairedrelaxation. Self ADLs. There is slight Q-T intervalprolongation. Assess left ventricular function.Height: (in) 72Weight (lb): 350BSA (m2): 2.70 m2BP (mm Hg): 114/63HR (bpm): 93Status: OutpatientDate/Time: at 10:10Test: TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: LV not well seen. There is prior inferiormyocardial infarction and probable anterior myocardial infarction as well.Diffuse non-specific ST-T wave abnormalities. NO BM.ENDO: FS AT 2200 173 W/2U REG SS INS. Mild to moderate [+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is mildly dilated. There isno pericardial effusion.IMPRESSION: Probably normal LV systolic function (due to poor imager quality,a regional wall motion abnormality cannot be excluded). LIMITED CT OF THE PELVIS WITH CONTRAST: The iliac vessels appear normal. NSR 70s, occ PVC. DENIES SOB.PT ON WEIGHT BASED HEPARIN. NPN 7P-7ANEURO: PT A/O X3. +BS. HISTORY: Dyspnea and shortness of breath. IMPRESSION: Limited secondary to technique. There is mild cardiomegaly. Handout for coumadin and DVT/PE given and reviewed with pt.Resp - Sats high 90s RA. FSBS covered by RISS. BG 166-221 FOR MY TIME.SKIN: NO BREAKDOWN NOTED.PLAN: CONT. Sinus tachycardia and occasional ventricular ectopy. MAG 1.7. There is abnormal septalmotion/position. AFEBRILE. BP STABLE. DENIES CHEST PAIN.GI/GU: DIET. No 2D orDoppler evidence of distal arch coarctation.AORTIC VALVE: Normal aortic valve leaflets (3). The unopacified large and small bowel are grossly normal. The aorta, aortic arch, and pericardium appear normal. Sinus rhythm with slowing of the rate as compared to the previous tracingof . NO COUGH PRESENT.CV: NSR-ST WITH PVC'S. Ventricular ectopy is no longer recorded. The mitral valve appears structurally normal with trivial mitralregurgitation. 1700 glu is 179 an coveredactivity:oob to chair and can amb with min assistance to toiletplan: pt is called out bp 10-118 sys which is lower than pt usual 130-140 sys preadmit. Teaching started re:coumadin. There is moderate pulmonary artery systolic hypertension. LUNG SOUNDS DIMINSIHED THROUGHOUT DUE TO PTS SIZE AND WT. OCCASIONAL PVC'S. The airways are patent to the level of the segmental bronchi bilaterally. PARTIALLY UPRIGHT PORTABLY AP CHEST: No prior studies are available for comparison. (GOAL IS TO KEEP PTT 60-100).GI/GU: + BS. MAGNESIUM SULFATE 2G IV X1.B/P 120/80-102/70. ALSO ON ORAL .SKIN: INTACT.HEPARIN AT 1500U/HR. PTT THERAP. Otherwise, no diagnostic interim change.Clinical correlation is suggested.TRACING #2 Delayed precordial progression suggesting prior anterior myocardialinfarction. POOR FLUID INTAKE. Denies pain. The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation. HE WAS STARTED ON HEPARIN.PMH: HTN, DM, MORBID OBSITY, URETUAL STONES S/P LITHOTRIPSY AND STENTS .ALLERGIES: NKDANEURO: PT A/OX3. The left ventricle is not well seen but theoverall LV systolic function is probably normal. ABD IS OBESE, NON-TENDER. No AS. NOW, ON 3L NC WITH ADEQUATE SATS. In the right middle lobe, there is a more nodular density measuring approximately 7 mm, but this is adjacent to a vessel, and not clearly separate from it. Evaluate for free air/infiltrates. PATIENT/TEST INFORMATION:Indication: Shortness of breath. The descending aorta is normal. Cont on heparin 1500U/hr, PTT therapeutic. WHILE AWAKE 117/79.GI/GU: DIET. Magnesium repleted. CT OF THE ABDOMEN WITH CONTRAST: Evaluation is significantly limited due to body habitus and artifact. no deficits notedcard: rat 80's with occasional to freq pvcs. VOIDS IN SMALL AMOUNTS VIA URINAL. BP 90'S-120'S/60'S-90'S.GU/GI: ABD IS OBESE WITH +BS. HR 80'S. RR teens.CV - BP 120s-130s/80s. Compared to the previous tracing of ventricular ectopyhas abated and the rate has slowed. There is likely bibasilar atelectasis. No resting LVOT gradient.RIGHT VENTRICLE: RV not well seen. WITH CURRENT PLAN OF CARE. WEIGHT IN KE 158KG.CV:NSR HR 85-90 WITH PVC NOTED. ON DIET AND TOLERATING WELL.ENDO: SSI WITH COVERAGE. Further evaluation of lymph adenopathy is slightly limited due to body habitus and artifact. NO BM. NO CHANGE. (Over) 8:33 PM CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: eval for pe or aortic dissection Field of view: 36 Contrast: OPTIRAY Amt: 150 FINAL REPORT *ABNORMAL! PERLA. Mild to moderatetricuspid regurgitation with moderate pulmonary hypertension. Clinical correlation is suggested.TRACING #1 REFORMATTED IMAGES: There are large bilateral pulmonary emboli. lovenox, check with team. MICU nursing progress note 7A-12noonNeuro - A&O x 3. card echo from yest showed no clots but mod pulm htn.resp: decreased o2 to 2l nc and pt was desating in am on RA but now 93-95 on RA and > 96 with o2 pt remains on 1500 units heparin /hr ptt in theraputic range for 3 draws and not needed til am. No AR. CALLED OUT. No identified lymph adenopathy. TECHNIQUE: Axial images through the chest prior to and following administration of IV contrast. SLEPT IN NAPS.RESP: LUNGS CLEAR BILAT UPPER LOBES, DIM IN THE BASES. M/SICU NPN FOR 7A-7P: NKDA FULL CODE PLEASE CAREVUE FLOWSHEET FOR MORE DETAILSNEURO: AAOX3. | 11 | [
{
"category": "Echo",
"chartdate": "2117-12-15 00:00:00.000",
"description": "Report",
"row_id": 62473,
"text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath. Assess left ventricular function.\nHeight: (in) 72\nWeight (lb): 350\nBSA (m2): 2.70 m2\nBP (mm Hg): 114/63\nHR (bpm): 93\nStatus: Outpatient\nDate/Time: at 10:10\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: LV not well seen. No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV not well seen. Abnormal septal motion/position.\n\nAORTA: Normal aortic root diameter. Normal aortic arch diameter. No 2D or\nDoppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV inflow pattern\nc/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. The left ventricle is not well seen but the\noverall LV systolic function is probably normal. There is abnormal septal\nmotion/position. The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation. There is no aortic valve\nstenosis. The mitral valve appears structurally normal with trivial mitral\nregurgitation. The left ventricular inflow pattern suggests impaired\nrelaxation. There is moderate pulmonary artery systolic hypertension. There is\nno pericardial effusion.\n\nIMPRESSION: Probably normal LV systolic function (due to poor imager quality,\na regional wall motion abnormality cannot be excluded). Mild to moderate\ntricuspid regurgitation with moderate pulmonary hypertension.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-12-17 00:00:00.000",
"description": "Report",
"row_id": 1363305,
"text": "MICU nursing progress note 7A-12noon\nNeuro - A&O x 3. OOB->chair this AM. Self ADLs. Denies pain. Teaching started re:coumadin. Handout for coumadin and DVT/PE given and reviewed with pt.\n\nResp - Sats high 90s RA. Lungs CTA, diminished at bases. RR teens.\n\nCV - BP 120s-130s/80s. NSR 70s, occ PVC. Magnesium repleted. Cont on heparin 1500U/hr, PTT therapeutic. Coumadin to be increased to 15mg tonight for INR 1.4 this AM. ? whether pt may go home on Lovenox until coumadin therapeutic, team is investigating with pharmacy whether pt will receive adequate coverage d/t obesity.\n\nGI - Abd obese. +BS. Appetite good. FSBS covered by RISS. Also on glyburide and actos.\n\nGU - Voiding QS via foley.\n\nSocial - Pt has had many phone calls, wife in to visit and aware of plan to transfer pt to floor.\n\nPlan - Pt to go to floor today. Coumadin 15mg tonight. ? lovenox, check with team.\n"
},
{
"category": "Radiology",
"chartdate": "2117-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853444,
"text": " 8:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: upright chest look for infiltrate/free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with dyspnea, nausea\n REASON FOR THIS EXAMINATION:\n upright chest look for infiltrate/free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dyspnea, nausea. Evaluate for free air/infiltrates.\n\n PARTIALLY UPRIGHT PORTABLY AP CHEST: No prior studies are available for\n comparison. There is mild cardiomegaly. It is difficult to exclude free air\n on this study due to semi upright technique. No focal consolidations are\n seen. There is likely bibasilar atelectasis.\n\n IMPRESSION:\n Limited secondary to technique. No definite free air is visualized, but if\n there is high clinical suspicion, dedicated radiographs or left\n lateral decubitus films should be obtained. No overt pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-12-14 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 853448,
"text": " 8:33 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: eval for pe or aortic dissection\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with doe and presyncopal episode today\n REASON FOR THIS EXAMINATION:\n eval for pe or aortic dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SADk 9:16 PM\n large bilateral pe in left main and right main and subgemental\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n\n HISTORY: Dyspnea and shortness of breath.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial images through the chest prior to and following\n administration of IV contrast. Axial images with IV contrast were then\n obtained through the abdomen and pelvis. Optiray was administered due to the\n rapid rate of bolus injection needed. Multiplanar reformatted images were\n obtained.\n\n CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There is a large pulmonary\n embolus within the left main pulmonary artery and multiple left segmental and\n subsegmental branches. There is also a large pulmonary embolus in the right\n main pulmonary artery and multiple segmental and subsegmental branches.\n to all lobar pulmonary artery branches. In the right middle lobe, there is a\n more nodular density measuring approximately 7 mm, but this is adjacent to a\n vessel, and not clearly separate from it. In both lower lobes, there are\n peripheral opacities which are more linear as opposed to wedge- shaped, more\n likely atelectasis. The aorta, aortic arch, and pericardium appear normal.\n There is left ventricular enlargement. There are no pathologically enlarged\n axillary, hilar or mediastinal lymph nodes. Further evaluation of lymph\n adenopathy is slightly limited due to body habitus and artifact. The airways\n are patent to the level of the segmental bronchi bilaterally. There are no\n pleural or pericardial effusions.\n\n CT OF THE ABDOMEN WITH CONTRAST: Evaluation is significantly limited due to\n body habitus and artifact. The liver, spleen, adrenal glands, pancreas,\n kidneys are grossly normal. The gallbladder is also grossly normal. There is\n no free air or free fluid in the abdomen. The descending aorta is normal. No\n identified lymph adenopathy. The unopacified large and small bowel are\n grossly normal.\n\n LIMITED CT OF THE PELVIS WITH CONTRAST: The iliac vessels appear normal. No\n evidence of free fluid.\n\n BONE WINDOWS: There are no suspicious osteolytic or sclerotic lesions.\n (Over)\n\n 8:33 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: eval for pe or aortic dissection\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n Extensive degenerative changes about the spine.\n\n REFORMATTED IMAGES: There are large bilateral pulmonary emboli.\n\n SSION: Extensive bilateral pulmonary emboli within the left and right\n pulmonary arteries and multiple subsegmental branches to all lobes.\n 2. No aortic dissection. These findings were discussed with Dr. \n in the emergency department immediate following the study.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-12-16 00:00:00.000",
"description": "Report",
"row_id": 1363303,
"text": "neuro: pt is a&o x3 and oob to chair and able to get up with supervision only min assist. no deficits noted\n\ncard: rat 80's with occasional to freq pvcs. bp 10-118 sys which is lower than pt usual 130-140 sys preadmit. no sob or chest pain. card echo from yest showed no clots but mod pulm htn.\n\nresp: decreased o2 to 2l nc and pt was desating in am on RA but now 93-95 on RA and > 96 with o2 pt remains on 1500 units heparin /hr ptt in theraputic range for 3 draws and not needed til am. coumadin increased to 10 mg\nno sob.\n\ngi: had bm but not tested as on toilet. 2gm na diet. takes good amt of water\n\ngu: output last on toilet approx 200 cc and no output since\n\nendo; on two oral agents and requires insulin coverage for almost every fingerstick. 1700 glu is 179 an covered\n\nactivity:oob to chair and can amb with min assistance to toilet\n\nplan: pt is called out\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-12-17 00:00:00.000",
"description": "Report",
"row_id": 1363304,
"text": "GENERAL: PT IS CALLED OUT TO FLOOR. WAITING FOR BED AVAILABILITY.\n\nNEURO: A&O. SLEPT IN NAPS.\n\nRESP: LUNGS CLEAR BILAT UPPER LOBES, DIM IN THE BASES. PT IS AFEBRILE.\n\nC/V: HR 80'S AND SINUS. OCCASIONAL PVC'S. BP 90'S-120'S/60'S-90'S.\n\nGU/GI: ABD IS OBESE WITH +BS. VOIDS IN SMALL AMOUNTS VIA URINAL. TOLERATING DIET. NO BM.\n\nENDO: FS AT 2200 173 W/2U REG SS INS. HEPARING INFUSING AT 1500U/HR. LABS DRAWN THIS AM.\n\nSOCIAL: BROTHER AND FRIEND VISITED LAST EVENING. PT ANXIOUS TO GET BACK TO WORK.\n\nPLAN: TRANSFER TO FLOOR WHEN BED AVAILABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-12-15 00:00:00.000",
"description": "Report",
"row_id": 1363300,
"text": "NPN 7A-7P ADMISSION NOTE:\n\nPT 59Y/O MALE WHO WAS ADMIT VIA ED WITH DX OF LARAGE BILAT PE LEFT MAIN AND RIGHT MAIN AND SUBGEMENTAL. HE WAS STARTED ON HEPARIN.\nPMH: HTN, DM, MORBID OBSITY, URETUAL STONES S/P LITHOTRIPSY AND STENTS .\nALLERGIES: NKDA\nNEURO: PT A/OX3. ABLE TO MAE.\nRESP: LS DIMINSHED BILAT. O2 SAT 95%-98% ON 3L VIA NC. DENIES SOB.\nPT ON WEIGHT BASED HEPARIN. WEIGHT IN KE 158KG.\nCV:NSR HR 85-90 WITH PVC NOTED. MAG 1.7. MAGNESIUM SULFATE 2G IV X1.\nB/P 120/80-102/70. DENIES CHEST PAIN.\nGI/GU: DIET. +BS NO BM. ABD LARGE AND ROUND SOFT. VOIDING IN URINAL.\nSKIN: INTACT.\nAXCESS: 20G PIV IN BILAT HANDS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-12-15 00:00:00.000",
"description": "Report",
"row_id": 1363301,
"text": "M/SICU NPN FOR 7A-7P: NKDA FULL CODE\n\n PLEASE CAREVUE FLOWSHEET FOR MORE DETAILS\n\nNEURO: AAOX3. PERLA. MAE. DANGLING ON SIDE OF BED TODAY WITH NO C/O DIZZINESS.\n\nRESP: INITIALLY, INCREASED O2 TO 5L NC THIS AM DUE TO DESATURATION WHEN ASLEEP. NOW, ON 3L NC WITH ADEQUATE SATS. RR REGULARE AND UNLABORED. LUNG SOUNDS DIMINSIHED THROUGHOUT DUE TO PTS SIZE AND WT. SOME SOB WITH EXCERTION NOTED. NO COUGH PRESENT.\n\nCV: NSR-ST WITH PVC'S. BP STABLE. AFEBRILE. SOME GENERALIZED DEPENDENT EDEMA NOTED. IV ACCESS IS #20 G RIGHT PIV WITH HEPARIN GTT AT 1500 UNITS/HR. PTT THERAP. X 2 WITH LATEST BEING 64. (GOAL IS TO KEEP PTT 60-100).\n\nGI/GU: + BS. ABD IS OBESE, NON-TENDER. NO BM. VOIDS IN URINAL. ON DIET AND TOLERATING WELL.\n\nENDO: SSI WITH COVERAGE. BG 166-221 FOR MY TIME.\n\nSKIN: NO BREAKDOWN NOTED.\n\nPLAN: CONT. WITH CURRENT PLAN OF CARE. MONITOR PTT LEVEL FREQUENTLY. MONITOR PER PROTOCOL. TX OUT TO TELEMENTRY BED WHEN AVAILABLE. WATCH FOR S/SX'S OF BLEEDING/MORE CLOTS THROWING TO LUNGS, ETC.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-12-16 00:00:00.000",
"description": "Report",
"row_id": 1363302,
"text": "NPN 7P-7A\n\nNEURO: PT A/O X3. DENIES CP/SOB/PALP.\nRESP: LS DIMINSHED BILAT. O2 SAT ON 2L VIA NC 96%.\nCV:NSR WITH PCV NOTED. HR 80'S. B/P DROP WHEN SLEEPING DOWN TO 88/40(65). WHILE AWAKE 117/79.\nGI/GU: DIET. POOR FLUID INTAKE. +BS NO BM. VOIDING IN URINAL 200-300 CC OF DARK YELLOW URINE.\nENDO: FINGER STICKS QID, WITH RSSI. ALSO ON ORAL .\nSKIN: INTACT.\nHEPARIN AT 1500U/HR. LAST PTT 93.4. NO CHANGE. THAT IS THE THIRD PTT WITH IN PROTOCOL LIMIETS.\nPOC: STARTED COUMADIN . START ASA . CALLED OUT.\n\n"
},
{
"category": "ECG",
"chartdate": "2117-12-14 00:00:00.000",
"description": "Report",
"row_id": 122191,
"text": "Sinus tachycardia and occasional ventricular ectopy. Prior inferior myocardial\ninfarction. Delayed precordial progression suggesting prior anterior myocardial\ninfarction. Left anterior fascicular block. Compared to the previous tracing\nof there is frequent ventricular ectopy, the rate has increased,\nnon-specific ST-T wave abnormalities persist and a deep Q wave in lead II is\nnow in evidence. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2117-12-15 00:00:00.000",
"description": "Report",
"row_id": 122190,
"text": "Sinus rhythm with slowing of the rate as compared to the previous tracing\nof . Ventricular ectopy is no longer recorded. There is prior inferior\nmyocardial infarction and probable anterior myocardial infarction as well.\nDiffuse non-specific ST-T wave abnormalities. There is slight Q-T interval\nprolongation. Compared to the previous tracing of ventricular ectopy\nhas abated and the rate has slowed. Otherwise, no diagnostic interim change.\nClinical correlation is suggested.\nTRACING #2\n\n"
}
] |
|
17,298 | 152,745 | A/P: Pt is a yo female with history of hypertension, AF and recent bilateral pulmonary embolism presents with hypoxia * 1. Respiratory Failure: She was originally treated for a CHF exacerbation as with an increased BNP, but with diuresis, there was no noted improvement in her respiratory status, and her creatinine became elevated suggesting she was intravascularly hypovoleimc. On admission to the ICU, she was treated with vancomycin, zosyn, and flagyl for a possible aspiration pneumonia, but was not noted to improve, her severe spinal kyphosis and cardiomegaly likely exacerbated her dyspnea, steroids were later added for a possible COPD component, but she again was noted to have increasing oxygen requirements. A family discussion was held, and the family felt supportive comfort measures were most appropriate, and her oxygenation was maintained with bipap until family could arrive, then she was transitioned to a NRB and a morphine drip and expired. . # PE- No new PE on CTA continued on lovenox treatment dose * # Atrial fibrillation - Patient tachycardic, was maintained on her lopressor and diltiazem, and with IV lopressor when she did not tolerate PO medication * # ARF- This was likely secondary to over diuresis, and CHF, as with an elevated BNP, her creatinine was monitored which continued to rise, even with fluid hydration, she became oligouric at the end of her hospital course. . # Anemia: Stable, likely chronic disease, normocytic . # FEN-soft food, monitor lytes, I/O goal even . Medications on Admission: Bumetanide 2mg QAM Calcium/vit D 500mg Diltiazem CD 240mg QD Protonix Senna Colace Erythromycin oint to left eye at bedtime Lovenox 40mg sc BID Ferrous sulfate 325 Lactobacillilus 1 tab tid 128 q4h while awake Metoprolol 12.5mg Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Respiratory Failure Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None | Flagyl and vanco d/c and zosyn decreased to tid. RECEIVED DULCOLAX PR. Given albuter/atrovent nebs. WITH PULM. MICONAZOLE APPLIED.ID: AFEBRILE. Compared with one day earlier, an NG tube is in place, tip extending beneath diaphragm, off film. DENIES CP.GI: TOL. ASPIRATED. Don't do hospital things".O: For complete VS see CCU flow sheet.ID: Pt remains afebrile with low WBCs. "CV: REMAINS IN A-FIB WITH HR 95-108. ABG 7.35/63/94/36. BP 90-149/58-81. She desats to mid 80s off 02. PH 7.27 DR OF RESULTS. DIURESED ~200CC WITH LASIX.ID: AFEBRILE. Aloe-vest anti-fungal applied and position changed frequently.COMFORT/ACTIVITY: pt denied pain today. Probable mild CHF. O2 SATS DOWN TO 78-85% ( FINGER STAS ARE POSITIONAL) RR-30 COURSE BS NOTED, UPPER AIRWAY WHEEZES. SHE IS ORIENTED X2.GU: POOR U/O PT HAD BEEN ON NS @ 75CC/HR BUT D/CD AFTER RESP EVENTS ABOVE. Again seen is marked cardiomegaly, bibasilar effusions, and underlying collapse and/or consolidation. Breath sounds with upper airway wheezes, diminished aeration. ON IV PIPERACILLIN. CON'T ON LOPRESSOR 25MG AND DILTIAZEM 60MG. settling down briefly ,tolerated for approx. Bipap re started with pt. TACHY TO 130. DISTENDED. GIVEN ADDITIONAL NEBS. NEBS PER RPT WITHOUT EFFECT. BIPAP OFF @ 0300. BS+. CCU NSG NOTE: ALT IN CV/RESPS: "Where am I. Again seen is marked cardiomegaly with an ectatic unfolded aorta. ALB/ATRV NEBS COMPLETED AS ORDERED. BS COURSE. U/O 5-30CC/HR AWAITING AM CREAT. ASP PNA. BS COURSE BILAT. ACUTE EPISODE OF WHEEZING. TRANSFERRED TO CCU AS MICU BORDER FOR POSSIBLE MASK VENT/BIPAP/INTUBATION.NEURO: ORIENTED TO PERSON ONLY. WHILE ON CC7, VOMITTED & ? DR AND IN TO ASSESS PT. TRANSFER TO CCU AS MICU BORDER ON FOR BIPAP TX ASP PNA. Unable to obtain sputum sample.CV: Pt remains in afib with rates 103-140. EDEMA, & AFIB WHO WAS TRANSFERRED FROM REHAB->CC7 FOR HYPOXIA. BIPAP AS TOL. Also again seen are small-to-moderate bilateral pleural effusions, presumably with underlying collapse and/or consolidation. TOL BIPAP X2/HR, DIFFICULT TO OBTAIN SEAL, INTERMITTENTLY PULLING OFF MASK. DILUTIONAL ( PT RECEIVED FLUID BOLUS AND NS GTT OVERNOC FOR LOW U/O)COMFORT: C/O R SHOULDER PAIN FROM ROTATOR CUFF. Resp CareFollowed patient overnight with albuterol/atrovent nebs. She is intermittently more appropriate. PLANS TO VISIT TODAYA/P: YR OLD WITH HX PE, ARRTHYMIAS,PULM EDEMA,A-FIB, INITIALY ADM FROM REHAB TO CC7 FOR HYPOXIA. CONT. CONT. LASIX 20MG IV X1 WITH LITTLE EFFECT. U/O 16-21CC/HR. Sats back in mid -90s. frequently pulls off) Will re attempt non invasive or intubate if needed. HAD STOOL X1 MOD GREEN FORMED GUAIC NEG. SL. VBG AS ORDERED. Lung sounds had wheezes in the apical areas that cleared after treatments. NEED FEEDING TUBEMONITOR FLUID STATUSASP PRECAUTIONSBIPAP PRN Breath sounds decreased aeration with upper airway wheezes. hemodynamically stable.Sats stableP: Monitor for resp instablility. YR. OLD WOMAN WITH HX PE, ARRHYTHMIAS, PULM. ABD. AWAITING AM VBG RESULT.NEURO: HOH, R EAR IS THE BEST. ( WAS 1.8 ON ) URINE IS YELLOW WITH SED NOTEDGI: ASP PRECAUTIONS A MUST. F/U W/ SPUTUM RESULTS. PRN haldol given x1 for agitation c effect.CV- Remains in AF no vea, HR 109-130. Bs expiratory wheezes bilaterally. TOL DILT AND LOPRESSOR WELL.GI: KEPT NPO, NGT PLACED FOR MEDS (PT. Respiratory Care:Patient given Albuterol/Atrovent nebs Q6hr. HAS SINCE PULLED OUT NGT). Spec results pending.ID- Afeb, wbc 3.4 conts on zosyn for asp PNA.GI/GU- Strict asp precautions, tol boost puddings. LS coarse throughout, AM cxr done ? BUN 52 Cre 2.3A/P: Cont plan of care, ? IV ABX FOR PNA. Has a weak non-productive cough, no sputum when sx.ID- Afeb, wbc 5.0, conts on Zosyn for ?asp PNA.GI/GU- Strict Aspiration precautions. ALB/ATR NEBS GIVEN Q6HRS.CV: HR 80-115 AFIB, NO VEA NOTED. Remains on strict asp precautions.CV- Tele Afib, HR 130s->90s p lopressor/dilt doses given with SBPs 150s->98-120. NO TRUE ECTOPY.BP STABLE 116/84.RESP: UPPER RESP W/ COARSE BS CLEARING W/ COUGH. Faint bowel sounds heard.SKIN:- Pressure areas remains inatact, miconazole powder applied to sacral area. Held morning lopressor dose d/t BP parameters. Neb tx's by resp. Nursing Note 7a-7pS: ", the wrong package everyday".O: See careview for complete objective data.Neuro- Responding to vocal , more awake today->no haldol given.Answering yes/no to questions, + visual hallucinations. NBPs 90s-110/58-80. Placed on CPCP w/ improving SATS. Continue with IV antibotics. ASYSTOLIC, PT. Pt in DNR but remain may intubate. REC'D DILT AS ORDERED THIS SHIFT. O2 sats improving and wheezes decreasing over course of shift. Treating imperically for asp pna. C/O SLIGHT RIGHT SHOULDER DISCOMFORT ONLY WHEN REPOSITIONING ( PT. Ventilator D/c'd. Incont of loose OB- stool x1. Venous blood gas PC02 91, Drs' , action taken as within pts baseline. Respiratory therapistBreath sound bilaterally diminished,strong coughs but secretions swallowed, afebrile no WBC normal, remains on high flow neb but FiO2 weaned down to 60%, treated with Albuterol and Atrovent nebs last treatment around 1800 HR was around 120s, will continue to be closely monitored. NBPs 90s-140s/50s-60s, AM lopressor held per parameters, tol Dilt.Resp- Remains on a NRB @ 15L, sats 95-100%. Albuterol/Atrovent neb given without change. LETHARGIC ON ARRIVAL TO CCU, WILL OPEN EYES TO VERBAL COMMANDS. Nursing Note 7a-3pS: "Do it...Do it..."O: See careview for complete objective data.Neuro- Responds to verbal stim, nods to questions, follows commands inconsistantly. Conts with occ full body tremors, HO aware.Resp- Remains on a non-rebreather @ 15L with sats 94-100%. Given prn haldol x1 with good effect. CPAP d/c, placed back on NRB.SATS slowly dropping to 70's. VERY HOH, USES AMPLIFYING DEVICE. SON IN HEALTH CARE PROXY.DISPO: PT. LATEST CREAT 1.7.SKIN: INTACT. CHF VS ASPIRATION/PE. Voiding approx 30cc/hr dyu in foley. Lasix given via RN. RR mid 20's.Plan: Continue with Neb rx's Q6hr, Sxing prn. Apperas slightly oedematus in arms and legs.ID:- A febrile overnight, antibiotics givne as per chart.ENDO:- Is on daily PO steroids, blood sugars within normal limits.FAMILY:- No enquires as yet from family overngiht.PLAN:- To monitor conscious level without giving haloperidol, continue to observe resp staus awaiting sputum culture. | 26 | [
{
"category": "ECG",
"chartdate": "2123-06-23 00:00:00.000",
"description": "Report",
"row_id": 261200,
"text": "Atrial fibrillation\nModest diffuse nonspecific T wave changes\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2123-06-17 00:00:00.000",
"description": "Report",
"row_id": 261201,
"text": "Atrial fibrillation with a rapid ventricular response. Anterior T wave changes\nare non-specific. Repolarization changes may be partly due to rhythm. Compared\nto the previous tracing no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2123-06-17 00:00:00.000",
"description": "Report",
"row_id": 261202,
"text": "Atrial fibrillation with a rapid ventricular response. Anteroseptal T wave\nchanges are non-specific. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-06-24 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 920797,
"text": " 11:48 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval eval\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with afib, hx of PE presenting with hypoxia,\n\n REASON FOR THIS EXAMINATION:\n interval eval\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of patient with hypoxia, known pulmonary\n edema.\n\n Portable AP chest radiograph compared to the previous film done the same day\n earlier at 7:36 a.m.\n\n IMPRESSION: Mild improvement in moderate pulmonary edema. Moderate bilateral\n pleural effusions and bibasilar atelectasis are stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-06-19 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 920216,
"text": " 10:37 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: confirm ngt placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with afib, hx of PE presenting with hypoxia, s/p ngt\n placement\n REASON FOR THIS EXAMINATION:\n confirm ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post NG tube placement.\n\n CHEST, SINGLE VIEW.\n\n Compared with one day earlier, an NG tube is in place, tip extending beneath\n diaphragm, off film. Again seen is marked cardiomegaly, bibasilar effusions,\n and underlying collapse and/or consolidation. Probable mild CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-06-19 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 920187,
"text": " 5:11 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?aspiration\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with afib, hx of PE presenting with hypoxia\n\n REASON FOR THIS EXAMINATION:\n ?aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia, question aspiration.\n\n CHEST, SINGLE AP PORTABLE VIEW:\n\n Compared with earlier the same day, no significant change is detected. Again\n seen is marked cardiomegaly with an ectatic unfolded aorta. Also again seen\n are small-to-moderate bilateral pleural effusions, presumably with underlying\n collapse and/or consolidation. No CHF.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-21 00:00:00.000",
"description": "Report",
"row_id": 1488777,
"text": "CCU NSG NOTE: ALT IN CV/RESP\nS: \"Where am I. Don't do hospital things\".\nO: For complete VS see CCU flow sheet.\nID: Pt remains afebrile with low WBCs. Flagyl and vanco d/c and zosyn decreased to tid. Unable to obtain sputum sample.\nCV: Pt remains in afib with rates 103-140. BP has been stable rangin 102-114/50-60. He received dilt and lopressor and tolerated both.\nRESP: Pt sating 94-98% on 50% cool neb. She desats to mid 80s off 02. She has croupy cough but produced no sputum. She has decreased breath sounds at bases with occasional course breath sounds.\nRENAL: Pt conts to have poor urine output. She received 250 NS bolus at 1530, but output contd ~15 cc/hr. She is 500cc pos for today and ~1600cc pos LOS\nGI: Pt had swallowing study today and was OKd to have pureed food and nector consistency. Med ground and given in applesauce. She ate 2 boost puddings and some ground meat and potatoes today. No BM.\nSKIn: Pt has no breakdown, but coccyx area is very reddened. Aloe-vest anti-fungal applied and position changed frequently.\nCOMFORT/ACTIVITY: pt denied pain today. She was total lift to chair, which she tolerated well.\nMS: Pt alert most of day. She is oriented X 1, unable to remember date or where she is. She is intermittently more appropriate. She recognises family members and asks appropriate questions.\nA: Poor u/o. hemodynamically stable.Sats stable\nP: Monitor for resp instablility. Keep careful I & O. Assist pt with position changes. Monitor skin for breakdown. Give meds ground with pudding or boost puddings.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-22 00:00:00.000",
"description": "Report",
"row_id": 1488778,
"text": " YR. OLD WOMAN WITH HX PE, ARRHYTHMIAS, PULM. EDEMA, & AFIB WHO WAS TRANSFERRED FROM REHAB->CC7 FOR HYPOXIA. S/P FX FEMUR FROM FALL AT HOME, & HAS BEEN REHAB'ING AT REHAB SINCE DISCHARGE. WHILE ON CC7, VOMITTED & ? ASPIRATED. TRANSFERRED TO CCU AS MICU BORDER FOR POSSIBLE MASK VENT/BIPAP/INTUBATION.\n\nNEURO: ORIENTED TO PERSON ONLY. EXTREMELY HOH WITH SEVERELY IMPAIRED VISION.\n\nRESP: O2 SATS 97-100% ON 50% OFT. BS COURSE. C&R THICK YELLOW SPUTUM.\nRR 20-33. ACUTE EPISODE OF WHEEZING. DROPPED SAT 85%. TACHY TO 130. NEBS PER RPT WITHOUT EFFECT. INCREASED O2 TO 95% FM. HO CALLED TO SEE PT. LASIX 20MG IV X1 WITH LITTLE EFFECT. HALDOL 2.5MG VP X1 FOR INCREASED RESTLESSNESS. ABG 7.35/63/94/36. O2 SAT 93-100%. SX FOR MOD AMT THICK YELLOW SPUTUM.\n\nCARDIAC: HR 98-120 AFIB, NO ECTOPY. BP 90-149/58-81. DENIES CP.\n\nGI: TOL. SOFT SOLIDS WITHOUT DIFFICULTY. ABD. SL. DISTENDED. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING YELLOW URINE WITH SEDIMENT. U/O 16-21\nCC/HR. DIURESED ~200CC WITH LASIX.\n\nID: AFEBRILE. CONT. ON IV PIPERACILLIN. VANCO/FLAGGYL D/C'D.\n\nAM LABS PENDING.\n\nPLAN: ATTEMPT TO WEAN O2.\n CONT. WITH PULM. TOILET.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-20 00:00:00.000",
"description": "Report",
"row_id": 1488772,
"text": "Resp Care\nPatient placed on non-nvasive ventilation last evening, poorly tolerated due to discomfort and inability to maintain a good seal with n-g tube in place. Pt intermittently agitated but at times oriented and cooperative. Breath sounds with upper airway wheezes, diminished aeration. Given albuter/atrovent nebs. Strong cough prod. of very thick tan sputum (requires assistance with Yankaur) Initial abgs on floor with pco2>100, repeat down to 85. O2 sats on 50% aerosol 94-96 but drops precipitously when mask is off (pt. frequently pulls off) Will re attempt non invasive or intubate if needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-20 00:00:00.000",
"description": "Report",
"row_id": 1488773,
"text": " YR OLD WOMEN,FX L LEG REHAB SINCE .HX PE,ASP PNA,CHF,UTI,DEMENTIA .ADMITTED FROM FLOOR FOR DESATING TO 79. FOR BIPAP OR POSSIBLE INTUBATION .PT IS INTUBATION ONLY ,NO CPR.\n\nWHY ARE YOU DOING THIS TO ME ,I DONT WANT IT ,I WANT TO GO HOME .\n\nAFIB.TOL DILT AND LOPRESSER.\n\nSATS 97 WITH COOL MIST OPEN FM AT 50%,79 RM AIR.BS JUNKY.C/R YELLOW .\n\nTOOK CARDIAC MEDS C DIFFICULTY.STARTED C THICKENED LIQUIDS.SON INSISTED ON H2O BUT PT .WILL HOLD ALL BUT ESSENTIAL PO MEDS,TO BE GIVEN CRUSHED IN APPLESAUCE.SWALLOW EVAL TOMORROW C FEDDING TUBE .SON STATES PT HAS BEEN VOMITING FOR SEVERAL WEEKS P EATING .PASSING NEG SOFT STOOL.\n\nT 99.8 R.ON ANTIBX\n\nHUO 0 TO 28.LITTLE RESPONSE TO 250CC FLUID BOLLUS,GETTING 75 CC/HR NS.\n\nPT CALM TO AGITATED AT TIMES TAKING OFF 02 MASK .INTERACTING C SONS APPROPRIATELY.PT IS BLIND,VERY HOH,HAS AMPLIFIER ,HEARS BETTER IN R EAR.HAS TORN ROTATER CUFF R ARM,PAINFUL WHEN MOVED.SONS VERY INVOLVED IN CARE,WANT TO BE CALLED CHANGES\n\nPT C ASP PNA/CHF,INTERVACULRLY DRY. NEED FEEDING TUBE\n\nMONITOR FLUID STATUS\nASP PRECAUTIONS\nBIPAP PRN\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-20 00:00:00.000",
"description": "Report",
"row_id": 1488774,
"text": "Respiratory Care\nPt received neb treatments Q6 HRS today. Pt did not require NIV during shift. Lung sounds had wheezes in the apical areas that cleared after treatments. Care plan is to continue neb treatments and will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-21 00:00:00.000",
"description": "Report",
"row_id": 1488775,
"text": "Resp Care\nFollowed patient overnight with albuterol/atrovent nebs. Breath sounds decreased aeration with upper airway wheezes. Generally, sats in mid 90s on 50% face tent. Around 0100 pt became agitated and restless., desaturated to 88, calling out for help. Bipap re started with pt. settling down briefly ,tolerated for approx. 2hrs. Currently back on cool neb, intermittently restless and picking at leads, mask ,etc. Sats back in mid -90s.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-21 00:00:00.000",
"description": "Report",
"row_id": 1488776,
"text": "CCU NPN\n\nS:\" I DON'T WANT TO WEAR THIS MASK..TAKE IT OFF!\"\n\nCV: REMAINS IN A-FIB WITH HR 95-108. CON'T ON LOPRESSOR 25MG AND DILTIAZEM 60MG. SBP 92-107 WITH MAP'S 62-80.\n\nRESP: RECEIVED PT ON 50% OPEN FACE MASK. SATS 96-98%. NON PRODUCTIVE COUGH. C/DB ENCOURAGED, GENTLE CPT DONE. BS COURSE BILAT. ALB/ATRV NEBS COMPLETED AS ORDERED. VBG AS ORDERED. PH 7.27 DR OF RESULTS. RR-20'S APPEARS COMFORTABLE. @ 0045 PT AWOKE AGITATED,PICKING OFF CLOTHS AND PULLING AT LINES AND IV'S. MOANING C/O SOB. O2 SATS DOWN TO 78-85% ( FINGER STAS ARE POSITIONAL) RR-30 COURSE BS NOTED, UPPER AIRWAY WHEEZES. GIVEN ADDITIONAL NEBS. DR AND IN TO ASSESS PT. PT MOANING AND CON'T TO PULL OFF CLOTHS AND AT LEADS AND LINES. HALDOL 2.5MG GIVEN AND PT PLACED ON BIPAP 50%,5,10, CXR COMPLETED. SATS IMPROVING, RR- DOWN TO 20'S PT APPEARS MORE COMFORTBLE. TOL BIPAP X2/HR, DIFFICULT TO OBTAIN SEAL, INTERMITTENTLY PULLING OFF MASK. WRIST RESTRAINT APPLIED FOR SAFETY. BIPAP OFF @ 0300. SATS OVERNOC 98-100% RR-20-24. AWAITING AM VBG RESULT.\n\nNEURO: HOH, R EAR IS THE BEST. USES AMPLIFIER DEVICE. PT IS BLIND IN R EYE, MACULAR DEGENERATION IN L. SHE HAS PERIODS WHERE SHE CONVERSES WITH STAFF AND IS ABLE TO ANSWER QUESTIONS APPROPIATELY. OVER THE EVENING HOWEVER SHE BECAME MORE AGITATED AND UNCOPERATIVE WITH HER CARE. HALDOL IN SMALL DOSES GIVEN 2.5MG WHEN LUCID SHE CAN FOLLOW SIMPLE COMMNADS. MAE. SHE IS ORIENTED X2.\n\nGU: POOR U/O PT HAD BEEN ON NS @ 75CC/HR BUT D/CD AFTER RESP EVENTS ABOVE. U/O 5-30CC/HR AWAITING AM CREAT. ( WAS 1.8 ON ) URINE IS YELLOW WITH SED NOTED\n\nGI: ASP PRECAUTIONS A MUST. PT TAKES HER PILLS CRUSHED WITH APPLESAUCE. PT UNABLE TO TOL THICKET OR THIN LIQS. SHE C/O DIFFICULTY MOVING HER BOWELS. RECEIVED DULCOLAX PR. HAD STOOL X1 MOD GREEN FORMED GUAIC NEG. ABD SOFT + BS\n\nSKIN: HAS PERIANLE YEAST . MICONAZOLE APPLIED.\n\nID: AFEBRILE. ASP PNA. RECEIVING FLAGYL AND ZOYSN AWAITING AM WBC\n\nLABS: AM HCT 25.2 ? DILUTIONAL ( PT RECEIVED FLUID BOLUS AND NS GTT OVERNOC FOR LOW U/O)\n\nCOMFORT: C/O R SHOULDER PAIN FROM ROTATOR CUFF. TYLENOL GIVEN AND REPOSTIONED WITH CARE.\n\nDISPOSITION: INTUBATE ONLY, NO CPR> PT HAS 3 SONS. SON IS HCP AND HAS BEEN VERY ACTIVE IN DECISIONS AND PT CARE. PT'S GRANDAUGHTER CALLED ON EVES. PLANS TO VISIT TODAY\n\nA/P: YR OLD WITH HX PE, ARRTHYMIAS,PULM EDEMA,A-FIB, INITIALY ADM FROM REHAB TO CC7 FOR HYPOXIA. S/P FX FEMUR ON AFTER A FALL AT HOME. WHILE ON CC7 VOMITED AND ASP. TRANSFER TO CCU AS MICU BORDER ON FOR BIPAP TX ASP PNA. CON'T TO FOLLOW RESP STATUS. BIPAP AS TOL. ? SWALLOW STUDY TODAY. UPDATE FAMILY AS NEEDED.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-20 00:00:00.000",
"description": "Report",
"row_id": 1488771,
"text": "nursing progress note 7P-7A\nS: \"WHERE AM I? I DON'T WANT ANY OF THIS\"\n\nO: NEURO: PT. LETHARGIC ON ARRIVAL TO CCU, WILL OPEN EYES TO VERBAL COMMANDS. MOVING ALL EXTREMITIES ON BED. MORE ALERT AS EVENING PROGRESSED. CONVERSING WITH STAFF. AT TIMES CONFUSED TO PERSON, PLACE AND TIME. WRISTS RESTRAINTS ON WHILE PT. ON MASK VENTILATION TO PREVENT PULLING AT LINES/MASK. LATER IN , PT YELLING OUT, SEEMS MORE AGITATED, GIVEN HALDOL 5 MG IVP WITH GOOD EFFECT. SLEPT IN LONG NAPS. NOW AWAKE AND CONT TO PULL AT LINES/O2 MASK.\n\nRESP: ARRIVED ON 50% FM WITH O2 SATS 96%, LUNGS WITH CRACKLES THROUGHOUT. ATTEMPTED MASK VENTILATION. UNABLE TO ACHEIVE GOOD SEAL WITH MASK, PT. MOVING MASK ON FACE. BECOMING MORE AGITATED WHILE ON MASK VENT. PT. PLACED BACK ON 50% FM WITH O2 SATS 95-98%. COUGHING AND RAISING THICK, STICKY YELLOW SPUTUM. ALB/ATR NEBS GIVEN Q6HRS.\n\nCV: HR 80-115 AFIB, NO VEA NOTED. TOL DILT AND LOPRESSOR WELL.\n\nGI: KEPT NPO, NGT PLACED FOR MEDS (PT. HAS SINCE PULLED OUT NGT). INC MOD AMT OF GREEN/BROWN STOOL, GUIAC NEG.\n\nGU: FOLEY DRAINING MIN AMT OF URINE ~ 10 CC/HR. LATEST CREAT 1.7.\n\nSKIN: INTACT. C/O SLIGHT RIGHT SHOULDER DISCOMFORT ONLY WHEN REPOSITIONING ( PT. WITH ? TORN ROTATOR CUFF AS REPORTED BY SON).\n\nPT. VERY HOH, USES AMPLIFYING DEVICE. PT. BLIND IN LEFT EYE AND HAS MACULAR DEGENERATION IN RIGHT EYE.\n\nSOCIAL: RESIDES AT REHAB AT PRESENT, WIDOWED, HAS 3 SONS WHO ARE VERY INVOLVED IN MOTHER'S CARE. SON IN HEALTH CARE PROXY.\n\nDISPO: PT. IS DNR WITH EXCEPTION TO INTUBATE IS NECCESSARY.\n\nA: ADMITTED TO CCU (MICU BORDER) FOR RESP DISTRESS, ? CHF VS ASPIRATION/PE. MONITOR LABS LYTES, I/O,O2 SATS. MASK VENT IF NECCESSARY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-22 00:00:00.000",
"description": "Report",
"row_id": 1488779,
"text": "Respiratory Care:\n\nPatient given Albuterol/Atrovent nebs Q6hr. Pt. desating to mid 80's on 50% cool mist. Fio2 increased to 95% via HFN. Bs expiratory wheezes bilaterally. Albuterol/Atrovent neb given without change. Lasix given via RN. O2 sats improving and wheezes decreasing over course of shift. NIV not required this shift. Congested cough. Sx'd orally for moderate amount of thick yellow secretions. Ventilator D/c'd. O2 sats 96-97%. RR mid 20's.\nPlan: Continue with Neb rx's Q6hr, Sxing prn. Wean Fio2 as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-22 00:00:00.000",
"description": "Report",
"row_id": 1488780,
"text": "Nursing Note 7a-3p\nS: \"Do it...Do it...\"\nO: See careview for complete objective data.\nNeuro- Responds to verbal stim, nods to questions, follows commands inconsistantly. Very HOH, conts using a hearing device until her hearing aide is repaired. PRN haldol given x1 for agitation c effect.\nCV- Remains in AF no vea, HR 109-130. NBPs 90s-110/58-80. Held morning lopressor dose d/t BP parameters. +DP/PTs by doppler.\nResp- Remains on FM ventilation, Fi02 weaned to 50% but became tachy in 30s, Sats <92%. Returned to 60%, sats holding >95%. Has a weak non-productive cough, no sputum when sx.\nID- Afeb, wbc 5.0, conts on Zosyn for ?asp PNA.\nGI/GU- Strict Aspiration precautions. Thick-it all liqs, tol boost puddings. Abd soft +bs, incont sm amt of soft brown stool. Voiding approx 30cc/hr dyu in foley. Given 250cc NS x1. BUN 52 Cre 2.3\nA/P: Cont plan of care, ? family meeting tonight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-22 00:00:00.000",
"description": "Report",
"row_id": 1488781,
"text": "Respiratory therapist\nBreath sound bilaterally diminished,strong coughs but secretions swallowed, afebrile no WBC normal, remains on high flow neb but FiO2 weaned down to 60%, treated with Albuterol and Atrovent nebs last treatment around 1800 HR was around 120s, will continue to be closely monitored.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-22 00:00:00.000",
"description": "Report",
"row_id": 1488782,
"text": "CCU NPN 3-11PM\nS: \"end this game now\"\nO:Neuro: pt alert at times, occ answers questions clearly, othertimes voice faint and incomprehensible, knew she was at the > Sleeping much of the time, has periods of increased agitation, pulling off mask. Recognized daughter in law when she visited this eve, minimal conversation but did respond to her.\n\nResp: LS with exp wheezes thoughout, junky cough, enc to C&DB, able to bring sputum to mouth x1, suctioned out with yankar, thick pale greenish in color. Neb tx's by resp. Sats 90-100% on 80% high flow mask. (sats at higher level when sleeping and relaxed)\n\nCV: HR 107-125 a.fib, on dilt po (took crushed in applesauce)\nBP 97-123/60-70. Given 250cc NS bolus this afternoon with little change in UO ~20cc/hr. Is even for the day, positve 1600cc LOS(CCU)\n\nGI: able to take boost pudding and some applesauce, nectar consis apple without sign of aspiration. No stool this eve.\n\nSoc: son in, feels combination of lasix and lopressor was what made mother ill. feels that she should be able to get back to her previous level of functioning. Plan for family meeting with all her sons tomorrow at 3PM to discuss further plan of care.\n\nSkin: intact.\n\nID: afebrile, cont on zosyn.\n\nA/P: frail yr old with h/o pe on lovenox, failure to thrive since fx leg, transferred to ccu on sunday for resp distress, on bipap breifly though not tolerated well by her. Treating imperically for asp pna. Pt in DNR but remain may intubate. Plan for family meeting tomorrow to furter discuss plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-25 00:00:00.000",
"description": "Report",
"row_id": 1488789,
"text": "MICU NPN\nPt's SATS dropping to 70's on 100% NRB. Placed on CPCP w/ improving SATS. Arousable only to painful stimuli. MD met with family and decision made to make CMO. CPAP d/c, placed back on NRB.SATS slowly dropping to 70's. Morphine gtt at 1 mg/hr,started at 1600. Family has been with patient all afternoon.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-25 00:00:00.000",
"description": "Report",
"row_id": 1488790,
"text": "PT. FOUND WITH HR 35 ON ROUNDS. (PT. CMO). FAMILY PRESENT WITH PT. MSO4 GTT INCREASED TO 3 MG/HR. REPOSITIONED FOR COMFORT. RR 5, ON 100% NRB. PT. ASYSTOLIC, PT. EXPIRED. DR. NOTIFIED. COMFORT PROVIDED TO MANY FAMILY MEMBERS WHO WERE AT BEDSIDE.\nBELONGINGS SENT HOME WITH SON .\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-23 00:00:00.000",
"description": "Report",
"row_id": 1488783,
"text": "CCU NPN 1900-0700\n Y/O FEMALE S/P ASPIRATION W/ PNA.\n\nS/O: SEE CARVUE FOR COMPLETE OBJ DATA.\nNEURO: PT VERY HARD OF HEARING. MAE ON BED. PURPOSEFUL REACHING FOR FACE MASK. ? LEVEL OF ORIENTATION, DIFFICULT TO ASSESS.\n\nCV: AFIB HR > 100. REC'D DILT AS ORDERED THIS SHIFT. NO TRUE ECTOPY.\nBP STABLE 116/84.\n\nRESP: UPPER RESP W/ COARSE BS CLEARING W/ COUGH. NT SXN'D X'S 2 OVER NIGHT. ORAL SUCTION MORE EFFECTIVE, PT ABLE TO COUGH UP SECRETIONS WHEN STIMULATED. SPEC SENT, THICK TAN SECRETION. O2 SAT DROPPING INTO 80'S EARLY IN SHIFT. IMPROVED TO MID- 90'S, CURRENTLY ON HIGH FLOW NEB 15L, 80%. VENOUS GAS 7.24 CO2 38. NEBS GIVEN Q6HR.\n\nGI:INCONT OF LOOSE BROWN STOOL W/ TURNING/REPOSTIONING. ASPIRATION PREC'S MAINTAINED. TOOK PILLS CRUSHED W/ APPLESAUCE.\n\nGU: CREAT 2.3 BUN 53. MIN U/O 10-20 CC'HR. URINE AMBER COLORED.\n\nSKIN: RASH TO PERINEUM\n\nA/P:RESP STATUS TENUOUS, NT/ORAL SXN AS NEEDED W/ DROP IN O2 SAT'S.\nCARDIAC MEDS FOR RATE CONTROL. IV ABX FOR PNA. F/U W/ SPUTUM RESULTS.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-23 00:00:00.000",
"description": "Report",
"row_id": 1488784,
"text": "Nursing Note 7a-7p\n Pt responding to vocal stimulus, answers with a yes/no to questions. C/o back discomfort relieved with repositioning. Hearing aide in R ear, opens eyes on command. Given prn haldol x1 with good effect. Family visited & had meeting with team to discuss POC, no changes made thus far.\nCV- AF rare PVCs, HR 90s-130s. NBPs 90s-140s/50s-60s, AM lopressor held per parameters, tol Dilt.\nResp- Remains on a NRB @ 15L, sats 95-100%. Sx x2 nasal+oral for mod amts thick tan sputum. Spec results pending.\nID- Afeb, wbc 3.4 conts on zosyn for asp PNA.\nGI/GU- Strict asp precautions, tol boost puddings. Incont of loose OB- stool x1. Voiding 15-25cc/hr dyu, 500cc NS bolus given with little effect. I+O +2400 LOS.\nSkin- Coccyx/perineum rash resolving.\nA/P: yo female tnsf to CCU for management hypoxia/asp PNA. Family met with team to discuss POC, no changes as yet. Cont plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-24 00:00:00.000",
"description": "Report",
"row_id": 1488785,
"text": "CCU Progress note 1900-0700\nRESP:- Initially on NRB mask at 15 litres, sa02 100%, therefore changed to normal facemask and oxygen weaned down to 10 litres, Sa02 remain 100, RR 16-22 and regular. Venous blood gas PC02 91, Drs' , action taken as within pts baseline. Bilateral air entry heard to all lungfields, but diminished at the bases. Not coughed/required suctioning as yet overnight.\n\nCV:- Moniotred in A-fib overnight, rate 109-140. Given 2x 2.5mg IVP metoprolol, with good effect, did become slightly hypotensive post bolus, but recovered. SBP 89-150, MAP 60-80 overnight. Peripherally warm to touch. Given 500cc fluid bolus over 60 min, to help urine output, no change. AM labs sent awaiting results.\n\nNEURO:- HAs apperaed very sleepy overnight, only really waking on cares and interventions, therefore not given further haloperidol. Has had periods of calling out and saying \"I do'nt want this\", given reassurance.\n\nGU:- Foley catheter continues to drain small amounts 10-20cc/hr, given 500cc fluid bolus with little effect. Foley catheter flushed with 20cc NS. Draining clear/cloudy yellow urine.\n\nGI:- Abdomen soft and distended. Not given anything orally overnight as too sleepy to risk aspiration. Bowels open small amount, soft brown stool. Fiant bowel sounds herad.\n\nACCESS:- Has the oner peripheral IV in rt Ac, patent able to draw labs from line.\n\nSKIN:- Nursed on Lt side and back overnight. Pressure areas remain intact, barrier cream applied to sacral area and heels. Apperas slightly oedematus in arms and legs.\n\nID:- A febrile overnight, antibiotics givne as per chart.\n\nENDO:- Is on daily PO steroids, blood sugars within normal limits.\n\nFAMILY:- No enquires as yet from family overngiht.\n\nPLAN:- To monitor conscious level without giving haloperidol, continue to observe resp staus awaiting sputum culture. To continue to carryout skin care. To continue to give full explination of care to Mrs and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-24 00:00:00.000",
"description": "Report",
"row_id": 1488786,
"text": "Nursing Note 7a-7p\nS: \", the wrong package everyday\".\nO: See careview for complete objective data.\nNeuro- Responding to vocal , more awake today->no haldol given.\nAnswering yes/no to questions, + visual hallucinations. No c/o pain, sob. Conts with occ full body tremors, HO aware.\nResp- Remains on a non-rebreather @ 15L with sats 94-100%. Sx x2 sm/mod amts of thick tan sputum. LS coarse throughout, AM cxr done ? results. Remains on strict asp precautions.\nCV- Tele Afib, HR 130s->90s p lopressor/dilt doses given with SBPs 150s->98-120. +DP/PTs by doppler.\nGI/GU- Tol boost puddings/applesauce for meals, no aspirating noted. Urine op remains poor, 250cc bolus x1 given with no effect. +3L LOS.\nID- Afebrile, conts on Zosyn for asp PNA.\nA/P: yo female tx for asp PNA/hypoxia. Cont plan of care, support family members.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-25 00:00:00.000",
"description": "Report",
"row_id": 1488787,
"text": "CCU prgress note 1900-0700\nRESP:- Remains on NRB mask at 15 litres, Sa02 89-96%, de-saturated to 87-89 so suctioned for small amount of yellow sputum, weak cough, sa02 improved to 93-94%. RR 24 and regular, dose increase on cares' and interventions. Bilateral air entry heard to all lungfields, but diminished at the bases.\n\nCV:- HR better controlled to night, monitored in A-fib rate 96-110s' no PVC/PACs' noted. BP 96-110 overnight, taken PO metoprolol without problems. Peripherally warm to touch. Am labs to be sent at 6am.\n\nNEURO:- Slightly more awake than previous nights, but remains very sleepy, not given any Haldol inview of this. Rosued by voice and cares and will open eyes when encouraged. Moves arms mainly, minimal movement form lower limbs. Appears confused at times reaching out at things mid air and picking at bedding, and mumbling.\n\nGU:- Urine output poor overnight, 10-20cc/hr, draining yellow slightly cloudy urine. Given 250cc fluid bolus with little effect.\n\nGI:- Tollerated PO meds with applesauce and pudding well, followed aspiration precautions. Abdomen remains soft and distended. Bowels not yet moved overnight. Faint bowel sounds heard.\n\nSKIN:- Pressure areas remains inatact, miconazole powder applied to sacral area. Nursed on Lt side and back (cannot lay on rt side due to shoulder injury). Full bedbath and sheet change given prior to settling.\n\nACCESS:- Has x1 peripheral IV, patent and able to draw blood from it.\n\nID:- Afebrile overnight, suctioned for small amount of thickish yellow secretions, still awaiting sputum culture. No other signs of infection. Antibiotics given as per chart.\n\nENDO:- On daily PO steroids, not on insulin sliding scale.\n\nFAMILY:- Visited by son and friends evening, no other enquires as yet overngiht.\n\nPLAN:- DNR but can be intubated if needed, to continue to attempt to wean down oxygen therapy as per Sa02. Moniotor swallow and follow aspiration precautions. Continue with IV antibotics. To continue to give full explination of care to Mrs and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-06-25 00:00:00.000",
"description": "Report",
"row_id": 1488788,
"text": "Pt placed on NIV 100% 20/5 for desats and increased WOB. Pt quite uncomfortable and NIV withdrawn per family - pt now CMO. Holding nebs due to tachycardia - rate 140. BS coarse crackles.\n"
}
] |
70,433 | 181,971 | 74 y/o F w/ PMH of htn, ETOH, who is admittted with pancreatic duct calcification for ERCP # Pancreatitis- Secondary to pancreatic calcification (?calcified stone) blocking pancreatic duct. Plan for ERCP pending bowel rest, pain control. No fever, leukocytosis. Hold off on abx. - pain control w/ morphine pca - NPO/IVF hydration - ERCP recs, Dr. to see. - check calcium (10.2 at OSH), triglycerides - trend amylase/lipase # Htn- ca channel blocker if needed, currently normotensive #PPx- hep SQ, PPI # FEN- 7-10lb wt loss, intolerant of POs. nutrition consult for TPN; PPN for now. PICC request, TPN started on and has continued until discharge.Plan is for 2 months of TPN # Code- Full = = = = = = = = = = = = = = = = = ================================================================ She then went to the OR on for: Laparoscopic cholecystectomy with cholangiogram. | INDICATION: Right carotid endarterectomy with shortness of breath. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum and bladder are within normal limits. Note is made of mild intrahepatic biliary dilatation. The central venous line was removed, and pressure held until hemostasis was achieved. The uterus and left adnexa are within normal limits. TECHNIQUE: Non-contrast MDCT acquired axial images of the abdomen followed by contrast-enhanced axial images of the abdomen and pelvis from the lung bases to the pubic symphysis. The mediastinal contours are unchanged including the tortuous descending aorta. Newly occurred very small opacity in the region of the costophrenic angle, right, corresponding to a minimal pleural effusion. for change FINAL REPORT REASON FOR EXAMINATION: Dyspnea. The right PICC and left subclavian central venous catheter are unchanged in position. The catheter is in regular position, the tip is located 1.0 to 2.0 cm distally to the venous confluence, towards the lateral aspect of the superior vena cava. There is a small hiatal hernia. Subcentimeter hepatic cyst in the right hepatic lobe. IMPRESSION: Mild new vascular engorgement/ mild failure in a patient with extensive atherosclerosis and moderate cardiomegaly. RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: scale and Doppler son of the right internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. MRA CIRCLE OF : The left vertebral artery is dominant with a diminutive right vertebral artery. REPORT: There is normal compressibility, augmentation, and respiratory variation in the deep veins of the right upper extremity. IMPRESSION: Post-interventional left-sided pneumothorax without diaphragmatic depression and without mediastinal shift. Focal chronic dissections are present within the distal thoracic aorta and mid abdominal aorta. The spleen, adrenal glands, and left kidney are within normal limits. Note is made of some mild upper lobe fullness consistent with some pulmonary edema. In addition, there is a single, small intimal flap located within the descending thoracic aorta (image 84), located laterally which represents a small type B dissection. MRA NECK: There is a diminutive right vertebral artery. CT OF THE ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: The lung bases are clear. (Over) 9:59 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: please evaluate for aortic dissection Admitting Diagnosis: PANCREATITIS Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) MRI/MRA brain and MRA neck to evaluate cerebral vasculature No contraindications for IV contrast FINAL REPORT INDICATION: Right-sided weakness status post laparoscopic cholecystectomy. There is a trivial/physiologic pericardialeffusion. Normal ascending aorta diameter. Abnormal septalmotion/position.AORTA: Normal aortic diameter at the sinus level. Normal main PA. No Doppler evidence for PDAPERICARDIUM: Trivial/physiologic pericardial effusion. Normal aortic arch diameter. Trivial mitral regurgitation is seen. No MR. LVinflow pattern c/w impaired relaxation.TRICUSPID VALVE: Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. False LV tendon (normal variant). No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild ST-T waveabnormalities. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Mild mitralannular calcification. Mild mitralannular calcification. Normaltricuspid valve supporting structures. Mildly dilated ascending aorta. No PR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.Conclusions:The left atrium is normal in size. IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Right PIC line goes up into the neck and out of view. Left atrial enlargement. Left atrial abnormality. Mildly thickened aortic valveleaflets. There is an anterior space which most likely represents a fatpad.IMPRESSION: No intracardiac source of embolism identified. Focal calcifications inascending aorta. Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. Source of embolism.Height: (in) 61Weight (lb): 108BSA (m2): 1.46 m2BP (mm Hg): 130/76HR (bpm): 80Status: InpatientDate/Time: at 12:11Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). Right ventricular chamber size and free wall motionare normal. There is an anteriorspace which most likely represents a fat pad, though a loculated anteriorpericardial effusion cannot be excluded.Conclusions:The left atrium is normal in size. Compared to the previous tracingof no significant change.TRACING #1 Theascending aorta is mildly dilated. IMPRESSION: Uncomplicated fluoroscopically guided PICC line repositioning of the right arm. The estimated pulmonary arterysystolic pressure is normal. Mild symmetric leftventricular hypertrophy with preserved biventricular systolic function.Impaired relaxation. Heart size top normal. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Mild thickening of mitral valve chordae. Mild thickening of mitral valve chordae. Left ventricular wall thickness, cavity size andregional/global systolic function are normal (LVEF 70%) There is noventricular septal defect. TECHNIQUE: Non-contrast head CT scan. Compared to the prior tracingof no diagnostic interim change. Consider left atrial abnormality. Right ventricular chamber size and free wall motion are normal. The left ventricularinflow pattern suggests impaired relaxation. There is mild periventricular and subcortical white matter hypodensity, which is consistent with micro vascular ischemia. The other radiographic findings are unchanged. The aortic valve leaflets (3) are mildlythickened but aortic stenosis is not present. Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded. Focal calcifications inaortic root. Focal calcifications inaortic root. Sinus rhythm. Sinus rhythm. | 30 | [
{
"category": "Radiology",
"chartdate": "2119-11-29 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 989621,
"text": " 4:20 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: Assess for thrombus near PICC insertion site\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with 2-lumen PICC 5 Fr placed \n REASON FOR THIS EXAMINATION:\n Assess for thrombus near PICC insertion site\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Duplex ultrasound of right lower upper extremity.\n\n INDICATION: Patient with swelling around PICC insertion site.\n\n TECHNIQUE: Grayscale, color flow, and pulse wave Doppler insonation of the\n upper limb vessels was performed using dynamic compression maneuvers where\n appropriate to assess for vessel patency.\n\n COMPARISONS: The study was compared to .\n\n REPORT:\n\n There is normal compressibility, augmentation, and respiratory variation in\n the deep veins of the right upper extremity. There is no evidence of DVT.\n\n CONCLUSION:\n\n No DVT.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-12-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 990347,
"text": " 1:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please r/o recurrnace of pneumo\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with pneumo s/p pigtail d/c'ed on .\n REASON FOR THIS EXAMINATION:\n please r/o recurrnace of pneumo\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Status post pneumothorax with pigtail removed today. Assess for\n recurrent pneumothorax.\n\n COMPARISON: .\n\n SUPINE AP CHEST: The left pigtail pleural catheter has been removed, and\n there is no evidence of recurrent pneumothorax. The right PICC and left\n subclavian central venous catheter are unchanged in position. Cardiac and\n mediastinal contours are unchanged. Retrocardiac opacity is likely due to\n left lower lobe atelectasis and a small left effusion. Staples overlie the\n right lateral neck.\n\n IMPRESSION: No evidence of recurrent pneumothorax post-pigtail catheter\n removal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-12-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 990110,
"text": " 5:23 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval central line\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman s/p L subclavian central line placement\n REASON FOR THIS EXAMINATION:\n eval central line\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH\n\n Status post placement of a central venous catheter over the left subclavian\n vein. The catheter is in regular position, the tip is located 1.0 to 2.0 cm\n distally to the venous confluence, towards the lateral aspect of the superior\n vena cava. There is a large left-sided pneumothorax with a gap width of 2.0\n cm. No signs of mediastinal deviation, no diaphragmatic depression.\n\n IMPRESSION: Post-interventional left-sided pneumothorax without diaphragmatic\n depression and without mediastinal shift. Regular course and normal position\n of the newly placed central venous access, left. The other radiographic\n findings are unchanged as compared to , at 4:21 p.m.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2119-12-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 989860,
"text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 6AM PLEASE. Eval. for change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL ADDENDUM\n Findings were discussed with Dr. over the phone with Dr. \n at the time of dictation.\n\n\n\n 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 6AM PLEASE. Eval. for change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with dyspnea\n REASON FOR THIS EXAMINATION:\n 6AM PLEASE. Eval. for change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Dyspnea.\n\n Portable AP chest radiograph compared to chest CT from and\n chest radiograph from .\n\n The heart size is mildly enlarged but stable. The mediastinal contours are\n unchanged including the tortuous descending aorta. There is overall increased\n vascular engorgement predominantly in the upper lungs, which might represent\n mild volume overload. There is bibasal crowdness of the vessel, which might\n also be in part explained by vascular engorgement. Small bilateral pleural\n effusion is present.\n\n The right PICC line tip terminates in mid SVC. The patient is after a recent\n surgery in the right upper neck.\n\n IMPRESSION: Mild new vascular engorgement/ mild failure in a patient with\n extensive atherosclerosis and moderate cardiomegaly. Small new pleural\n effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-11-27 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 989237,
"text": " 12:05 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: please evaluate for stroke. MRI/MRA brain and MRA neck to e\n Admitting Diagnosis: PANCREATITIS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with right sided weakness s/p lap chole\n REASON FOR THIS EXAMINATION:\n please evaluate for stroke. MRI/MRA brain and MRA neck to evaluate cerebral\n vasculature\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right-sided weakness status post laparoscopic cholecystectomy.\n Please evaluate for stroke.\n\n COMPARISON: Head CT dated .\n\n TECHNIQUE: Multiplanar T1W, T2W, FLAIR, and diffusion-weighted images of the\n head were obtained. 3D time-of-flight images of the circle of were\n obtained. 2D time-of-flight images of the cervical vessels as well as\n gadolinium-enhanced MRA images were also obtained.\n\n MRI HEAD: There are multiple areas of increased signal on diffusion-weighted\n images, the largest in the left medial frontoparietal lobe, with other smaller\n areas in the right occipital lobe and left cerebellum, and punctate foci in\n the left frontal and parietal lobe with associated hyperintense signal\n abnormality on FLAIR images consistent with acute infarction. There is\n heterogeneity on GRE images in the largest area of infarction in the left\n medial fronto-parietal lobe consistent with blood products.\n There multiple round areas of white matter FLAIR hyperintensity with more\n confluent periventricular FLAIR signal hyperintensity without associated\n abnormality on diffusion-weighted images consistent with chronic small vessel\n ischemia. There is a probable retention cyst in the left maxillary sinus.\n\n MRA CIRCLE OF : The left vertebral artery is dominant with a diminutive\n right vertebral artery. No areas of aneurysmal dilatation are seen. There is\n a fetal-type origin of the left posterior cerebral artery.\n\n MRA NECK: There is a diminutive right vertebral artery. Left vertebral\n artery is patent. There is high-grade stenosis at the origin of the right\n internal carotid artery with another area of high-grade stenosis at the right\n internal carotid artery approximately 2 cm more distal to this area. Both\n distal internal carotid arteries measure 4 mm.\n\n IMPRESSION:\n\n 1. Multiple areas of infarction in the left frontal, left parietal, right\n occipital, and left cerebellum consistent with an embolic etiology. There is\n evidence of hemorrhage in the largest area of infarction. Distribution is\n consistent with a proximal source, including a cardiac source.\n (Over)\n\n 12:05 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: please evaluate for stroke. MRI/MRA brain and MRA neck to e\n Admitting Diagnosis: PANCREATITIS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. High-grade stenosis at the origin of the right internal carotid artery\n with a second area of high-grade stenosis 2 cm distal to this region.\n\n Findings were discussed with Dr. at approximately 6pm on .\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-12-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 990023,
"text": " 4:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out effusion vs. pna\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman s/p R carotid endarterectomy now w/ shortness of breath\n REASON FOR THIS EXAMINATION:\n rule out effusion vs. pna\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Chest x-ray.\n\n INDICATION: Right carotid endarterectomy with shortness of breath. Rule out\n pneumonia.\n\n COMPARISON: Comparison is made with the previous chest radiograph from\n .\n\n FINDINGS: This is a semi-upright portable AP chest radiograph. The heart\n size is enlarged. There is background emphysematous change. Some minimal\n blunting of the left costophrenic angle is noted. A right PICC line is in\n situ the tip of which is seen in the cavoatrial junction. The patient is\n status post recent surgery in the right side of the neck. The aorta is\n tortuous. Note is made of some mild upper lobe fullness consistent with some\n pulmonary edema.\n\n IMPRESSION:\n 1. Slight progression of pulmonary edema in patient with cardiomegaly and\n blunting of the left costophrenic angle.\n 2. Right PICC line the tip of which is located in the cavoatrial junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-12-02 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 990037,
"text": " 6:36 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: RISING RULE OUT COMMON BILE DUCT OBSTRUCTION\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman s/p lap chole w/ rising total bili\n REASON FOR THIS EXAMINATION:\n rule out common bile duct obstruction\n ______________________________________________________________________________\n FINAL REPORT\n\n COMPARISON: CT abdomen, .\n\n COMPARISON: \n\n RIGHT UPPER QUADRANT ULTRASOUND: The patient is status post cholecystectomy.\n The liver is unremarkable without focal or textural abnormalities. There is\n no intra- or extra-hepatic biliary dilatation. The portal vein is patent with\n appropriate hepatopetal flow. Intra-parenchymal and pancreatic ductal\n calcifications are stable.\n\n IMPRESSION:\n 1. No intra-hepatic biliary dilatation.\n 2. Intra-parenchymal and pancreatic ductal calcifications are stable.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-12-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 990126,
"text": " 8:34 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: position and status of PTX\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman s/p chest cathetar placement for PTX\n REASON FOR THIS EXAMINATION:\n position and status of PTX\n ______________________________________________________________________________\n FINAL REPORT\n SEMI-ERECT RADIOGRAPH\n\n Comparison to at 5:35 p.m. In the interval, a chest tube has\n been inserted into the left hemithorax. The previously visible pneumothorax\n has almost completely resolved, the lung is well expanded. No other relevant\n interval changes.\n\n IMPRESSION: After insertion of a chest tube in the left hemithorax, the left\n lung is now completely expanded, the left-sided pneumothorax has completely\n resolved.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2119-12-02 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 990102,
"text": " 4:05 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: infiltrate\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with apnea\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n Comparison to , 4:03 a.m. The central venous catheter is\n still in place. Newly occurred opacity behind the heart, corresponding to\n retrocardiac atelectasis. Newly occurred very small opacity in the region of\n the costophrenic angle, right, corresponding to a minimal pleural effusion.\n otherwise, no interval changes.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2119-12-08 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 991011,
"text": " 3:31 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place today\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt: 10\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with\n REASON FOR THIS EXAMINATION:\n please place today\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old woman requiring TPN.\n\n RADIOLOGISTS: The procedure was performed by Drs. and . Dr.\n , the attending radiologist, was present and supervising throughout.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the left brachial\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copy ultrasound images were obtained before establishing intravenous\n access. A peel-away sheath was then placed over a guidewire and the PICC line\n measuring initially 36 cm in length was placed over the wire. There was a\n left central venous line via an IJ approach already in place. The PICC line\n despite several attempts continually would migrate from the superior vena cava\n into the azygos vein. A shorter as well as a longer PICC length was\n attempted, and none of the lines would remain in the superior vena cava. The\n central venous line was removed, and pressure held until hemostasis was\n achieved. Finally, it was decided to shorten the PICC to 31 cm and place it\n within the left brachiocephalic vein, where it was unable to extend into the\n azygos vein. Position of the catheter was confirmed by a fluoroscopic spot\n film of the chest. The peel-away sheath and guidewire were then removed. The\n catheter was secured to the skin, flushed, and sterile dressing applied. The\n patient tolerated the procedure well. There were no immediate complications.\n\n IMPRESSION: Ultrasound and fluoroscopically guided 5 French double-lumen PICC\n line placement via the left brachial venous approach. Despite multiple\n attempts, the line would not remain in the superior vena cava and continually\n the tip migrated to the azygos vein, therefore, the decision was made to leave\n the tip in the left brachiocephalic vein. Final internal length is 31 cm. The\n line is ready for use. These findings were discussed with at the\n time of the procedure.\n\n\n\n (Over)\n\n 3:31 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place today\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-11-27 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 989218,
"text": " 9:59 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please evaluate for aortic dissection\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with right sided weakness s/p lap chole\n REASON FOR THIS EXAMINATION:\n please evaluate for aortic dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CTA OF CHEST ON \n\n CLINICAL HISTORY: Right-sided weakness, question aortic dissection.\n\n TECHNIQUE: Helical acquisition of CT images performed through the thorax\n during dynamic infusion of 100 cc of intravenous nonionic contrast following\n departmental CTA protocol. Coronal, sagittal, and bilateral oblique reformats\n also provided. No prior studies available for comparison.\n\n FINDINGS: There is extensive atherosclerotic disease with a large amount of\n soft plaque/mural thrombus throughout the aorta which contains multifocal\n small penetrating ulcers. In addition, there is a single, small intimal flap\n located within the descending thoracic aorta (image 84), located laterally\n which represents a small type B dissection. There is no extension to the\n aortic arch or the ascending aorta. The ascending aorta is prominent,\n measuring 3.8 cm at the level of the main pulmonary artery. At this level,\n the descending aorta measures 2.6 cm. There is no pericardial effusion. There\n are dense coronary artery calcifications and calcifications at the aortic\n root.\n\n No discrete focal airspace consolidation is seen, however, there are extensive\n emphysematous changes and regions of air trapping. Small bibasilar pleural\n effusions are noted. No suspicious pulmonary nodules. No pneumothorax.\n Trachea and central airways are patent. No abnormal lymphadenopathy in the\n axillae, mediastinum or hila.\n\n Below the diaphragm, there is limited visualization of the solid organs,\n however, no abnormalities are seen. There is a small hiatal hernia.\n Subcentimeter hepatic cyst in the right hepatic lobe.\n\n IMPRESSION:\n 1. Extensive aortic and great vessel atherosclerosis with mural thrombus,\n multiple small penetrating ulcers and a small type B dissection, which does\n not involve the aortic arch or great vessels.\n 2. Extensive emphysematous changes and small bibasilar effusions. Severe\n coronary artery disease, as evidenced by dense calcifications.\n\n\n (Over)\n\n 9:59 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please evaluate for aortic dissection\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-11-23 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 988793,
"text": " 9:52 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: Look for abscess, necrosis, worsening pancreatitis. Compare\n Admitting Diagnosis: PANCREATITIS\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with pancreatitis from a pancreatic duct stone- now with a\n fever and worsening abdominal pain. Performs a CTA pancreas\n REASON FOR THIS EXAMINATION:\n Look for abscess, necrosis, worsening pancreatitis. Compare to the older CT\n done at hospital that is loaded on PACS.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 74-year-old female with pancreatitis and pancreatic duct\n stone. Patient now with fever and worsening abdominal pain. Evaluate\n pancreas.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast MDCT acquired axial images of the abdomen followed by\n contrast-enhanced axial images of the abdomen and pelvis from the lung bases\n to the pubic symphysis. Multiplanar reformatted images were obtained.\n\n CT OF THE ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: The lung bases are\n clear. The liver demonstrates few subcentimeter hypodensities which are too\n small to characterize. The gallbladder is somewhat distended measuring 5.3 cm\n in diameter. There is mild gallbladder wall edema, pericholecystic fat\n stranding and hyperemia within the adjacent liver parenchyma. Note is made of\n mild intrahepatic biliary dilatation. Common bile duct remains normal in\n caliber without filling defect. A 6-mm pancreatic duct stone is again\n identified within the head of the pancreas with proximal ductal dilatation.\n Mild stranding is seen surrounding the pancreatic head, however, without\n necrosis or pseudocyst.\n\n The spleen, adrenal glands, and left kidney are within normal limits. In the\n right kidney, there is mild cortical thickening involving the lower pole,\n which may be related to prior infection. The intra-abdominal loops of large\n and small bowel maintain a normal caliber without evidence of obstruction.\n\n The abdominal aorta shows extensive mural thrombus and large amount of\n atherosclerotic/ulcerative plaques. Focal chronic dissections are present\n within the distal thoracic aorta and mid abdominal aorta. Tight stenosis is\n noted at the SMA origin, however, remains patent distally. The celiac and \n are normally opacified. No intra- abdominal free air or free fluid is\n identified. Small mesenteric and retroperitoneal lymph nodes are present,\n which do not meet CT criteria for pathologic enlargement.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum and bladder are within\n normal limits. The uterus and left adnexa are within normal limits. The\n right adnexa is not well seen. There is extensive sigmoid diverticulosis\n without evidence of diverticulitis. No free fluid or lymphadenopathy is\n (Over)\n\n 9:52 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: Look for abscess, necrosis, worsening pancreatitis. Compare\n Admitting Diagnosis: PANCREATITIS\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appreciated.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesion is identified.\n\n IMPRESSION:\n 1. Gallbladder is distended with mild edema, pericholecystic fat stranding\n and hyperemia of the adjacent liver parenchyma, which may be seen with acute\n cholecystitis. Recommend HIDA for further evaluaiton.\n\n 2. 6-mm pancreatic duct stone is again identified within the pancreatic head\n with proximal ductal dilatation. Mild pancreatic inflammation is present\n without evidence of necrosis or pseudocyst.\n\n 3. Extensive mural thrombus and large amount of atherosclerotic/ulcerative\n plaques throughout the aorta with small foci of chronic dissection. Tight\n stenosis is seen at the SMA origin, however, remains patent distally.\n\n 4. Sigmoid diverticulosis without evidence of diverticulitis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-11-22 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 988587,
"text": " 4:30 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: LOOK FOR CLOT/PT HAS RT SIDED PICC LINE IN RT ARM REDNESS/R/O CLOT\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with PICC in rt UE and redness, swelling and pain at the\n site.\n REASON FOR THIS EXAMINATION:\n Look for clot\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old female with right upper extremity swelling post-PICC\n line placement. Evaluate for DVT.\n\n No comparison studies.\n\n RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: scale and Doppler son of\n the right internal jugular, subclavian, axillary, brachial, basilic and\n cephalic veins were performed. Normal augmentation, compressibility, flow and\n waveforms are demonstrated. The right PICC is demonstrated within the right\n basilic vein.\n\n IMPRESSION: No evidence of DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-12-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 990217,
"text": " 1:16 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: chest tube to WS; CXR at 1PM \n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with\n REASON FOR THIS EXAMINATION:\n chest tube to WS; CXR at 1PM \n ______________________________________________________________________________\n FINAL REPORT\n Comparison to :50 a.m. The left-sided chest tube and the\n bilateral venous access lines are in unchanged position. Also the other\n radiographic aspects are without relevant changes.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2119-11-24 00:00:00.000",
"description": "CHOLANGIOGRAM,IN OR W FILMS",
"row_id": 988918,
"text": " 8:21 PM\n CHOLANGIOGRAM,IN OR W FILMS Clip # \n Reason: CHOLE\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ? biliary duct dilatation.\n\n There is free passage of contrast into the well-filled biliary ducts without\n calculus or strictures.\n\n IMPRESSION: No filling defects or strictures within the biliary tree.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-11-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 988350,
"text": " 8:34 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check placement of right basilic PICC line 53 cm plea\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with\n REASON FOR THIS EXAMINATION:\n please check placement of right basilic PICC line 53 cm please page IV nurse\n with wet thanks \n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 8:46 A.M. ON .\n\n HISTORY: Right basilic PIC.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Right PIC line goes up into the neck and out of view. Heart size top normal.\n Lungs clear. No pneumothorax, pleural effusion or mediastinal widening,\n suggesting bleeding. There is mediastinal fullness, probably due to an\n enlarged thyroid gland.\n\n The IV nurse to report these findings, as requested.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-11-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 988934,
"text": " 11:47 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for CVA acutely post-op\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with new AMS and rt sided weakness\n REASON FOR THIS EXAMINATION:\n eval for CVA acutely post-op\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old female with new right-sided weakness, evaluate for\n CVA, postop.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: There is no hemorrhage, mass effect, shift of the normally midline\n structures, or major vascular territorial infarct. The -white matter\n differentiation is preserved. There is mild periventricular and subcortical\n white matter hypodensity, which is consistent with micro vascular ischemia.\n Overlying soft tissues and osseous structures are unremarkable. There is a\n left maxillary antral retentions cyst. There are calcifications within the\n left vertebral artery.\n\n IMPRESSION:\n\n 1. No hemorrhage or mass effect.\n\n 2. There is high clinical suspicion for stroke. An MRI with\n diffusion-weighted images would be more sensitive for evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-11-21 00:00:00.000",
"description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE",
"row_id": 988370,
"text": " 10:02 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please repo malpositioned PICC in jugular thanks\n Admitting Diagnosis: PANCREATITIS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with\n REASON FOR THIS EXAMINATION:\n please repo malpositioned PICC in jugular thanks\n ______________________________________________________________________________\n FINAL REPORT\n PICC line repositioning.\n\n INDICATION: Malposition of indwelling PICC line. The procedure was explained\n to the patient. A timeout was performed.\n\n RADIOLOGIST: Drs. and performed the procedure. Dr. , the\n Attending Radiologist, was present and supervised the entire procedure.\n\n TECHNIQUE AND FINDINGS: Initial fluoroscopic image demonstrates tip of\n catheter in jugular vein. Using sterile technique, the indwelling right arm\n PICC line was successfully advanced into the SVC under fluoroscopic guidance.\n The wire was removed. Final position of the catheter was confirmed by\n fluoroscopic spot film of the chest. The catheter was secured to the skin,\n flushed, and a sterile dressing applied. The patient tolerated the procedure\n well. There were no immediate complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line repositioning of\n the right arm. The tip is positioned in the SVC. The line is ready to use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-12-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 990175,
"text": " 7:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with CT placed PTX\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n\n Comparison to . Status post insertion of a left-sided chest\n tube. Unchanged complete expansion of the left lung, no discernible\n pneumothorax left. The other radiographic findings are unchanged.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2119-11-27 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 989209,
"text": " 9:24 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: ? TIA POST OP\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman s/p CCY with ?TIA\n REASON FOR THIS EXAMINATION:\n please r/o stenosis\n ______________________________________________________________________________\n FINAL REPORT\n DUPLEX CAROTID ULTRASOUND\n\n INDICATION: TIA.\n\n FINDINGS: There was considerable atherosclerotic plaque involving the carotid\n arteries bilaterally, right greater than left. On the right, peak velocities\n measured 414/123, 72, 110, and 59 cm/sec respectively in the right mid ICA,\n CCA, ECA, and vertebral arteries. The right ICA/CCA ratio measures 6.75.\n These findings are consistent with a right ICA stenosis in the 80-99% range.\n\n On the left, peak velocities measured 158/46, 68, 110, and 52 cm/sec\n respectively in the left mid ICA, CCA, ECA, and vertebral artery. The left\n ICA/CCA ratio measures 2.38. These findings are consistent with a left ICA\n stenosis in the 60-69% range.\n\n IMPRESSION: Severe right ICA stenosis (80-99%) and moderate left ICA stenosis\n (60-69%). Antegrade flow in both vertebral arteries.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2119-11-30 00:00:00.000",
"description": "Report",
"row_id": 85812,
"text": "PATIENT/TEST INFORMATION:\nIndication: Assess for Clots.\nHeight: (in) 60\nWeight (lb): 110\nBSA (m2): 1.45 m2\nBP (mm Hg): 164/70\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 09:16\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). False LV tendon (normal variant). No resting\nLVOT 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. Normal aortic arch diameter. Focal calcifications in aortic\narch.\n\nAORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR. Prolonged (>250ms) transmitral E-wave\ndecel time. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. There is an anterior\nspace which most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF 70%) There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. There are focal calcifications in the aortic arch. The number of\naortic valve leaflets cannot be determined. The aortic valve leaflets are\nmildly thickened. There is no aortic valve stenosis. No aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. Trivial mitral regurgitation is seen. The left ventricular\ninflow pattern suggests impaired relaxation. The estimated pulmonary artery\nsystolic pressure is normal. There is a trivial/physiologic pericardial\neffusion. There is an anterior space which most likely represents a fat pad.\n\nCompared with the findings of the prior study (images reviewed) of , the findings are similar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2119-11-28 00:00:00.000",
"description": "Report",
"row_id": 85813,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Source of embolism.\nHeight: (in) 61\nWeight (lb): 108\nBSA (m2): 1.46 m2\nBP (mm Hg): 130/76\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 12:11\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and 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. Abnormal septal\nmotion/position.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. No MR. LV\ninflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. No PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Right ventricular chamber size and free wall motion are normal. The\nascending aorta 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. No mitral regurgitation is seen. The left ventricular inflow pattern\nsuggests impaired relaxation. The pulmonary artery systolic pressure could not\nbe determined. There is an anterior space which most likely represents a fat\npad.\n\nIMPRESSION: No intracardiac source of embolism identified. Mild symmetric left\nventricular hypertrophy with preserved biventricular systolic function.\nImpaired relaxation. Mildly dilated ascending aorta.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2119-11-24 00:00:00.000",
"description": "Report",
"row_id": 219776,
"text": "Sinus rhythm. Left atrial enlargement. Compared to the prior tracing\nof no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-11-24 00:00:00.000",
"description": "Report",
"row_id": 219777,
"text": "Sinus rhythm. Early transition. No previous tracing available for comparison.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2119-12-06 00:00:00.000",
"description": "Report",
"row_id": 219770,
"text": "Sinus rhythm. Consider left atrial abnormality. Mild ST-T wave\nabnormalities. Since the previous tracing of probably\nno significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-12-05 00:00:00.000",
"description": "Report",
"row_id": 219771,
"text": "Sinus rhythm\nProbable left atrial abnormality\nNonspecific ST-T abnormalities - unstable baseline in precordial leads makes\nassessment difficult\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2119-12-04 00:00:00.000",
"description": "Report",
"row_id": 219772,
"text": "Sinus rhythm. Compared to the previous tracing shaky baseline in lead V2 does\nnot permit comparison. However, lead VI remains with ST segment elevations.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2119-12-04 00:00:00.000",
"description": "Report",
"row_id": 219773,
"text": "Sinus rhythm. Compared to the previous tracing ST segments are now elevated\nin leads VI-V2 suggesting possibility of anterior current of injury. Clinical\ncorrelation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2119-12-02 00:00:00.000",
"description": "Report",
"row_id": 219774,
"text": "Sinus rhythm. Compared to the previous tracing no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2119-12-01 00:00:00.000",
"description": "Report",
"row_id": 219775,
"text": "Sinus rhythm. Left atrial abnormality. Compared to the previous tracing\nof no significant change.\nTRACING #1\n\n"
}
] |
31,165 | 191,746 | The patient was admitted on . She was made NPO, a nasogastric tube was placed for decompression, and IV fluids were started. . -PICC line placed, TPN started due to profound malnourishement. Heme/Onco team was consulted, and evaluated patient on for pancytopenia. . -continued with TPN, NGT, IVF . -After failing to resolve the obstruction conservatively, the patient was taken to the operating room where a laparotomy, lysis of adhesions, and 25 cm small bowel resection were performed. A nasogastric tube remained, a JP was placed intraoperatively, pain pump subcutaneously for pain relief, dilaudid PCA for pain, and IV fluids for rescucitation were given. . -POD1-continued TPN and IV fluids, NG tube remained in place, continued monitoring on the floor. Required 1 liter of fluid bolus for marginal urine output. Urine output stabilized in the evening. NGT removed today, but remained NPO. . -POD2-continued TPN and IV fluids. Started with sips of clears. Foley was removed. She was able to urinate without difficulty. She ambulates with assist. Feels & appears weak. SBP-80-90 with some complaints of feeling dizzy. Physical therapy consulted. Her HCT dropped from 30 to 20%. She was repleted with 2 units of PRBC. . -POD3-Increased JP bulb drain output- fluid dark red in color, previously more serosanguinous. . -POD4-Nursing staff reported mental status changes resulting in a trigger. EKG revealed changes consistent with possible pulmonary embolism. CTA ordered which ruled out PE, but considerable for either hemmorhage or pulmonary edema. Due to patient's change in status, she was transferred to Trauma ICU for closer monitoring. . -ICU: Intubated due to progressive desaturation and tachypenia related to pulmonary edema & bilateral pulmonary infiltrates. Patient aggressively diuresed. Vasopressors initiated for decrease in blood pressure with adequate response. Central line inserted at bedside. Respiratory status monitored . -ICU: Continued with respiratory decompensation, remained intubated. New GNR in blood cx from -continues with vancomycin, levofloxacin, flagyl, & fluconazole. Urology consulted. Surgical intervetion not indicated due to patient's compromised respiratory status. Right nephrostomy tube inserted per Urology recommendations due to hydronephrosis, and fluid volume overload. Vasopressors & sedation weaned as tolerated. . -ICU: pain pump site erythematous & fluctuant. Patient pre-medicated. Site opened at bedside, pus-like exudate expressed from site. Culture sent. Continued to wean pressors and sedation as tolerated. Labwork notable for mild thrombocytopenia-HIT panel sent, and positive. All heparin products discontinued. Culture data followed. Continued with IV antibiotics for sepsis and TPN for severe malnutrition. Nutrition and Physical Therapy consulted. Albumin started for intravascular depletion. Extubated on -respiratory status stablized. Midline abdominal incision opened at bedside due to erythema. Proximal wound with visible small loop of bowel. Areas packed with W-D dressing. Vacuum dressing applied on at bedside. Patient's general status stabilized. . : Transferred back to . Fluconazole discontinued, other antibiotics & albumin continued. Mental status with mild confusion-A/Ox2-3. Bed alarm set & other safety precautions initiated. Started on a Regular diet with supplements. Calorie counts. Vacuum dressing continued. . : AVSS, afebrile. TPN weaned and discontinued. Tolerating regular high protein diet with Ensure supplements. Continued with Vac dressing to abdominal incision, changed every 3 days. Site improving, CDI. Continues with IV Vancomycin & Zosyn to treat both bacteremia and enterococcus growth in urine both cultures from . Right nephrostomy remains patent with clear, yellow urine. Right Abdominal JP drain continues to drain moderate amounts of serous fluid. Check weekly creatinine levels. old Bupivicaine subcutaneous pump site-continues with W-D packings. Site healing with decreased erythema. Evaluated per Physical & Occupational therapy. Ambulates with assist. Physical condition decompensated due to prolonged malnourishment. She will benefit from aggressive physical therapy, nutrition, and wound assessment & management. . UROLOGY: She will need to make an appointment to have right nephrosotomy replaced in 1 month, and then follow-up with Dr. for further management. | The nasogastric tube has been removed in the interval, the two central venous access lines persist. Right IJ and right subclavian central venous catheters terminate in the distal superior vena cava.There is unchanged upper lobe opacity. Findings consistent with small bowel obstruction with a transition point at the anastomotic site in the pelvis. FINDINGS: There is a right-sided infusion port which terminates in the distal superior vena cava. New moderate right-sided hydronephrosis and hydroureter to the level of the sacral promontory, beyond which point the ureter is not seen. A short-term abdominal radiograph can be obtained. FINDINGS: In comparison to previous examination, the endotracheal tube has been removed. Right-sided hydronephrosis and hydroureter with nephrostomy catheter in place. The rectum and distal colon are decompressed, as is the bladder by a Foley catheter. Imaged portion of the heart and pericardium appear within normal limits. SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPH: Contrast is seen in the decompressed large bowel. Progression of pneumoperitoneum, both free and loculated in a lower abdominal/pelvic collection with rim enhancement. Left hemidiaphragm is slightly elevated with an air-filled loop of colon just below it. There is retained barium in the colon which on the single cross-sectional slice shows significant artifact. Small and large bowel dilatation, with an appearance more suggestive of ileus. The pre-existing intraparenchymal opacities that are slightly more extensive in the left than in the right lung are unchanged. There is right hydronephrosis and a dilated ureter. There is a small amount of free air under the diaphragm consistent with recent surgical history. Significant bowel dilatation, better appreciated on recent prior CT examinations. TECHNIQUE: MDCT images of the chest were obtained both without and with 70 cc of nonionic intravenous Optiray contrast. (Over) 7:05 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: ?PE Admitting Diagnosis: BOWEL OBSTRUCTION Contrast: OPTIRAY Amt: 70 FINAL REPORT (Cont) TAKEN TO CT TO R/O PE WHICH WAS -, BUT BILAT INFILTRATES NOTED. need to replace CL.resp- lung sounds clear. PALP PULSES, VENODYNNES. PT ON VANCO TID WITH LEVEL FOR THIS A.M., RESTARTED ZOSYN , FLUCONAZO FOLLOWS COMMANDS, MAE'S.CV: TACHYCARDIC MOST OF NOC. ET tube re-taped. Pepcid for prophylaxis.GU: foley patent draining approx. TPN infusing. See Carevue for details.ID: WBCs coming down, afebrile. On fluc, vanco, levoquin, flagyl. Lytes pending.Endo: BS covered per sliding scale.ID: tmax 98.8; conts. TAPER OF ATIVAN. Wean levophed as pt tolerates. Zosyn d/c'd. on pepcid. wean levo and vent as tol. Cont vent wean. LEVO AND FLAGYL D/C'D. wound cx sent. K/MAG/CALACCESS: PT WITH RIGHT IJ/RIGHT PAC. CONT TPN. Pt with RIJ/Right POC for central access.Resp: LS clr. De-access POC when able. lap with resection , perc. JP drainage sent for creatine. PB's for DVT prophylaxis.Heme: hct 28.4 this am.Access: L radial a-line and RIJ TLCL wnl. on ativan PRN. ?R/T PAIN VS UNDER RESUSCITATION. biloius output. POC conts. Conts. SEE CAREVUE FOR SERIAL VS.R: LUNGS CLEAR BILAT AND DIM AT BASES. FINAL REPORT INDICATION: ET tube placement. START OF BOWEL REGIMEN. mod amt serosang drainage. CONT ANBX ? SURVEILANCE BLD CULT PENDINGLYTES: REPLETED PER ORDERS. MONITOR U/O. Gas's adeq. Palpable pulses, venodynnes on. Monitor u/o from nephrostomy and foley. Cont tpn, npo. Inc. sm. CXR x2 done (desat, new CVL placement).GI: Abdomen softly distended, hypoactive BS, no BM. with obvious edema.GI: Belly slightly distended. Affect/questions appropriate, emotional support provided.A: 59yo s/p exp. Creatinine sent on JP fluid- value: 112. Pt with OGT to wall suction with bilious outputs. 10:04 AM ABDOMEN (SUPINE & ERECT) Clip # Reason: ?resolving SBO? ABG ON CURRENT VENT SETTINGS 7.40/50/98/32. CVP 8-9. cont to 3 space, hands and feet 2+ edema. Pt on Sq heparin, venodynnes.Resp: LSCTA, on psupp . cont on famotidine. Dilaudid PCA d/c'd. Cont anbx's. fluconazole d/c. TPN infusing. cont on metoclopride. right IJ wnl, DDI. wound to be cx. Cont anbx. drainage sent for cx. wean vent as tol. changed this am.ID- afebrile. Cont TPN. EKG done. TPN cont. + tympanic bs. cont to require levophed. A.m. trough level sent for vanco. OGT d/c with extubation. Stage 1 noted to coccyx and buttock. D/c Picc line by IVRN. lactate 1. prn fentayl ordered.neuro- pt lethargic. tip sent for cx. Flagyl d/c'd . hypo bs. explaination given to pt about ETT and saftey. Wean levophed. hypoactive BS. Hypoactive BS. Lyte repletion. lytes wnl.skin- abd inc as stated. pt proned for proceedure. fluid sent for creatinine. Pt remains on Levophed, at present time requiring lgr doses. RIJ placed, right PAC accessed. ABG wnl 7.39/37/109/23. Pt cont on TPN. JP to right abd. Follow up hct. 1st set neg.resp- extubated. dsg to be done QD. Pt bolus'd prn to maintain adeq CVP. cont on Levo/Fluc/vanco. Pt agreeing to be electively intubated. ABG 7.52/30/91/25/1.GI- NPO. HIT panel sent.resp- cont on CPAP. CE sent. Pt febrile, rigoring at the time. Pt with left brachialcephalic picc line. post extubation St eppression noted on monitor. already on vanco, flagyl, and levoflox. Add zosyn /fluconazole to anbx's. Q-T interval prolongation.Clinical correlation is suggested. OGT to LCWS bilious output. Monitor u/o, nephrostomy tube. Cont TPN, Abd drsgs as ordered. Abd wound ecchymotic/erythemic, upper aspect of inc with serous sang drainage. to be changed QD. Turn prn. Wound approximated. c-diff in stool, spec to be sent. dilaudid pca for pain .12/6/1.2. Vent wean to extubate. POC accessed, right IJ placed with confirmation plcmt via cxray. pt cont on albumin. DSD placed. Pt NPO with OGT. cont to monitor temp. Barrier crm and criticaid prn. Monitor hct. lasix given for pulm infiltrates. + peripheral pulses. + peripheral pulses. + peripheral pulses. + peripheral pulses. + peripheral pulses. | 52 | [
{
"category": "Radiology",
"chartdate": "2180-02-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 996261,
"text": " 8:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?acute pulmonary process\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman s/p partial small bowel obstruction now with wheeze\n REASON FOR THIS EXAMINATION:\n ?acute pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n\n COMPARISON: .\n\n FINDINGS: In comparison to previous radiograph, the tubes and lines are in\n unchanged position. Unchanged small amount of infradiaphragmatic air and\n distention of bowel loops. In the lung parenchyma, very mild discoid\n atelectasis is seen bilaterally. Otherwise, no relevant changes, no newly\n appeared parenchymal consolidations. The size of the cardiac silhouette is\n unchanged.\n\n IMPRESSION: No relevant interval changes.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2180-02-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 997501,
"text": " 4:25 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: check cvl placement\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with cvl changed over guidewire.\n REASON FOR THIS EXAMINATION:\n check cvl placement\n ______________________________________________________________________________\n WET READ: DMFj 9:51 PM\n Right CVL with tip in the lower SVC in good position.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n FINDINGS: In comparison with earlier study of this date, there are two right\n central lines in place, both of which extend to the lower portion of the SVC.\n There may be some increasing opacification on the left.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 997421,
"text": " 10:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o lobar collapse\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with sepsis, on vent with desaturations.\n REASON FOR THIS EXAMINATION:\n r/o lobar collapse\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sepsis, on ventilator with desaturations, to evaluate for lobar\n collapse.\n\n FINDINGS: In comparison with study of , the diffuse bilateral pulmonary\n opacifications appear less prominent bilaterally. The various tubes remain in\n place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-18 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 998083,
"text": " 4:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: PO/IV contrast to assess abdominal fluid collections, urinom\n Admitting Diagnosis: BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman s/p small bowel resection and right ureter damage\n REASON FOR THIS EXAMINATION:\n PO/IV contrast to assess abdominal fluid collections, urinoma, damage of right\n ureter\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post small bowel resection and right ureteral damage.\n Please assess fluid collections, urinoma, and damage of right ureter.\n\n COMPARISON: .\n\n TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic\n symphysis following the intravenous administration of Optiray. Coronal and\n sagittal reformatted images are provided.\n\n CONTRAST: Oral and intravenous non-ionic contrast.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Bilateral pleural effusions,\n left greater than right, are slightly increased from . Patchy\n opacities are present in the lung bases bilaterally. Imaged portion of the\n heart and pericardium appear within normal limits. Marked heterogeneity of\n the hepatic parenchyma is again noted, although to a slightly less prominent\n degree than on , and may reflect severe focal fatty\n infiltration. Hyperdense material in the gallbladder could reflect excreted\n contrast or gallstones. There is no biliary dilation and the portal veins are\n patent. The pancreas, spleen, and adrenal glands appear unremarkable.\n\n Pneumoperitoneum has increased since the previous examination, including free\n air within the upper abdomen and loculated gas within a fluid collection in\n the lower abdomen/upper pelvis. There is increased distention of multiple\n loops of small bowel with air-fluid levels. A segment of small bowel in the\n left lower quadrant (2:32) shows marked mural thickening and edema, a new\n finding. No mesenteric venous gas is detected. The transition point of bowel\n dilation is approximately at the level of the small bowel anastomosis in the\n lower pelvis (2:32). The mesenteric venous and arterial vessels appear\n patent centrally.\n\n A nephrostomy tube is present on the right terminating in the right renal\n collecting system. There is moderate hydronephrosis on the right and\n persistent dilation of the right ureter to the level of the iliac brim. The\n ureter is not opacified with contrast. The left kidney appears unremarkable.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: A catheter enters via a right\n paramedian approach and terminates in the deep pelvis. Loculated gas within a\n rim-enhancing fluid collection that measures approximately 3.7 x 13.2 cm, is\n (Over)\n\n 4:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: PO/IV contrast to assess abdominal fluid collections, urinom\n Admitting Diagnosis: BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n present adjacent to a markedly edematous loop of small bowel. Small bowel\n distal to the anastomosis is collapsed but does contain some oral contrast.\n The rectum, anastomosis, and sigmoid colon, appear unchanged.\n\n Diffuse stranding is present throughout the subcutaneous tissues consistent\n with anasarca.\n\n BONE WINDOWS: Bone windows show no lesions worrisome for osseous metastatic\n disease.\n\n IMPRESSION:\n 1. Findings consistent with small bowel obstruction with a transition point\n at the anastomotic site in the pelvis. New marked edema within a loop of\n bowel in the left lower quadrant is potentially concerning for ischemia.\n 2. Progression of pneumoperitoneum, both free and loculated in a lower\n abdominal/pelvic collection with rim enhancement.\n 3. Right-sided hydronephrosis and hydroureter with nephrostomy catheter in\n place.\n 4. Anasarca.\n 5. Bilateral pleural effusions and patchy opacities likely reflecting\n infectious or inflammatory process.\n 6. Probable severe fatty infiltration of the liver.\n\n Results were discussed with at 5:30 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 997772,
"text": " 5:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with sepsis.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: In comparison to previous examination, the endotracheal tube has\n been removed. As a consequence, the lung volumes are slightly smaller than\n before. The pre-existing intraparenchymal opacities that are slightly more\n extensive in the left than in the right lung are unchanged. No newly appeared\n opacities. The size of the cardiac silhouette is also unchanged. The\n nasogastric tube has been removed in the interval, the two central venous\n access lines persist.\n\n IMPRESSION: No relevant changes after extubation.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2180-02-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 996937,
"text": " 11:37 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: assess for central line placement\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with hypoT, s/p R IJ placement\n REASON FOR THIS EXAMINATION:\n assess for central line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right IJ placement.\n\n COMPARISONS: at 21:43 hours.\n\n ONE AP SUPINE PORTABLE CHEST RADIOGRAPH: An ETT terminates 5 cm above the\n carina. A left subclavian CVC terminates at the junction of the left\n brachiocephalic vein and inferior vena cava. Right IJ and right subclavian\n central venous catheters terminate in the distal superior vena cava.There is\n unchanged upper lobe opacity. There is no effusion or pneumothorax. The\n heart size is normal. There are multiple dilated bowel loops in the upper\n abdomen, with residual barium.\n\n IMPRESSION:\n 1. Unchanged upper lobe air space consolidation.\n 2. Significant bowel dilatation, better appreciated on recent prior CT\n examinations.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-10 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 996759,
"text": " 10:44 PM\n ABDOMEN (SUPINE & ERECT); -76 BY SAME PHYSICIAN # \n Reason: eval for air, please take at 2145, (4h after Stat KUB at 174\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman s/p small bowel resxn with ureteral injury/leak,\n hydronephrosis\n REASON FOR THIS EXAMINATION:\n eval for air, please take at 2145, (4h after Stat KUB at 1745)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old woman status post small bowel resection with ureteral\n injury / leak, hydronephrosis; evaluate for air.\n\n COMPARISON: CT of 5 hours previously.\n\n SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPH: Free air is demonstrated over the\n right hemidiaphragm; for further details, please refer to the CT of 5 hours\n previous.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-06 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 996074,
"text": " 4:50 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: BOWEL OBSTRUCTION\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with SBO\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON AT 17:00.\n\n INDICATION: SBO.\n\n FINDINGS:\n\n A Port-A-Cath is seen on the right with the tip in the SVC and there is a left\n central venous catheter with the tip at the distal brachiocephalic vein. No\n PTX. Left hemidiaphragm is slightly elevated with an air-filled loop of\n colon just below it. There is no focal consolidation and some left basilar\n atelectasis is seen on the lateral view. This is accompanied by posterior\n effusion likely on the left as well. There is no free air under the\n diaphragm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-03 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 995646,
"text": " 4:23 PM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: 59 yo abd pain r/o obstruccion\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with\n REASON FOR THIS EXAMINATION:\n 59 yo abd pain r/o obstruccion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old woman with abdominal pain, query obstruction.\n\n COMPARISON: None.\n\n AP SUPINE PORTABLE ABDOMINAL RADIOGRAPH: Multiple air-filled dilated loops of\n small bowel. Contrast material is seen within the transverse and descending\n colon. Probable surgical clips demonstrated in the pelvis. No gross osseous\n abnormality.\n\n IMPRESSION: Probable partial small-bowel obstruction, although if large-bowel\n contrast material was introduced from below this could represent a complete\n obstruction.\n\n COMMENT: These results were communicated to Dr. at 5:35 p.m. on\n by Dr. for Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-10 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 996724,
"text": " 4:02 PM\n CT ABDOMEN W/O CONTRAST; FEE ADJUSTED IN SPECIFIC SITUATION Clip # \n Reason: 59 yo felamle sp bowel ressection poss ureteral leak, please\n Admitting Diagnosis: BOWEL OBSTRUCTION\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n ABORTED CT OF THE ABDOMEN DATED .\n\n The images are submitted now for interpretation. Scout view of the abdomen,\n frontal and lateral and single cross-sectional image through the upper abdomen\n was obtained. There is retained barium in the colon which on the single\n cross-sectional slice shows significant artifact. It appears that at that\n time a decision was made to defer the study for later time, which was done.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-04 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 995716,
"text": " 8:54 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place DL PICC unsuccessfull bedside placement\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with\n REASON FOR THIS EXAMINATION:\n please place DL PICC unsuccessfull bedside placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 59-year-old woman with history of T4 N0 colon cancer\n post sigmoidectomy and total abdominal hysterectomy on requiring TPN.\n\n RADIOLOGISTS: Dr. and Dr. . Dr. , the Attending\n Radiologist, was present and supervised the entire procedure.\n\n Procedure explained to patient and timeout performed.\n\n TECHNIQUE: The right arm was prepped and draped in the standard sterile\n fashion. Using a 21 gauge needle, the right brachial artery was inadvertently\n punctured, and hemostasis was achieved uneventfully using manual pressure. The\n left arm was then prepped and draped in the standard sterile fashion. The\n left brachial vein was then punctured under direct ultrasound guidance using a\n micropuncture set. Hard copies of ultrasound images were obtained before and\n immediately after establishing intravenous access. A peel-away sheath was\n then placed over a guidewire and a double- lumen PICC measuring 39 cm in\n length was placed through the peel-away sheath with its tip positioned in the\n distal SVC under fluoroscopic guidance. The position of the catheter was\n confirmed by a fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied. Distal pulses,\n strength and sensation were intact in the right arm post procedure.\n\n IMPRESSION: Ultrasound and fluoroscopically guided left brachial PICC line\n placement via the left brachial venous approach. Final internal length is 39\n cm with the tip positioned in the distal SVC. The line is ready to use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-10 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 996753,
"text": " 7:31 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: eval for air, ileus\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman s/p small bowel resxn with ureteral injury/leak,\n hydronephrosis\n REASON FOR THIS EXAMINATION:\n eval for air, ileus\n ______________________________________________________________________________\n WET READ: 10:39 PM\n Known dilated abnormal small bowel loops. Moderate-severe right hydro\n secondary to ureteral injury. Free air, post-op. Contrast in colon.\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: CT of 2 hours prior.\n\n SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPH: Contrast is seen in the decompressed\n large bowel. There is dilatation of the small bowel. There is right\n hydronephrosis and a dilated ureter. Free air is seen under the right\n hemidiaphragm. For further details, please see the CT of two hours prior.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 996176,
"text": " 3:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for postop pulm edema\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman s/p small bowel resection\n REASON FOR THIS EXAMINATION:\n eval for postop pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 15:58.\n\n INDICATION: Abnormal breath sounds.\n\n COMPARISON: at 17:00.\n\n FINDINGS:\n\n The right CVL and NGT remain in place. Some distension of air-filled bowel\n loops are seen on the left and lower down in the central abdomen. This has\n not significantly changed from prior. The current study shows no interval\n change in the appearance of the lungs with a slightly shallower level of\n inspiration. There is a small amount of free air under the diaphragm\n consistent with recent surgical history. No evidence for failure or new\n focal consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-11 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 996794,
"text": " 7:05 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ?PE\n Admitting Diagnosis: BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman sp small bowel resection with A-a gradiant, EKG changes,\n mental status change, desaturation\n REASON FOR THIS EXAMINATION:\n ?PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A-a gradient, EKG changes, and mental status changes; evaluate\n for pulmonary embolus.\n\n COMPARISONS: Chest radiographs from and .\n\n TECHNIQUE: MDCT images of the chest were obtained both without and with 70 cc\n of nonionic intravenous Optiray contrast. Multiplanar reformations were\n essential to interpretation.\n\n FINDINGS: There is a right-sided infusion port which terminates in the distal\n superior vena cava. A left-sided PICC line terminates at the junction of the\n left brachiocephalic vein and superior vena cava. There are no central\n filling defects in the pulmonary arteries. Evaluation of the segmental and\n subsegmental branches is limited by bolus timing. There is no thoracic aortic\n dissection or aneurysm. The heart is normal and there is no pericardial\n effusion. Small bilateral pleural effusions are simple. Scattered non-\n pathologically enlarged lymph nodes in the subcarinal and hilar regions\n measure up to 9 mm in short axis. There is dense ground glass opacity and\n interlobular septal thickening involving predominantly the upper lobes, in\n addition to the right middle lobe and lingula to a lesser degree. There are\n scattered similar opacities involving both lower lobes as well. Liner density\n in the left lower lobe is compatible with atelectasis. Limited images of the\n upper abdomen are insufficient for diagnosis. Heterogeneity of the liver is\n suggestive of fatty infiltration.\n\n OSSEOUS STRUCTURES: There are no suspicious lytic or blastic lesions.\n\n IMPRESSION:\n 1. No evidence of central pulmonary embolus.\n 2. Ground glass opacity and interlobular septal thickening involving both\n lungs with upper lobe predominance. Based on CT findings, differential\n considerations would include hemorrhage, pulmonary edema, and aspiration.\n After discussion with the clinical service, hemorrhage would be favored, as\n the patient has no history of congestive heart failure and has been n.p.o. for\n multiple days.\n\n These findings were conveyed to by at\n approximately 9:30 a.m. on .\n (Over)\n\n 7:05 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ?PE\n Admitting Diagnosis: BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-12 00:00:00.000",
"description": "INTRO CATH RENAL PELVIS FOR DRAINAGE",
"row_id": 997006,
"text": " 12:33 PM\n PERC NEPHROSTO Clip # \n Reason: placement of R nephrostomy tube\n Admitting Diagnosis: BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * INTRO CATH RENAL PELVIS FOR DR INTRO CATH TO PELVIS FOR DRAIN *\n * ANTEGRADE UROGRAPHY *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n The report should state that the patient was sedated under MAC anesthesia not\n conscious sedation.\n\n\n 12:33 PM\n PERC NEPHROSTO Clip # \n Reason: placement of R nephrostomy tube\n Admitting Diagnosis: BOWEL OBSTRUCTION\n Contrast: OPTIRAY Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with ureteral injury s/p exlap/LOA, now draining urine into\n abdomen.\n REASON FOR THIS EXAMINATION:\n placement of R nephrostomy tube\n ______________________________________________________________________________\n FINAL REPORT\n NEPHROSTOMY TUBE\n\n INDICATION: 59-year-old woman with ureteral injury and hydronephrosis based\n on recent CT.\n\n Details of the procedure and possible complications were explained to the\n patient's husband and informed consent was obtained.\n\n RADIOLOGISTS: Dr. and Dr. . Dr. , staff radiologist,\n was present for the entire procedure.\n\n TECHNIQUE: Using sterile technique, local anesthesia, and conscious sedation,\n the right kidney was localized with ultrasound and accessed under direct\n ultrasound guidance with Accustick system. A Nephrostogram was performed,\n demonstrating mild hydronephrosis and dilated ureter all the way to the distal\n segment. No passage of contrast material was noted into the urinary bladder.\n Based on the nephrostogram findings, it was decided to place a nephrostomy\n tube. wire was advanced through the Accustick sheath and the sheath\n removed. 8 French nephrostomy tube was then placed over the wire with the\n pigtail loop formed in the renal pelvis. The wire was removed and the\n catheter was secured to the skin and connected to the bag for external\n drainage.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Ultrasound and fluoroscopically guided right nephrostomy tube\n placement for right-sided urinary obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 997186,
"text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval PNA\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with sepsis\n REASON FOR THIS EXAMINATION:\n eval PNA\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP view on .\n\n COMPARISON: Chest radiograph on at 23:53.\n\n HISTORY: 59-year-old woman with sepsis, evaluate for pneumonia.\n\n FINDINGS: There is slight worsening of the airspace disease, previously noted\n but now has progressed involves the bases, especially on the left side. The\n lung volumes are diminished. An endotracheal tube distal tip projects\n approximately 3 cm above the carina bifurcation. A right central subclavian\n and IJ line terminate in the mid portion of the SVC. The heart is not\n enlarged.\n\n A feeding tube is seen with distal tip in the left upper quadrant.\n\n IMPRESSION:\n\n 1. Worsening airspace disease, likely pneumonia, now involving in addition to\n the upper lobes, the left lower lobe.\n\n 2. Lines, catheters and tubes are in stable anatomical position as before.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-10 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 996733,
"text": " 5:00 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: 59 yo felamle sp bowel ressection poss ureteral leak, please\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 yo felamle sp bowel ressection poss ureteral leak, please eval\n REASON FOR THIS EXAMINATION:\n 59 yo felamle sp bowel ressection poss ureteral leak, please eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old woman status post bowel resection with a possible\n ureteral leak.\n\n COMPARISONS: None.\n\n TECHNIQUE: MDCT images of the abdomen and pelvis were obtained with 150 cc of\n non-ionic intravenous Optiray contrast. There was then residual oral contrast\n noted throughout the colon as well. Multiplanar reformations were essential\n to interpretation.\n\n ADBOMEN: There is scattered ground-glass opacity at both lung bases. Linear\n density in both lower lobes is compatible with atelectasis. Bilateral pleural\n effusions are simple and small. Most compatible with severe fatty\n infiltration. Multiple gallstones are present. The spleen, pancreas, and\n adrenal glands are within normal limits.\n\n There is dense colonic contrast streak artifact, slightly limiting the study.\n Both kidneys enhance symmetrically. There is moderate right-sided\n hydronephrosis and hydroureter extending to the level of the sacral\n promontory, with the ureter measuring up to 10 mm. It cannot be followed\n beyond this point.\n\n There is a small amount of free fluid in the right pericolic gutter, which\n appears simple. There is no pathologic lymph node enlargement. There are\n scattered calcifications lining the aorta, without aneurysm. There is severe\n wall thickening involving the majority of the small bowel loops, which are\n proximally dilated and distally decompressed. The colon is also proximally\n dilated and distally decompressed. Scattered free intraperitoneal air is\n compatible with recent surgery. There is a midline anterior abdominal wall\n surgical incision site which contains both fluid and air as well as a fluid-\n fluid level, measuring up to 30 mm in diameter.\n\n PELVIS: There are multiple surgical clips in the rectal fossa, and a surgical\n drain courses along the right pelvic sidewall and terminates in the deep\n pelvis. The rectum and distal colon are decompressed, as is the bladder by a\n Foley catheter. There is diffuse stranding in the subcutaneous tissues.\n\n OSSEOUS STRUCTURES: There is sclerosis of the sacrum, with bilateral anterior\n cortical step-off sites.\n\n IMPRESSION:\n (Over)\n\n 5:00 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: 59 yo felamle sp bowel ressection poss ureteral leak, please\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. New moderate right-sided hydronephrosis and hydroureter to the level of\n the sacral promontory, beyond which point the ureter is not seen.\n\n 2. Small and large bowel dilatation, with an appearance more suggestive of\n ileus. A short-term abdominal radiograph can be obtained.\n\n 3. Sacral insufficiency fractures.\n\n The findings regarding the right kidney were conveyed to Dr. by\n Dr. at approximately 5:30 p.m. on .\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 996791,
"text": " 5:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with mental status change\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Mental status changes.\n\n Portable AP chest radiograph compared to .\n\n Mediastinal vascular engorgement , bilateral hilar engorgement and bilateral\n mid and upper lung zone opacities are new and giving the radiological\n appearance and rapid progression are consistent with pulmonary edema,\n aspiration or hemorrhage. Although, there is no significant pleural effusion,\n small amount of pleural fluid cannot be excluded. Free air demonstrated on\n the previous chest radiograph below the diaphragms is not seen on the current\n exam.\n\n The right internal jugular line tip is in the mid SVC. The left PICC line tip\n crosses the midline and terminates at the junction of the left brachiocephalic\n vein and SVC.\n\n IMPRESSION: New parenchimal opacities , might be due to pulmonary\n edema, aspiration or hemorrhage, please correlate clinically.\n\n DL\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2180-02-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 996930,
"text": " 9:51 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for ETT placement; also assess for change in position\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with increasing respiratory distress, intubated\n REASON FOR THIS EXAMINATION:\n assess for ETT placement; also assess for change in position of PICC line.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ET tube placement.\n\n COMPARISONS: at 0559 hours.\n\n AP PORTABLE SUPINE CHEST X-RAY: An ET tube terminates 3.9 cm above the\n carina. A nasogastric tube terminates in the stomach. A left subclavian PICC\n line terminates at the junction of the left brachiocephalic vein and superior\n vena cava. A right subclavian catheter terminates in the distal superior vena\n cava. There has been slight interval progression in the upper lobe and\n perihilar opacity. There is no pleural effusion or pneumothorax. Multiple\n dilated bowel loops are again noted.\n\n IMPRESSION:\n\n 1. Interval progression of the upper lobe and perihilar opacities. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-02-05 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 995908,
"text": " 10:04 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ?resolving SBO?\n Admitting Diagnosis: BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with sigmoidectomy for bowel cancer, now with high grade SBO\n REASON FOR THIS EXAMINATION:\n ?resolving SBO?\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SUPINE AND ERECT ON AT 10:14\n\n INDICATION: Followup to assess for suspected small-bowel obstruction.\n\n COMPARISON: .\n\n FINDINGS:\n\n Residual contrast media outlines the large bowel. There are persistent\n dilated proximal loops visualized in the small bowel. A nasogastric tube is\n coiled in the gastric antrum.\n\n IMPRESSION: Persistent features of mechanical small-bowel obstruction without\n evidence for free air or pneumatosis.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-14 00:00:00.000",
"description": "Report",
"row_id": 1660924,
"text": "Resp Care: Pt continues on mechanical ventilation: PSV 5/8 40%. No changes overnight. VE 7.5-8.0 LPM. Most recent ABG: 7.37/49/129/29/2. LS clear bilaterally. Pt suctioned for scant/small amounts of thick blood tinged secretions. RSBI this am: 48. PLAN: continue current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-14 00:00:00.000",
"description": "Report",
"row_id": 1660925,
"text": "NPN 7pm-7am\n\nROS: See carevue for exact data\n\nUneventful noc.\n\nN: Pt awake calm on fentanyl drip and prn ativan. Follows commands, MAE's. Pt denies pain.\n\nCV: HR SR-ST 80-105, no ectopy noted. Remains on levo drip at .18. Maps through the noc just over 60, no room for titration down. CVP 4-10. Palpable pulses, venodynnes on. Pt with RIJ/Right POC for central access.\n\nResp: LS clr. Suctioning smal amts of thick, blood tinged secretions. Pt remains intubated on cpap psupp. Gas's adeq. RR 8-20. Sats 97-100%, at times pt biting on tube mouth guard prn.\n\nGI: Abd soft, positive BS. TPN infusing. Pt with OGT to wall suction with bilious outputs. Left side of abd still with errythema.\n\nGu: u/o via nephrostomy and foley, minimal from NP. Catheter urine is amber in color adeq amts. Nephrostomy output still dark, bloody, good amts, now starting to pick up.\n\nSkin: Midline abd incision opened. Wet to dry to wound, red in color, some serous sang drainage. Errythema cont to left side of wound. Right nephrostomy tube intact. A.m. care done.\n\nLytes: K and mag repleted\n\nHem: Stable\n\nId:Wbc ct increasing, temp solid 99.8 via night. Zosyn d/c'd. Cont on flagyl, levoflox, vanco.\n\nEndo:better control of blood sugars.\n\nSocial: no calls \n\nPlan: Cont with fentanyl/ativan for comfort with tube. Maintain MAP > 60, wean levo as tolerated. Cont vent wean. Cont tpn, npo. Monitor u/o from nephrostomy and foley. Monitor wound sites change as needed. Await plan for pt to go to the OR, ? day. Provide support to pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-14 00:00:00.000",
"description": "Report",
"row_id": 1660926,
"text": "NPN 7a-7p\n\nneuro- pt lightly sedated can wake when stimulated. on ativan PRN. pain well controlled with fentanyl gtt 100mcg/hr. pt able to nod to answer questions and follow commands. MAE. attempts to grab ETT if not restrained even with explaination.\n\ncv- NSR 90's. levophed weaned to .1mcg/kg/min to keep map >60. tol well. p-boots on. HIT panel resulted HIT+. all heparin products d/c. ? need to replace CL.\n\nresp- lung sounds clear. sx small to moderate amt thick blood tinged sputum. sat 99-100%. cont on vent support. CPAP 5ps 8 peep. TV 500's. fi02 40%. cxr this am resulted as worsening airspace diseade, likely pnumonia now involving upper lobes and LLL.\n\nGI- and soft and distended. NPO. ogt to sx. biloius output. on pepcid. TPN cont.\n\ngu- foley and nephrostomy tube combine for good u/o volume. foley clear yellow urine, nephrostomy tube cont to be blood tinged but clearing. JP drainage sent for creatine. CVP 8-9. cont to 3 space, hands and feet 2+ edema. creat in blood .4\n\nskin- abd incision opened by surgical team yesterday. red, swollen, warm and tender area on left abd excized this am. wound cx sent. both areas w-d dressing changed. mod amt serosang drainage. coccyx remains pink, no breakdown.\n\nID- t-max 100.4 cont on zosyn, flagyl, fluconazole,levoflox, and vanco. vanco level this am 9.3. vanco increased to 1250 .\n\nendo s/s coverage.\n\nsocial- friend in to visit.\n\nplan- ? Ct abd to further investigate for source of infection. cont to monitor wound cx. ? change out CL due to HIT. wean levo and vent as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-17 00:00:00.000",
"description": "Report",
"row_id": 1660937,
"text": "59 YR OLD WOMAN WITH SIGNIFICANT HX OF COLON CA, ADMITTED ON THE 17TH FOR HIGH GRADE BOWEL OBSTRUCTION. TO ON THE 20TH FOR EXP LAP, LYSIS OF ADHESIONS, COMPLICATED BY INJURY TO URETER. WAS ON 9 AND DESATTED REQUIRING INCREASED O2. PT ALSO HAD MENTAL STATUS CHANGES. TAKEN TO CT TO R/O PE WHICH WAS -, BUT BILAT INFILTRATES NOTED. PT ADMITTED TO TSICU FOR POOR ABG AND CHANGES ON EKG/SEPSIS\n\n INCREASING O2 REQUIREMENTS AND WOB--> INTUBATED. HYPOTENSIVE PRESSORS (LEVOPHED) AND FLUID RESUSCITATION FOR SEPSIS. SEDATED ON PROP/FENT GTT\n\nWEANED FROM PROPOFOL, SEDATED ON ATIVAN AND FENTANYL GTT\n\n IR FOR PERC NEPHROSTOMY\n\n ABD WOUND OPENED FOR ERRYTHEMA/SWELLING\n\n HIT POSITIVE, CVL CHANGED TO HEPARIN FREE, SEROTONIN RELEASE ASSAY SENT OFF. ALB 25%\n\n WEANED FROM LEVOPHED, EXTUBATED AFTERNOON\n\n NSG NOTE (SEE CAREVUE FOR EXACT DATA)\n\nN: PT EXTUBATED AFTERNOON. ORIENTED TO SELF ONLY, CONFUSED, PERIODS OF AGITATION, YELLING OUT. HALDOL 1 MG WITH NO EFFECT, .5 ATIVAN GIVEN. ATTEMPTING TO STAY AWAY FROM BENZO'S BUT IN PAST GIVEN LG DOSES NOW AFRAID OF W/DRAWAL. SMALL DOSE GIVEN . ? NEED TO WEAN.BILAT WRIST IMMOBILIZERS AND MITTS FOR PULLING AT TUBES. FENTANYL FOR PAIN WTH GOOD EFFECT IN SMALL DOSES. FOLLOWS COMMANDS, MAE'S.\n\nCV: TACHYCARDIC MOST OF NOC. ?R/T PAIN VS UNDER RESUSCITATION. HR 80-105. NO ECTOPY NOTED. CVP RANGING OCCAS UP TO 6. ALBUMIN X4 DOSES, NO MAINTENANCE FLUIDS EXCEPT FOR TPN. NO EXTRA FLUIDS WARRANTED BY DR. . PT CONT WITH ST DEPRESSION, CYCLE CK'S, LAST SET 6-7AM. LAST 2 SETS NEG. PALP PULSES, VENODYNNES. PT OFF LEVOPHED, MAP'S MAINTAINED WELL OVER 60. HIT SEROTONIN LEVEL STILL PENDING\n\nRESP: EXTUBATED AND DOING WELL. GAS'S OK, PAO2 IMPROVED. PT REMAINS ON HUMIDIFIED VENTURI MASK AT 100% WEANED TO 70%. SATS 98-100% ONCE OFF MASK PT WILL TO 80'S. LS COARSE TO CLR, SOME FINE CRACKLES TO LEFT UPPER LOBE. STRONG COUGH, CPT .\n\nGI: ABD SOFTLY DISTENDED, POSITIVE BS. 2 SM STOOLS (GREEN)\nCONT WITH TPN.\n\nGU: ADEQ U/O BETWEEN NEPHROSTOMY AND CATHETER. NEPHROSTOMY TUBE LIGHTENING LESS BROWN. AUTO DIURESING WELL, GENERALIZED EDEMA DECREASING. PT WITH 1, 70 CC OUTPUT ALL NOC. JP SENT FOR CREATININE OVER THE NEXT FEW DAYS PER PRIMARY TEAM. CRT/BUN ADEQ.\n\nSKIN: ABD WOUND MIDLINE OPEN TO DRAINAGE AT UPPER ASPECT AND LOWER ASPECT OF WOUND. ANOTHER SMALL STAB WOUND TO LEFT OF UMBULICUS STILL WITH INCREASED ERRYTHEMA. BOTH SITES OPEN WITH AQUACEL G AND DSD. COPIOUS AMOUNTS FROM ABD AROUND 330-4AM WITH TURN. SOAKING THROUGH DRSGS WITH YELLOW/SEROUS DRAINAGE. DR. AND CRIMSON MD TO EVAL. EXAMINED WITH NO INTERVENTION AT CURRENT TIME. APPROX LITER OUT ABD. COCCYX IMPROVING, LESS PINK. ABRASION TO RIGHT POS HIP/BUTTOCKS. FREQUENT SKIN CARE NEEDED. ? NEED TO VAC ABD WOUND TODAY.\n\nENDO: BLD SUGARS PER SLIDING SCALE WELL CONTROLLED.\n\nHEM: STABLE 28\n\nID: WBC TRENDING DOWN TO 5. PT ON VANCO TID WITH LEVEL FOR THIS A.M., RESTARTED ZOSYN , FLUCONAZO\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-14 00:00:00.000",
"description": "Report",
"row_id": 1660927,
"text": "Respiratory CAre:\nPt remains orally intubated and vented. No vent changed done this shift. Lung sounds slightly coarse. Suctioned for small bloody tinged secretions. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-17 00:00:00.000",
"description": "Report",
"row_id": 1660938,
"text": "(Continued)\nLE. LEVO AND FLAGYL D/C'D. SURVEILANCE BLD CULT PENDING\n\nLYTES: REPLETED PER ORDERS. K/MAG/CAL\n\nACCESS: PT WITH RIGHT IJ/RIGHT PAC. TEAM WANTED PAC DE-ACCESSED . CONSULTED IV TEAM THERE SUGGESTION WAS TO LEAVE UNTIL SEROTONIN RESULT BACK. KVO CONT'D\n\nPLAN: CONT TO MONITOR NEURO EXAM, CONFUSION. MEDICATE FOR PAIN PRN, ? TAPER OF ATIVAN. MAINTAIN ADEQ MAP > 55-60 PER TEAM. MAINTAIN ADEQ O2, FOLLOW GAS'S, WEAN OXYGEN, CPT/I/S WHEN ABLE. CONT TPN. ? START OF BOWEL REGIMEN. MONITOR U/O. PLAN FOR OR ? WHEN TO REPAIR URETER. MAINTAIN ADEQ SKIN INTEGRITY, WOUND CHANGES AS ORDERED, MONITOR LARGE OUT PUTS. REPLETE LYTES AS NEEDED. MONITOR HCT, COAGS, AWAIT SEROTONIN LEVEL. AWAIT PENDING CULTURES. MONITOR TEMPS. CONT ANBX ? STIM TEST. LAST CYCLE CK AT 7AM. CONT TO MONITOR, UPDATE FAMILY AS NEEDED, CONT WITH CURRENT PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-17 00:00:00.000",
"description": "Report",
"row_id": 1660939,
"text": "T-SICU NPN 0700-1900\n\nPlease see carevue for specifics.\n\nEvents: abd VAC placed this afternoon.\nOOB to chair this eve, tol. well. MS slowly improving.\nAwaiting sodium citrate to de-access POC.\n\nROS:\nNeuro: Lethargic, MAE's, follows commands. Able to state her name, that it's , stating year is 37, or . Also aware she's in the hospital, able to state \"\". Conts. with confusion, non-sensical statements at times. c/o dull abd pain at 4-7 on pain scale 0-10; 25-50mcg fentanyl prn with improvement per pt report. Cont. to re-orient prn. Zyprexa prn ordered.\n\nCV: HR 90-100's SR/ST, occ. PVC's, BP 80-110's/50's, CVP 1-2, registering negative numbers much of shift. Skin warm, dry. Pedal pulses palpable. PB's for DVT prophylaxis.\nHeme: hct 28.4 this am.\nAccess: L radial a-line and RIJ TLCL wnl. POC conts. with KVO, awaiting sodium citrate to de-access POC per PEVA recs (pt HIT positive).\n\nResp: LS clear, diminished at bases, occ. coarse. Weak, occ. productive cough. Transitioned to face tent as pt pulling at face mask. Face tent currently at 40% with O2sats 96-100%, RR 20's. Appears tachypneic at times, less so as day progresses. Denies difficulty breathing. Enc. C+DB, IS (reaching 500ml), chest PT as tol.\n\nGI: abd softly distended, BS present, NPO, conts. TPN as ordered. Inc. sm. soft brown smears of stool x2 today. Pepcid for prophylaxis.\n\nGU: foley patent draining approx. 35-100's cc/hr with nephrostomy draining 85-100's cc/hr. JP with 70cc this shift. Lytes pending.\n\nEndo: BS covered per sliding scale.\n\nID: tmax 98.8; conts. vanco/zosyn/fluconazole.\n\nSkin: back intact, coccyx pink, unchanged, barrier cream applied. VAC placed this afternoon. Dry wick dsg placed to L side of abd wound. Generalized edema slowly improving.\n\nPsych/social: pt's husband and a friend in this afternoon. Pleased to see pt more calm, with resolving edema. Affect/questions appropriate, emotional support provided.\n\nA: 59yo s/p exp. lap with resection , perc. nephrostomy , hemodynamically stable with improving mental status, s/p VAC placement today\n\nP: Monitor VS, I/O, labs, mental status. Cont. aggressive pulmonary hygiene, skin care. Increase activity as tolerated. De-access POC when able. Cont. ongoing open communication, comfort and support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-18 00:00:00.000",
"description": "Report",
"row_id": 1660940,
"text": "NPN 7p-7a\n\nS: Pt is a 59 yo female admitted to the hospital on with SBO, underwent ex-lap on with lysis of adhesions, admission to TSICU after desaturation episode on floor , ruled out for PE for---> probable cause of SOB was pleural effusions, R ureter injury after ex-lap, sent to IR for nephrostomy placement, VAC dressing placed over abdomen for excessive serous drainage, multiple bowel movement over the past few days.\n\nO: Pt remains lethargic, alert and oriented to person, place, situation, but NOT time, follows simple motor commads, pleasant affect, fentanyl q3-4 hrs for abdominal pain, stable hct at 26.4, WBC count WNL's, febrile in 99's, NSR 80-90 bpm, hypotensive with MAP's > or equal to 60 mmHg, palp pedal pulses, skin warm and moist, pneumo boots applied, HIT positive, sodium citrate flush in Port a cath, R IJ TLC for access, L aline, upper airways clear and lower lobes diminished to auscultation, strong cough with no productivity, normal resp rate with shallow depth, weaned to NC o2 4.0 l/min, R nephrostomy patent, foley with clear yellow urine, IVF at KVO, electrolytes repleated this shift, VAC dressing with heavy output (peritoneal fluid verses urine), low creatinine in abdominal fluid indicates probable peritoneal fluid, multiple loose dark stools, talk to team about fecal incont mgmt due to altered digestive anatomy and fragile skin, blood sugars requiring no insulin supplementation, TPN infusing per pharmacy recommendations, see careview for specific skin care issues.\n\nA: Unfortunate female recovering from SBO, injured R ureter, colon cancer, fluid shifts, and pleural effusions; mental status continues to improve, pt is mobilizing fluid independently without use of diuretics, tol less oxygen support.\n\nP: Cont to monitor and assess as ordered, replete albumin as needed per team due high probability of peritoneal fluid loss, maintain patency of tubes lines and drains, pulmonary hygiene, maintain seal of VAC dressing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-18 00:00:00.000",
"description": "Report",
"row_id": 1660941,
"text": "NPN\nN: PT ALERT/ORIENTED X2-3. PLEASANT/COOPERATIVE. GIVEN MSO4 FOR DSG CHANGE AND OTHERWISE HAS DENIED NEED FOR MED.\n\nCV: NSR 70-80S. NO ECTOPY. PT HAVING LG FLD LOSSES FROM ABDOMEN REQUIRING FLD BOLUS 500CC X2 AND ALBUMIN FOR HYPOTENSIVE EPISODES SBP 70S/MAP 50S. RESPONDS WELL TO FLDS. SEE CAREVUE FOR SERIAL VS.\n\nR: LUNGS CLEAR BILAT AND DIM AT BASES. SATS 99% ON 4LNC. WEANED TO 2L. USING I.S. WITH ENCOURAGEMENT.\n\nGI: NPO. BELLY SOFT/DISTENDED/TENDER. INCISION OPEN AT UPPER POLE AND LOWER POLE. AT UPPER POLE SM AMT BOWEL EXPOSED. WOUND DEBRIDED AT BY SURGICAL HO AND VAC DSG REPLACED. PT HAVING LG AMT SEROUS DRAINAGE FROM WOUND. BS PRESENT. PT WITH LG AMTS LIQ BROWN STOOL. RECTAL BAG PLACED.\n\nGU: URINE CLEAR YELLOW AND DRAINING IN GOOD AMTS FROM FOLEY AND NEPHROSTOMY TUBE.\n\nID: AFEBRILE. VANCO DOSE HELD THIS AM AT 8 D/T LEVEL 22. DECREASED DOSE.\n\nENDO: GLUCOSE COVERED WITH RISS.\n\nA/P: ABD CT THIS AFTERNOON, PAIN MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-19 00:00:00.000",
"description": "Report",
"row_id": 1660942,
"text": "NPN 7p-7a\n\nN: Alert and oriented x 4, follows simple commads, requires morphine sulfate for intermittent pain control, PERRLA, lorazepam 0.5 mg adequate for anxiety control.\n\nCV: R IJ CVL, sinus dysrhythmia, hypotensive with MAP > 60 mmHg, palp pedal pulses, + generalized edema, pneumatic boots, HIT positive no heparin products, stable Hct -max 99's, WBC count WNL's (resolving neutropenia secondary to chemotherapy).\n\nResp: Clear upper lobes, diminished lower lobes, strong cough---> nonproductive, normal resp rate with shallow depth, encourage to deep breath and cough, poor tol to chest PT due to deconditioned state, oxygen saturation > 93% on room air.\n\nGU: Foley with adequate clear yellow urine output, R nephrostomy with adequate darker yellow urine, electrolyte repleted, renal markers WNL's.\n\nGI: TPN, soft abdomen, active bowel sounds, fecal incontinence bag required manipulation to remain patent, tender abdomen around R JP drain.\n\nEndo: sliding scale insulin with coverage provided.\n\nSkin: see careview for multiple skin care issues.\n\nMS: requires moderate encouragement to get out of bed, deconditioned.\n\nA/P: Cont to monitor and assess as ordered, pain mgmt, pulmonary hygeine, accurate intake and outputs, transfer to the flooor when able.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-15 00:00:00.000",
"description": "Report",
"row_id": 1660928,
"text": "T/SICU Nursing Progress Note\nS:\nO: Review of systems\nNeuro: pt. sedated with fentanyl @ 100 mcg/hr. Wakes to name, follows commands. With coughing becomes agitated and quickly goes to grasp tube. Ativan 2mg iv X 1. Denies pain.\nCVS: continues on levophed, titrating to keep map >60, unable to wean off. CVP 3-8. Peripheral pulses present, venodynes in use.\nRESP: remains intubated with thick white secretions. On PSV 5, peep 8 40%. Some CO2 retention on abg (50). Coarse upper breath sounds, diminished bases.\nRENAL: Adequate urine output per nephrostomy and foley, jp. Lytes repleted. Weight today 67.5, up 10+kg from admission weight. Pt. with obvious edema.\nGI: Belly slightly distended. OG with bilious output. No stool. On famotidine for prophylaxis.\nHeme: hct 28 this am. Pt. HIT+, needs follow up lab at 2pm today. ??need to change central line.\nID: afebrile. On fluc, vanco, levoquin, flagyl. WBC down to 9.4 this am.\nSKIN: midline abdominal wound open. Wet to dry dressing done. Foul smelling serosanginous drainage. L sided stab wound with serosanginous drainage and erythema surrounding it. Area has extended past previous marked territory. HO notified. Coccyx area reddened.\nSocial: no calls from family tonight\nLINES: R subclavian portacath accessed and RIJ triple lumen in place, L radial art line also present.\nA: continues to be levo dependent. Foul smelling abdominal wound and redness extending in L abdomen.\nP: ??change central line because of +HIT, follow cultures and adjust antibiotics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-15 00:00:00.000",
"description": "Report",
"row_id": 1660929,
"text": "RESP CARE NOTE\nPT REMAINED ON SAME VENT SETTINGS OF PSV 5/8/40% OVERNIGHT. BS COARSE AT TIMES AT UPPER LOBES. SUCTIONING MOD AMTS OF THICK WHITE SECRETIONS. CHANGED TO HEATED WIRE CIRCUIT. ABG ON CURRENT VENT SETTINGS 7.40/50/98/32. RSBI 45.\nPLAN: CONT ON CURRENT SETTINGS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-15 00:00:00.000",
"description": "Report",
"row_id": 1660930,
"text": "Respiratory Care:\nPt remians orally intubated and vented. Pt acutely desaturated to low 80's. Pt placed back on AC, PEEP increased to 10 and FIO2 60%. Follow up ABG showed acid base within normal with hyperoxymea. FiO2 weaned to 40%, SpO2 100%. Lung sounds slightly coarse. Suctioned for small thick bloody tinged secretions. Plan is to wean back to PS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-15 00:00:00.000",
"description": "Report",
"row_id": 1660931,
"text": "Nursing Progress Note\nSee Carevue for specific data.\n\nSignificant Events: CVL changed over wire. Pt had stab incision on left abdomen extended twice to promote drainage. Pt had asymptomatic desat episode in AM (sats to 84-88%, suctioned/oral sxn, repositioned, CXR, ABG, encouraged to open mouth/deep breathe, ambu)- sats returned to 96-100% when oral airway inserted; vent changed from CPAP/PS to CMV and increased FiO2. Fentanyl gtt turned down from 100mcg/hr to 50mcg/hr.\n\nNeuro/Pain: Pt arouses to voice, occasionally spontaneously opening eyes. Moves all extremities, follows commands. Communicates by mouthing words and nodding head. Fentanyl gtt at 50mcg/hr for sedation/pain control adequate for pt with 50mcg boluses during repositioning/procedures. Pt also getting Ativan PRN 1-2mg for sedation/comfort.\n\nCV: Attempted to wean pt off levophed in conjunction with decreasing fentanyl gtt, but pt ended up requiring increased dose of levophed. Pt required boluses for procedures throughout the day, levophed weaned whe pt comfortable and maintain MAP's greater than 60. HR 80-90's, no ectopy, NSR. ABP 80-90's systolic, MAP 60-65, currently on .22mcg/kg/min-see Carevue for details. Palpable pedal pulses, no heparin-serotonin release antibody labs sent at 14:00. CVL changed over wire to non-heparin CVL d/t HIT-tip sent for culture. 2g Calcium, 40mEq K+ repleted. CVP 5-8: team does not want to give additional fluid, discussed albumin 25% administration.\n\nResp: Lung sounds coarse throughout, suctioned for pink/yellow thick secretions. Vent changes per carevue, pt currently on CMV, 40% FiO2. VAP care per protocol. ET tube re-taped. CXR x2 done (desat, new CVL placement).\n\nGI: Abdomen softly distended, hypoactive BS, no BM. Pt continues on flagyl-team discussed discontinuing since pt had negative Cdiff culture x1. TPN continues, fat added to 18:00 bag. OG tube to suction draining bilious fluid.\n\nGU: Pt has foley and nephrostomy tube. Foley draining clear, yellow urine- 7-100+cc/hr. Nephrostomy tube draining brown fluid with some sediment: 70-110cc/hr. Pt also has bulb (JP) suction in perineum draining pink tinged clear fluid: 80+cc/hr. JP had large amounts of drainage in AM requiring frequent emptying, slowed throughout shift. Creatinine sent on JP fluid- value: 112. Team suspects JP drainage may be ascites.\n\nSkin: Pt repositioned q1-2 hrs. Skin on back is pink, pt has stage 1 pressure sore on coccyx which is unchanged-moisture barrier cream applied. Abdomen is open with wet to dry dsg-appears pink with some pus, no odor. Abdominal stab incision on left abdomen is draining small-medium amounts of serous-serosanguinous fluid to dsd-team wants wet to dry dsg after some drainage has wept out of incision. Skin around stab is still pink, hard, blanchable. See Carevue for details.\n\nID: WBCs coming down, afebrile. Antibiotics continue per orders.\n\nEndo: Insulin administered per RISS.\n\nSocial: Husband and son called during the day-plan to come visit tomor\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-15 00:00:00.000",
"description": "Report",
"row_id": 1660932,
"text": "Nursing Progress Note\n(Continued)\nrow at 14:00-could not make it in today to visit pt.\n\nPlan: Manage pain and sedation while maintaining BP. Wean levophed as pt tolerates. Discontinue flagyl? Administer Albumin 25%? Continue pulmonary toilet. Continue to support pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-16 00:00:00.000",
"description": "Report",
"row_id": 1660933,
"text": "RESP CARE NOTE\nABLE TO WEAN PT OVERNIGHT FROM AC TO PSV 5/5/40% WITH VT 500 AND RR 16. BREATH SOUNDS COARSE AT APICES. SUCTIONING THICK TAN SECRETIONS EARLY IN SHIFT, NOW WHITE AND YELLOW. LAST ABG ON % 7.45/45/123/32. RSBI 76.\nPLAN: CONT ON CURRENT SETTINGS AS TOLERATED\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-16 00:00:00.000",
"description": "Report",
"row_id": 1660934,
"text": "Nursing Progress Note 7pm-7am\n\nROS: See carevue for exact data\n\nN: Pt remains on fentanyl gtt, ativan prn for sedation. Pt arouses easily, follows commands, MAE's. Will quickly attempt to reach for ETT if wrist immobilizers are off. Pt denies pain.\n\nCV: Hr SR 70's-90's, occasionally to 102-105 with agitation, coughing. No Ectopy noted. Art line correlating with NIBP, following art line pressures. Maintaining MAP>60. Labile BP earlier in shift, hypotensive after IVP fentanyl 50 mcg. Map down to 50's. MD Sun aware CVP at time , albumin 25 % administered. Pt remains on Levophed, at present time requiring lgr doses. Albumin with good response, able to wean down to .1 mcg. Venodynnes on, palpable pulses, ext warm. Serotonin level for Hit sent .\n\nResp: Pt initially on CMV to psupp gas's 745/45/123/32/7. Pt with slight metabolic alkalosis, Sats 97-99%. Pt weaned to , no repeat gas obtained, no changes. Suctioning thick yellow secretions.\n\nGi: Abd softly distended. hypoactive BS. Pt with OGT to LWS with bilious outputs. Pt cont on TPN. No BM.\n\nGu: Pt with right nephrostomy tube and foley with sufficient u/o. Nephrostomy tube brown/yellow with some sediment begining to clear.\nJP with crt, per primary team jp output is questioned to be ascites. Urine lytes sent . Creat 15/Na 96/K 20.\n\nSkin: Abd incision open x2 areas. Upper and lower aspect of wound. Drsg be with wet to dry. Wound pink/red, some yellow areas with yellow slough noted. Smaller incision to left of abd wound from where s/p lidocaine pump was. Area opened to drainage. Currently packing with DSD due to wound with drainage. Both sites draining serous/sang drainage. Stage 1 improving to coccyx, abrasion noted to buttock. Barrier crm and criticaid prn. Turn prn. Bilat multipodis boots.\n\nEndo: Bld sugars controlled 115-120's. Sliding scale as ordered.\n\nLytes: Mag, calcium repleted.\n\nHem: Stable at 28\n\nID: Tmax 99.5 PO. cont on Levo/Fluc/vanco. Flagyl d/c'd . A.m. trough level sent for vanco. This a.m. will be dose #4 on lgr vanco dose.\n\nSocial: Friends in to visit at change of shift. Husband to come in this a.m.\n\nPlan: Cont with fentanyl and ativan for sedation. Maintain MAP >60. Wean levophed. Vent wean as tolerated. Cont TPN, Abd drsgs as ordered. Monitor u/o, discuss urine lytes on rounds. Bld sugars per sliding scale. Lyte repletion. Monitor hct. Cont with levo/flu/vanco, pending vanco level this a.m. Await result of serotonin level. ? Plan for pt to go to OR. Cont to closely monitor and provide support. Will pass on to next shift for continuing coverage.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-16 00:00:00.000",
"description": "Report",
"row_id": 1660935,
"text": "Addendum to previous note\n\nPer urology they want a.m. creatinine sent on pt's JP drain for the next couple of days. Will pass on to next shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-16 00:00:00.000",
"description": "Report",
"row_id": 1660936,
"text": "NPN 7a-7p\n\nevents. pt extubated this afternoon, directly after extubation sats dropped to 77, abg sent pao2 46, pt encouraged to cough fi02 incresed to 70% from 35% via face tent. pao2 increased to 84 with sat up to 87%. cont metabolic alkalosis. no . lung sounds clear. levo weaned to off. Fentanyl gtt off. prn fentayl ordered.\n\nneuro- pt lethargic. no ativan given post extubation. oriented to self and family only, thinks she is in , wanting to go home, does not know the date. pulling at tubes ( mostly face mask). fentanyl prn for pain. OOB to chair for pulmonary toilet, attempting to get out of chair.\n\nCV- HR 100's st. b/p 100's map in the 70's. team will tol map >55. + peripheral pulses. albumin ordered Q6hrs x4doses. HIT +. team wanted port-a-cath de-accessed today but due to +HIT unable to flush line with heparin. IV team called for consultation. no return call yet. post extubation St eppression noted on monitor. EKG done. no problem. CE sent. 1st set neg.\n\nresp- extubated. face mask at 100% fi02. sat 97-100%. lung sounds clear. encourage to cough and deep breath. weak cough when trying to illicit cough, strong and productive when turned.\n\nGI- abd soft but distended. + tympanic bs. no stool. OGT d/c with extubation. TPN cont. pepcid d/c and ordered in TPN.\n\nGU- cont auto diuresis. net neg 1.4liters. foley clear yellow, nephrostomy tube pink tinged. good out put. JP 35cc out sreo sang drainage sent for creatinine. CA++ 1.07 2gm ca given.\n\nskin- abd inc debrided by surgery. dressing changed to aquacel AG. to be changed QD. changed this am.\n\nID- afebrile. T-max 99.9 vanco level 14.3, dose incresed to 1gm TID. PICC cx pending, urine cx pending, blood cx drawn today for servalience. MRSA swabs negative. wound cx from 28th grew out proteus vulgais. cx from the 27th proteus vulgais and e-coli.\n\nendo- s/s coverage.\n\nplan- urology suggested abd CT, surgical team does not feel it is needed at this time. abd dsg changed to aquacel QD. pt needs good pulmonary toilet, encourage coughing and deep breathing, sx if neccesary. OOB to chair. cont to monitor cx and ID status. support pt and family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-19 00:00:00.000",
"description": "Report",
"row_id": 1660943,
"text": "NPN 7a-7p\n\nneuro- alert and orinted X3. and cooperative. OOB to chair pivioting with assist, tol well. morphine given X1 for pain during dressing change. no ativan requested.\n\nCV- NSR rate 80's, b/p map >60. + peripheral pulses. p-boots for prohpalaxis. right IJ wnl, DDI. A-line left radial wnl.\n\nresp- cont on room air. lung sounds clear. using IS when encouraged, and coughing and deep breathing.\n\nGI- abd soft. +BS. may have full liquid diet. tol clears today. TPN cont at 64cc/hr. fecal inc bag intact. brown liquid stool draining.\n\nGU- foley draining clear yellow urine, right nephrostomy tube has good output. also clear yellow. net neg 800cc today.\n\nskin- abd wound to Vac. cannister changed x3 for 1500cc out put. surgical team aware. pt cont on albumin. may be incresed due to high wound drainage. left abd wound changed and re- by surgical team.\n\nID afebrile. fluconazole d/c. vanco level this am 15.9, cont on Vanco and zosyn.\n\nplan- cont pulm toilet, OOB as tol. cont to monitor wound drainage. ? c-diff in stool, spec to be sent. advance diet to full liquids.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Report",
"row_id": 1660922,
"text": "Respiratory Care:\nPt remains orally intubated and vented. No vent changes done this shift. Lung sounds clear. Suctioned for small thick bloody tinged secretions. Plan is to remain intubated for OR procedure.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Report",
"row_id": 1660923,
"text": "NPN 7a-7p\n\nevents- PiCC d/c by IV nurse. tip sent for cx. Surgical team re-opened abd incision due to increased redness and swelling in abd next to the inc. wet to dry dsg ordered. wound to be cx. Urology will not take pt to OR to fix right ureter due to sepsis.\n\nneuro- pt wakes appropriatly when stimulated. able to follow commands and nods head. no c/o pain but occasional c/o anxiety. does wake startled and coughing at times and attempts to pull out ETT. pt cont on fentanyl gtt 100mcg/hr and ativan prn. bilat wrist restraints to protect tubes and for saftey.\n\nCV- nsr in the 90's. cont to require levophed. drug titrated to maintain map >60. currently .18 mcg/kg/min. + peripheral pulses. p-boots and sq heparin for prophalaxis. platletts down. HIT panel sent.\n\nresp- cont on CPAP. 40% peep 8 ps 5. tv 500-600. rate 10-20 abg wnl. 7.35/44/81/25/-1 with sat mid 90's. lung sounds clear sx mod amt thick blood tinged to brown sputum.\n\nGI- and soft but distened. + BS. no stool. OGT to sx with bilious output. pepcid for prophalaxis. cont on TPN 63cc/hr.\n\nGU- u/o >30/hr combining foley and nephrostomy tube. foley output dark amber, nephrostomy tube bloody but clearing. CVP low . cont to 3d space. hands and feet swelling 2+ edema. net + 1.5 liters today. lytes wnl.\n\nskin- abd inc as stated. wet to dry dsg changed for mod serosang out put. wound bed red, good color no odor. erythema next to wound marked. nephrostomy tube DDI, coccyx pink no breakdown.\n\nID- t-max 99.3. zosyn and fluconazole started today. already on vanco, flagyl, and levoflox. vanco level theraputic at 11.8.\n\nendo- bs 120-130's s/s coverage.\n\nsocial- husband in this am. spoke with urology, surgery and ICU teams about POC. all questions answered. son in to visit this am.\n\nplan- continue to tx sepsis with abx and hemodynamic support. no surgery per urology until after systemic infection is gone. cont to monitor kidney function. check cx of abd wound. wean vent as tol.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-11 00:00:00.000",
"description": "Report",
"row_id": 1660915,
"text": "admit note t/sicu 8a-7p\n\n59 yr female admitted on with sbo. pt had exp lap and small bowel resection complicated by injury to the right ureter. was on 9 and desatted requiring incresed o2. pt also experienced mental status changes. BNP 345. pt taken to CT for CTA of chest to r/o PE. no PE seen on CT. + bilat infiltrates noted.\n\nsignificant hx- colon ca with sigmoidectomy and bilat salpingoopherectomy. finished of radiation and chemo.\n\nallergies- strawberries.\n\nneruo- pt alert and oriented X3. dilaudid pca for pain .12/6/1.2. not requiring much pain med, using minimally. MAE.\n\nCV- ST low 100's. sb/p 110's. + peripheral pulses. p-boots on. CE neg x1 2nd set pending.\n\nheme- platletes 73. 1 unit given pre-op. plat up to 108.\n\nresp- requiring high fio2 on 70% face tent. sat mid 90's. desat to 80 without tent. lung sounds coarse uppers and diminished in lower lobes. strong productive cough. coughing and deep breathing, and IS encouraged. ABG 7.52/30/91/25/1.\n\nGI- NPO. abd soft and distended. no bowel sounds. cont on metoclopride. cont on TPN 63/hr.\n\ngu- foley clear yellow. lasix given for pulm infiltrates. net neg 1.6 liters today. on LR 37cc/hr ( to =100cc with tpn)\n\nskin- abd inc. sealed with dermabond. inc red and eccymotic area marked. small serosang drainage. DSD placed. dsg to be done QD. pt emaciated. coccyx pink. no breakdown. right hip abrasion, OTA. JP to right abd. large output. output may be mixed with urine per team.\n\nlines- left PICC, right PIV, right port-a-cath not accessed.\n\nID- temp 101. no abx at this time.\n\nendo- bs 150's s/s coverage.\n\nsocial- husband at bedside, updated throughout the day.\n\nplan- cont to monitor resp status. will cont to diurese to try and improve infiltrates and in turn oxygenation. cont to monitor temp. pt\nis pre-op for exp lap right retrograde pyelogram cystoscopy and right ureter repair for tonight pt is an add on. surgical and anesthesia concents signed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-12 00:00:00.000",
"description": "Report",
"row_id": 1660916,
"text": "Resp Care: Pt intubated for increased WOB and O2 requirements. Pt currently on AC 400x18 60%+10. Most recent ABG: 7.37/39/88/23/-2. LS diminished bilaterally. Sxn'd for small-moderate amounts of thick yellow secretions. RSBI not done secondary to 02 requirements. PLAN: possible OR today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-12 00:00:00.000",
"description": "Report",
"row_id": 1660917,
"text": "Nursing Progress Note 7pm-7am\n\nEvents of the night: Pt respiratory decompensating last evening. Tachypneic, increased work of breathing, nebs. Sats dropping to high 80's on 70% humidified mask. Pt placed on non-rebreather. Pt remained alert and oriented x3.Intubated by anesthesia at 21:40 for airway management. Propofol and fentanyl for sedation and pain. Dilaudid PCA d/c'd. Pt hypotensive, MAP <60, fluid resuscitated also requiring pressor therapy (levophed). POC accessed, right IJ placed with confirmation plcmt via cxray. Husband notified of event.\n\nROS: See carevue for exact data\n\nN: Before intubation oriented x3. While intubated still following commands, MAE's. Pt remains on propofol/fentanyl. Goal per attending to eventually wean from propofol and maintain on fentanyl/ativan post OR. Pain appears to be controlled.\n\nCV: Initially tachycardic, highest 120's-130's. After fluid resuscitated HR remained 70-80's. Rare PVC. Palpable pulses, venodynnes. CVP 8-16. Goal >12. Pt bolus'd prn to maintain adeq CVP. D5 initiated at 70, now KVO'd per team. RIJ placed, right PAC accessed. Pt with left brachialcephalic picc line. RIJ confirmed with xray. Repeat EKG, first set of 3 enzymes flat. Repeat 2nd x3 due to noted T wave conversion in L per resident . Ist set drawn at 4am, Slight bump in CPK/Trop back at 0.15 (Dr. and attending aware) 2nd and 3rd due 10am, 4pm. Following Lactates 1.5 down to 1.4.\n\nResp: Pt increasingly more tachypneic from 30-40's up to 40-50's. Dropping Spo2 low 80's from 90's. Pt agreeing to be electively intubated. Increased work of breathing noted. Pt febrile, rigoring at the time. Initially on AC with vent changes for adeq ventilation, changed to psupp due to asynchronus breathing. Saturation 97%.\n\nGI: Abd softly distended, tender to palpation. Hypoactive BS. Lg liquid stool with small clots visible. Cdiff spec sent.\n\nGu: u/o adeq amts, clr yellow.\n\nSkin: Pt jaundiced and cachectic. Stage 1 noted to coccyx and buttock. Barrier crm and frequent repositioning. Abd wound ecchymotic/erythemic, upper aspect of inc with serous sang drainage. Wound approximated. Jp x1 with copius outputs. Sangiunous to serous-sang, strong foul smelling, spec to be sent for cultured. Per team suggest output to be part urine from injured ureter.\n\nLytes: Repletion of mag, K, calcium.\n\nHem: Hct 23 transfused with 3 units PRBC. Hct after 2nd unit->28.\n\nID: Tmax 103.3, fully cultured , tylenol, Started on flagyl, vanco, levo. WBC from 2 up to 5.\n\nEndo: Sliding scale tightened bld sugars 160's.\n\nSoc: Husband updated on pt's status.\n\nPlan: Change sedation post OR to fentanyl/ativan per attending. OR this a.m. for repair of ureter. Cont fentanyl drip for pain. Monitor CV status, maintain MAP >60, wean levophed as tolerated. Vent wean to extubate. Jp spec to be sent for culture. Monitor skin integrity, breakdown. Repletion of lytes as tolerated. Follow up hct. Tighten sliding scale. Await pending cultures. Cont anbx's. Provi\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-12 00:00:00.000",
"description": "Report",
"row_id": 1660918,
"text": "(Continued)\nde support, cont current plan of care, ?OR time for this a.m.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-12 00:00:00.000",
"description": "Report",
"row_id": 1660919,
"text": "NPN 7a-7p\n\nsignificant events: OR cancelled for today to re-eval for possible OR in am. to IR angio for placement of nephrostomy tube. pt proned for proceedure. tol well. tube placed on right. bloody drainge returned. drainage sent for cx. + blood, sputum, JP, and urine cx noted today from spec sent yesterday.\n\nNeuro- propofol weaned off. pt sedated on ativan PRN and fentanyl for pain. wakes appropriatly. follows commands. nods head to answer questions. c/o pain in throat from ETT. wakes abruptly at times and attpempts to pull at ETT. explaination given to pt about ETT and saftey. bilat wrist restraints in place.\n\nCV- NSR 70-90's. levophed on to keep map >60. attempts to wean levo. currently at .1 mcg/kg/min. with bp 93/50 map 63. + peripheral pulses. ext cool from levo. tropi .15/.08/last set pending. crit 33. p-boots and sq heparin.\n\nresp- cont on vent support. on CPAP 50% TV650 rate 10-12 peep 10 ps 5. tol well. ABG wnl 7.39/37/109/23. lung sounds clear. suctioned thick blood tinged sputum.\n\nGI- abd soft but distended. hypo bs. OGT to LCWS bilious output. cont on famotidine. no stool this shift. rectal bag still in place. TPN cont at 63cc/hr.\n\nGU- urine via foley low avg 25cc/hr. amber in color. Nephrostomy tube in place >100cc bloody out put. lactate 1. CVP 5-8. 2 fluid bolus ( total 1500cc) given with little effect on CVP or U/O. JP bloody out put. fluid sent for creatinine. K 3.5 20 kcl given.\n\n\nskin- abd dsg D&I. coccyx stage 1 red.\n\nendo- bs 105. no s/s coverage needed.\n\nID afebrile. T-max 99.2. cx +. JP fluid + gm neg rods, sputum + gm neg rods, gm + cocci, and gm neg diplococci. blood + gm neg rods, urine + enterococcus. on vanco, levoflox, and flagyl.\n\nsocial- husband in to visit this am. spoke at lenght with urology and surgery teams. called this afternoon for update.\n\nplan- cont to wean levophed as tol to map >60. use minimal sedation as tol. cont to monitor fluid status goal CVP 12. cont abx for + blood cx. re-eval for possible OR tomorrow.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Report",
"row_id": 1660920,
"text": "Resp Care: Pt continues on mechanical ventilation: PSV 5/8 40%. LS clear bilaterally. Pt suctioned for small amounts of blood tinged secretions. RSBI: 29. PLAN: ? OR today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Report",
"row_id": 1660921,
"text": "Nursing Progress Note 7pm-7am\n\nROS: See carevue for exact data\n\nEvents: None \n\nN: Pt sedated on ativan and fentanyl with good effect. Pain well controlled. Follows commands, MAE's, easily arousable. Nodding yes and no to questions asked by RN.\n\nCV: SR-ST 70-105, no ectopy. Last CK set last noc, trop with sl bump to .09 from .08, Dr. aware no intervention. BP goal MAp >60, aggressive attempts to wean levophed with no success. Palpable pulses, ext's cool. Fluids at KVO. CVP 8-12. Pt on Sq heparin, venodynnes.\n\nResp: LSCTA, on psupp . Sats 97-100%. Psupp dropped to 8 for RISBI this a.m. . Noted drop in oxygenation, coarse lung sounds on exam after change on vent. Repeat gas sent. Suctioning scant bld thick secretions.\n\nGi: Abd softly distended. Errythema to left side of abd, warm to touch. Cellulitic in appearance. Team aware on rounds. Positive BS. TPN infusing. Pt NPO with OGT. Rectal bag d/'c\n\nGu: u/o via nephrostomy tube/catheter/JP. Nephrostomy tube serous sang in color. Output from JP significantly dropped. Foley output yellow sl pink in color. Fair amts.\n\nSkin: Abd with DSD, Jp to right side of abd. Midline inc approximated, draining serous fluid from upper aspect of wound. Abd warm to touch, cellulitic to left side. Stage 1 to coccyx unchanged. Small abrasion to posterior hip. Nephrostomy site inctact with DSD.\n\nLytes: All wnl, mag repleted for 1.7\n\nHem: Stable\n\nId: WBC ct increased to 7. Per team adding zosyn and fluconazole. ? Picc infected plan to pull by IV RN.\n\nEndo: wnl, beeter control tonight.\n\nSoc: Family call to say hi. Will be in visit this a.m.\n\nPlan: ? OR TODAY. Cont fentanyl/ativan for sedation. BP maintain map >60. Wean vasopressor as tolerated. Follow up blood gas. Cont TPN. Monitor u/o, nephrostomy tube. ? scan abdomen. Cont anbx. Skin integrity. Provide support, update family, cont current POC. D/c Picc line by IVRN. Add zosyn /fluconazole to anbx's.\n"
},
{
"category": "ECG",
"chartdate": "2180-02-16 00:00:00.000",
"description": "Report",
"row_id": 208761,
"text": "Sinus tachycardia with baseline artifact. Non-diagnostic repolarization\nabnormalities. Inferior myocardial infarction. Compared to the previous\ntracing of no major change.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-02-11 00:00:00.000",
"description": "Report",
"row_id": 208762,
"text": "Sinus tachycardia. Low QRS voltage in the limb leads. Non-diagnostic\nrepolarization abnormalities. Compared to the previous tracing of \nheart rate has increased. Otherwise, no major change.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-02-06 00:00:00.000",
"description": "Report",
"row_id": 208763,
"text": "Sinus bradycardia. Borderline low voltage. Q-T interval prolongation.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\n\n"
}
] |
15,623 | 130,650 | Brief MICU course: 57 y/o female with IDDM, CRI, HTN, MM, p/w hypoglycemia and hypertensive emergency. . 1. Hypertensive emergency Considered emergency given end-organ symptoms of increased Cr, h/a, blurry vision. Spike likely in setting of stress-response to hypoglycemia and possibly fact that today is her sister's death anniversary. Weaned Nipride gtt with BPs 130's-150s off nipride. Restarted low-dose BB and cozaar and CE's x 2 negative. . 2. Hypoglycemia - now resolved. Pt with recent episodes of hypoglycemia. Recently increased NPH to from last week. ? effect given hypoglycemia at 2 am. Continued with a lower dose of NPH at 6 units qAM and 4 units qPM and coverage with HISS. Held Actos while in MICU. . 3. CRI - +proteinuria, baseline 1.0-1.2. Likely some component of diabetic nephropathy, to see nephrologist on Monday. Acute on CRI likely decreased perfusion from hypertensive emergency. Encourage po, control BP as above. Cr trended down from 1.4 -> 1.1 in MICU. . 4. Anemia - chronic, with baseline 28-32, etiology unclear. . 5. Elevated IgG - to be followed with heme/onc, appt in 2 weeks for f/u . Brief floor course: Pt was transferred to floor one day after admission, and her blood pressure remained in SBP 120-130, with one o/n 160/100, which resolved without any change in medication. Blood sugar remained well controlled. Renal function was stable with a Cr of 1.2 at d/c. Hct 27.9 at discharge which is near her baseline of 28-32. At time of discharge, she was AFVSS. She was instructed to f/u with the day of discharge to get better control of her sugars. | Compared to the previous tracing of nodiagnostic interim change. Transferred to EW, where she was found to have bp 230/110. IN EW, pt started on nipride gtt, with sbp down to 170. Received 1 amp D50 with fsbs to 110. COMPARISON: Radiograph dated . Cx were sent as pt had intermittent shakes in EW although fsbs remained >100. A/P: 57 yr old Pt with IDDM, admit for hypoglyemia/hypertensive crisis. Lopressor added to antihypertensive regime, and sbp 130's-140's off Nipride. sats 00% RA. NPH held per team o/n. Had scheduled apt for with renal doctor to further w/u. fell asleep so not medicated o/n.CV: Nipride weaned off as per careview. is hCP. Reports headache/L frontal. Team to notify Oncology of pt's admit. Pt transferred to MICU for further care.Review of Systems:Neuro: Pt A+O x 3, in NAD. Sbp 130's-140's, HR 60's-70's past several hrs. Today, pt felt sweaty/confused, ems notified and pt found to have fsbs 31.. Prominent voltage in leads I and aVL for left ventricularhypertrophy. no stool o/n.Integ: intact.Access: 1 #18 piv to L antecube.Social: lives with husband. No interval change from the prior study. PORTABLE FRONTAL CHEST: Cardiac and mediastinal contours are stable. The density of the brain parenchyma is within normal limits. Also with + serum IGG, oncology following, r/o Multiple myeloma. fsbs now wnl. started on 25mg lopressor. Peaked P waves. NURSING MICU ADMIT NOTE: Please see FHPA for full details od pmh and of admit. Sinus rhythm. UO marginal at 15-20cc's/hr. Pt will need f/u with renal if still in house Monday. The ventricles are symmetric, and there is no shift of normally midline structures. 9:28 PM CT HEAD W/O CONTRAST Clip # Reason: r/o ICH MEDICAL CONDITION: 57 year old woman with HA, BV and HTN REASON FOR THIS EXAMINATION: r/o ICH No contraindications for IV contrast WET READ: MAlb FRI 9:42 PM No intracranial hemorrhage or mass effect. TECHNIQUE: Non-contrast head CT. CT OF HEAD WITHOUT IV CONTRAST: No intracranial hemorrhage is identified. rr teens.GU: reports + protein in urine recently. Evaluate for intracranial hemorrhage. IMPRESSION: No definite radiographic evidence of pneumonia. Pt is a 57 yr old female wiht PMH IDDM with 2 day h/o headache/blurred vision and yesterday had intermittent hypoglycemia (fsbs 50's-60's). on Cozaar at home.RESP: lS cta. The -white matter differentiation is preserved. IMPRESSION: No intracranial hemorrhage or mass effect is identified. recieved 500cc's ns bolus in ew, will ask team r/e further fluid bolus at this time.FE/GI: fsbs 232, med with 4u humalog insulin, with repeat fsbs 124. FINAL REPORT INDICATION: 57-year-old woman with headache, hypertension, and blurred vision. MAe. COMPARISON: . No evidence of pneumothorax. The lungs are grossly clear. The soft tissue and osseous structures are normal. There is no pleural effusion. 8:47 PM CHEST (PORTABLE AP) Clip # Reason: r/o pna/chf MEDICAL CONDITION: 57 year old woman with pna REASON FOR THIS EXAMINATION: r/o pna/chf FINAL REPORT INDICATION: Pneumonia. reports pain across lower back pain in recent weeks as well. Pt has not taken meds for pain at home. | 4 | [
{
"category": "ECG",
"chartdate": "2193-07-12 00:00:00.000",
"description": "Report",
"row_id": 185957,
"text": "Sinus rhythm. Prominent voltage in leads I and aVL for left ventricular\nhypertrophy. Peaked P waves. Compared to the previous tracing of no\ndiagnostic interim change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-07-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 921921,
"text": " 9:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with HA, BV and HTN\n REASON FOR THIS EXAMINATION:\n r/o ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MAlb FRI 9:42 PM\n No intracranial hemorrhage or mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old woman with headache, hypertension, and blurred\n vision. Evaluate for intracranial hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n CT OF HEAD WITHOUT IV CONTRAST: No intracranial hemorrhage is identified.\n The ventricles are symmetric, and there is no shift of normally midline\n structures. The -white matter differentiation is preserved. The density\n of the brain parenchyma is within normal limits. The soft tissue and osseous\n structures are normal.\n\n IMPRESSION: No intracranial hemorrhage or mass effect is identified. No\n interval change from the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 921918,
"text": " 8:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna/chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with pna\n REASON FOR THIS EXAMINATION:\n r/o pna/chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia.\n\n COMPARISON: Radiograph dated .\n\n PORTABLE FRONTAL CHEST: Cardiac and mediastinal contours are stable. The\n lungs are grossly clear. There is no pleural effusion. No evidence of\n pneumothorax.\n\n IMPRESSION: No definite radiographic evidence of pneumonia.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-07-13 00:00:00.000",
"description": "Report",
"row_id": 1464947,
"text": "NURSING MICU ADMIT NOTE:\n Please see FHPA for full details od pmh and of admit. Pt is a 57 yr old female wiht PMH IDDM with 2 day h/o headache/blurred vision and yesterday had intermittent hypoglycemia (fsbs 50's-60's). Today, pt felt sweaty/confused, ems notified and pt found to have fsbs 31.. Received 1 amp D50 with fsbs to 110. Transferred to EW, where she was found to have bp 230/110. IN EW, pt started on nipride gtt, with sbp down to 170. Cx were sent as pt had intermittent shakes in EW although fsbs remained >100. Pt transferred to MICU for further care.\nReview of Systems:\nNeuro: Pt A+O x 3, in NAD. MAe. Reports headache/L frontal. reports pain across lower back pain in recent weeks as well. Pt has not taken meds for pain at home. fell asleep so not medicated o/n.\nCV: Nipride weaned off as per careview. started on 25mg lopressor. Sbp 130's-140's, HR 60's-70's past several hrs. on Cozaar at home.\nRESP: lS cta. sats 00% RA. rr teens.\nGU: reports + protein in urine recently. Had scheduled apt for with renal doctor to further w/u. Also with + serum IGG, oncology following, r/o Multiple myeloma. UO marginal at 15-20cc's/hr. recieved 500cc's ns bolus in ew, will ask team r/e further fluid bolus at this time.\nFE/GI: fsbs 232, med with 4u humalog insulin, with repeat fsbs 124. NPH held per team o/n. Ate 1 piece whole wheat toast with peanut butter at HS. no stool o/n.\nInteg: intact.\nAccess: 1 #18 piv to L antecube.\nSocial: lives with husband. is hCP.\n A/P: 57 yr old Pt with IDDM, admit for hypoglyemia/hypertensive crisis. Lopressor added to antihypertensive regime, and sbp 130's-140's off Nipride. fsbs now wnl. Pt will need f/u with renal if still in house Monday. Team to notify Oncology of pt's admit.\n\n"
}
] |
85,685 | 141,544 | 39 yo male with history of IDDM and history of DKA, erosive esophagitis and chronic kidney disease presented with DKA. | Possible septal myocardial infarction of indeterminate age.Non-specific lateral ST-T wave changes. There are Q waves in leads V1-V2 that actuallyare large QS complexes raising a question of old septal myocardial infarction.The tracing is otherwise within normal limits. The P-R interval is short raising a question ofLown-Ganong- syndrome. Poor R wave progression, likely a normal variant. There has been interval removal of previously seen right internal jugular central venous catheter. Compared to the previous tracingof previously seen J point elevation in the early precordial leads isnot as prominent on the current tracing. FINDINGS: Single frontal view of the chest was obtained. IMPRESSION: New right IJ central venous line. Compared to tracing #2 previously seenST segment elevation in leads I and aVL along with diffuse ST segmentdepressions have resolved. Underlying rhythm appears to be sinus rhythm with atrialpremature beats. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No acute cardiopulmonary process. Diffuse non-specificST-T wave changes may be due to ischemia or left ventricular hypertrophy.Clinical correlation is suggested.TRACING #2 Normal sinus rhythm. LowQRS voltages in the limb leads. The lungs are clear without focal consolidation. No overt pulmonary edema is seen. There is a new right IJ line whose tip projects over the upper SVC. Sinus rhythm with ventricular premature contractions. This raises concern that the previous tracing wasindeed ischemic. The lungs remain clear and cardiomediastinal silhouette is within normal limits. Sinus tachycardia. Baseline artifact. No pneumothorax. COMPARISON: 9/7/20/12. 2:11 PM CHEST (PORTABLE AP) Clip # Reason: r/o pna MEDICAL CONDITION: History: 39M with hypotension and DM REASON FOR THIS EXAMINATION: r/o pna CONTRAINDICATIONS for IV CONTRAST: FINAL REPORT EXAM: Chest, single AP upright portable view. FINDINGS: Single portable view of the chest is compared to previous exam from earlier the same day. There is no right-sided pneumothorax. No pleural effusion or pneumothorax is seen. 3:21 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: line placement MEDICAL CONDITION: History: 39M s/p IJ placement REASON FOR THIS EXAMINATION: line placement FINAL REPORT PORTABLE CHEST, . Clinical correlation is suggested.TRACING #3 The other findings are similar.TRACING #1 HISTORY: 39-year-old male status post right IJ line placement. | 6 | [
{
"category": "Radiology",
"chartdate": "2133-11-17 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1256226,
"text": " 3:21 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 39M s/p IJ placement\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n HISTORY: 39-year-old male 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 line whose tip projects over\n the upper SVC. There is no right-sided pneumothorax. The lungs remain clear\n and cardiomediastinal silhouette is within normal limits.\n\n IMPRESSION: New right IJ central venous line. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-11-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1256221,
"text": " 2:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 39M with hypotension and DM\n REASON FOR THIS EXAMINATION:\n r/o pna\n CONTRAINDICATIONS for IV CONTRAST:\n\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single AP upright portable view.\n\n CLINICAL INFORMATION: 39-year-old male with hypertension and diabetes\n mellitus.\n\n COMPARISON: 9/7/20/12.\n\n FINDINGS: Single frontal view of the chest was obtained. There has been\n interval removal of previously seen right internal jugular central venous\n catheter. The lungs are clear without focal consolidation. No pleural\n effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are\n unremarkable. No overt pulmonary edema is seen.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n"
},
{
"category": "ECG",
"chartdate": "2133-11-17 00:00:00.000",
"description": "Report",
"row_id": 230682,
"text": "Sinus tachycardia. Possible septal myocardial infarction of indeterminate age.\nNon-specific lateral ST-T wave changes. Compared to the previous tracing\nof previously seen J point elevation in the early precordial leads is\nnot as prominent on the current tracing. The other findings are similar.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2133-11-18 00:00:00.000",
"description": "Report",
"row_id": 230679,
"text": "Normal sinus rhythm. The P-R interval is short raising a question of\nLown-Ganong- syndrome. There are Q waves in leads V1-V2 that actually\nare large QS complexes raising a question of old septal myocardial infarction.\nThe tracing is otherwise within normal limits.\n\n"
},
{
"category": "ECG",
"chartdate": "2133-11-18 00:00:00.000",
"description": "Report",
"row_id": 230680,
"text": "Baseline artifact. Underlying rhythm appears to be sinus rhythm with atrial\npremature beats. Poor R wave progression, likely a normal variant. Low\nQRS voltages in the limb leads. Compared to tracing #2 previously seen\nST segment elevation in leads I and aVL along with diffuse ST segment\ndepressions have resolved. This raises concern that the previous tracing was\nindeed ischemic. Clinical correlation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2133-11-17 00:00:00.000",
"description": "Report",
"row_id": 230681,
"text": "Sinus rhythm with ventricular premature contractions. Diffuse non-specific\nST-T wave changes may be due to ischemia or left ventricular hypertrophy.\nClinical correlation is suggested.\nTRACING #2\n\n"
}
] |
52,622 | 199,044 | HOSPITAL COURSE This is a 71yo M with PMHx COPD who presented with respiratory failure, s/p ICU stay for intubation/extubation, requiring diuresis for fluid overload, steroids for COPD exacerbation, treatment for CAP, now w slowly respiratory status . ACTIVE #. Hypercarbic Hypoxic Respiratory Failure: This patient presented with respiratory distress in the setting of leukocytosis and appearing volume overloaded; patient required intubation for hypoxia secondary to acute diastolic failure and COPD exacerbation. She was started on steroid pulse, aggressive diuresis, and antibiotics. Patient respiratory status improved, resulting in extubation; patient continued to improve; at time of discharge patient was satting low 90s on RA and had been diuresed to reported dry weight 163lb; patient discharged on prednisone taper. Given brisk response to diuresis, patient was discharged on decreased dosing of PO lasix, and continued spironolactone dosing. Continued advair, nebs. . INACTIVE #. Schizophrenia: Pt followed by Dr. at /Mass Mental. Continued Risperidone 2mg qhs, risperdal consta IM 37.5mg qweek (due ), benztropine 1mg daily. . #. Prostate Cancer: Held lupron as not available for inpatients, instructed to discuss w outpatient oncologist prior to restarting. . TRANSITIONAL 1. Code status: Patient remained full code for duration of hospitalization 2. Pending: No labs/studies pending at time of discharge 3. Transition of Care: Patient discharged to rehab with copy of discharge summary 4. Barriers to Care: Patient appears to have little insight into his seriousness of his disease process, shows no interest in stopping smoking | Crescentic hyperdensity overlying a lower thoracic vertebral body corresponds to a site of prior vertebroplasty. Moderate retrocardiac and right basal areas of atelectasis. FINDINGS: In comparison with the study of , the endotracheal tube and nasogastric tube have been removed. IMPRESSION: NG tube ends within the body of the stomach, an appropriate position. Pulmonary vascular crowding with possible Kerly B lines seen to suggest mild pulmonary vascular congestion. REASON FOR THIS EXAMINATION: plea reassess pulm status FINAL REPORT HISTORY: Shortness of breath. Sinus tachycardia. Normal sinus rhythm with frequent atrial premature beats. FINDINGS: Low lung volumes limit assessment of cardiomediastinal structures. There is a trace of ascites seen in the abdomen. FINDINGS: The inferior portion of the NG tube is visualized, ending in the body of the stomach. Pulmonary hypertension. Moderate cardiomegaly with mild pulmonary edema that is unchanged. COMPARISON: Chest radiograph . Respiratory distress. The main, right and left portal veins are patent with hepatopetal flow. FINDINGS: As compared to the previous radiograph, the patient has been intubated. IMPRESSION: Mild pulmonary congestion. IMPRESSION: AP chest compared to , 2:27 a.m. As before, the endotracheal tube is in standard position. There are slightly lower lung volumes with continued evidence of pulmonary vascular congestion in a patient with substantial emphysema. The patient is in mild interstitial pulmonary edema. COMPARISON: Torso CT, . COMPARISON: CT torso from . Nasogastric tube passes into the mid stomach and out of view. 7:34 AM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOPP ABD/PEL Reason: Please evaluate hepatic blood flow and splenic blood flow. Trace of ascites. Sinus rhythm. Frequent atrial premature beats versus wandering atrialpacemaker. Patent hepatic vasculature and patent splenic vein with numerous varices seen in the splenic hilum and in the midline. The visualized portions of the lung bases are unremarkable. Splenomegaly. The gallbladder has been surgically removed. Bilateral pleural effusions are presumed, but not substantial in size. Compared to the previoustracing of no significant change.TRACING #1 3:19 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: acute CT process? Evaluate ET tube. Forward flow is seen in the splenic vein and the SMV in the midline. TECHNIQUE: Portable AP radiograph of the chest. Compared to theprevious tracing of no diagnostic interval change. A small amount of air is seen within the colon. FINAL REPORT INDICATION: 71-year-old man with COPD and respiratory distress. Pulmonary vascular congestion in the setting of severe emphysema may produce more than the expected degree of hypoxia or dyspnea. Appropriate flow is seen in the hepatic veins and the main hepatic artery. Evaluate OG tube placement. Cardiomediastinal silhouette is unchanged. Aspiration and penetration was noted for both thin liquids and nectar. REASON FOR THIS EXAMINATION: Please evaluate hepatic blood flow and splenic blood flow. The tip of the endotracheal tube projects 4 cm above the carina. FINAL REPORT INDICATION: A 71-year-old man with respiratory failure, cirrhosis, splenomegaly and new thrombocytopenia. Evaluate for aspiration. The pancreas is unremarkable, but is only minimally visualized. An area of possible coalescent opacification at the right base laterally could represent a supervening pneumonia in the appropriate clinical setting. Low voltages in the limb leads. Cardiomediastinal silhouette is unremarkable. Heart is likely normal in size. IMPRESSION: 1. DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were obtained. Admitting Diagnosis: CONGESTIVE HEART FAILURE;CHRONIC PULM DISEASE;PNEUMONIA MEDICAL CONDITION: 71 year old man with COPD a/w resp distress, now s/p extubation w question of aspiration on bedside eval REASON FOR THIS EXAMINATION: aspiration? Same as tracing #1 with no significant change.TRACING #2 No interval development of large pleural effusion is noted on the right. 2:21 PM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: aspiration? 8:49 AM CHEST (PORTABLE AP) Clip # Reason: plea reassess pulm status Admitting Diagnosis: CONGESTIVE HEART FAILURE;CHRONIC PULM DISEASE;PNEUMONIA MEDICAL CONDITION: 71 year old man with Sob, hypoxic, please assess pulm status. Portable AP radiograph of the chest was reviewed in comparison to prior study obtained the same day earlier. Admitting Diagnosis: CONGESTIVE HEART FAILURE;CHRONIC PULM DISEASE;PNEUMONIA MEDICAL CONDITION: 71 year old man with severe hypoNa, respiratory failure, cirrhosis and volume overload, known splenomegaly and new thrombocytopenia. No biliary dilatation is seen and the common duct measures 0.6 cm. There are numerous varices seen in the midline and also in the splenic hilum. Compared to the previous tracing there is no change. FINDINGS: There is no focal liver lesion identified. 9:37 AM PORTABLE ABDOMEN Clip # Reason: Eval OGT placement Admitting Diagnosis: CONGESTIVE HEART FAILURE;CHRONIC PULM DISEASE;PNEUMONIA MEDICAL CONDITION: 71 year old man with COPD intubated for resp distress s/p OGT placement REASON FOR THIS EXAMINATION: Eval OGT placement FINAL REPORT INDICATION: History of COPD, intubated for respiratory distress. | 12 | [
{
"category": "Radiology",
"chartdate": "2159-06-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1193676,
"text": " 11:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 71 year old man with sat at 81%, bilateral crackles, product\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with sat at 81%, bilateral crackles, productive cough and dizzy\n REASON FOR THIS EXAMINATION:\n 71 year old man with sat at 81%, bilateral crackles, productive cough and dizzy\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: bilateral crackles and productive cough.\n\n TECHNIQUE: Portable AP radiograph of the chest.\n\n COMPARISON: Chest radiograph .\n\n FINDINGS: Low lung volumes limit assessment of cardiomediastinal structures.\n Pulmonary vascular crowding with possible Kerly B lines seen to suggest mild\n pulmonary vascular congestion. There is no pleural effusion or pneumothorax.\n Heart is likely normal in size. Cardiomediastinal silhouette is unremarkable.\n\n IMPRESSION: Mild pulmonary congestion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-06-25 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1194818,
"text": " 2:21 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: aspiration?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CHRONIC PULM DISEASE;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with COPD a/w resp distress, now s/p extubation w question of\n aspiration on bedside eval\n REASON FOR THIS EXAMINATION:\n aspiration?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man with COPD and respiratory distress. Evaluate for\n aspiration.\n\n COMPARISON: None.\n\n VIDEO OROPHARYNGEAL SWALLOW: Video oropharyngeal swallow was performed with\n multiple consistencies of barium in conjunction with the speech pathology\n team. Aspiration and penetration was noted for both thin liquids and nectar.\n For additional information, please see speech-language pathology note in web\n OMR.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-06-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1193707,
"text": " 3:19 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: acute CT process?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CHRONIC PULM DISEASE;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with hx of COPD, on BIPAP, with periodic increases in HR, eval\n for acute CT process\n REASON FOR THIS EXAMINATION:\n acute CT process?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Increase in heart rate in a patient with history of\n COPD.\n\n Portable AP radiograph of the chest was reviewed in comparison to prior study\n obtained the same day earlier.\n\n The patient is in mild interstitial pulmonary edema. Cardiomediastinal\n silhouette is unchanged. No interval development of large pleural effusion is\n noted on the right.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-06-19 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1193812,
"text": " 9:37 AM\n PORTABLE ABDOMEN Clip # \n Reason: Eval OGT placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CHRONIC PULM DISEASE;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with COPD intubated for resp distress s/p OGT placement\n REASON FOR THIS EXAMINATION:\n Eval OGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of COPD, intubated for respiratory distress. Evaluate OG\n tube placement.\n\n COMPARISON: CT torso from .\n\n FINDINGS: The inferior portion of the NG tube is visualized, ending in the\n body of the stomach. A small amount of air is seen within the colon. The\n visualized portions of the lung bases are unremarkable. Crescentic\n hyperdensity overlying a lower thoracic vertebral body corresponds to a site\n of prior vertebroplasty.\n\n IMPRESSION: NG tube ends within the body of the stomach, an appropriate\n position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-06-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1193974,
"text": " 3:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval ETT placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CHRONIC PULM DISEASE;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with cryptogenic cirrhosis, COPD, pul HTN currently intubated\n for resp distress\n REASON FOR THIS EXAMINATION:\n Eval ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:53 A.M., :\n\n HISTORY: Cryptogenic cirrhosis and COPD. Pulmonary hypertension.\n Respiratory distress. Evaluate ET tube.\n\n IMPRESSION: AP chest compared to , 2:27 a.m.\n\n As before, the endotracheal tube is in standard position. Pulmonary vascular\n congestion in the setting of severe emphysema may produce more than the\n expected degree of hypoxia or dyspnea. There is no evidence of pneumonia.\n Bilateral pleural effusions are presumed, but not substantial in size.\n Nasogastric tube passes into the mid stomach and out of view. No\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-06-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1193757,
"text": " 2:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CHRONIC PULM DISEASE;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with respiratory failure s/p extubation\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, status post intubation.\n\n COMPARISON: , 3:25 p.m.\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the endotracheal tube projects 4 cm above the carina.\n\n Moderate cardiomegaly with mild pulmonary edema that is unchanged. Moderate\n retrocardiac and right basal areas of atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-06-19 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1193779,
"text": " 7:34 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: Please evaluate hepatic blood flow and splenic blood flow.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CHRONIC PULM DISEASE;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with severe hypoNa, respiratory failure, cirrhosis and volume\n overload, known splenomegaly and new thrombocytopenia.\n REASON FOR THIS EXAMINATION:\n Please evaluate hepatic blood flow and splenic blood flow.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 71-year-old man with respiratory failure, cirrhosis,\n splenomegaly and new thrombocytopenia.\n\n COMPARISON: Torso CT, .\n\n FINDINGS: There is no focal liver lesion identified. No biliary dilatation\n is seen and the common duct measures 0.6 cm. The gallbladder has been\n surgically removed. The pancreas is unremarkable, but is only minimally\n visualized. The spleen is enlarged measuring 20.2 cm. There is a trace of\n ascites seen in the abdomen.\n\n DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were\n obtained. The main, right and left portal veins are patent with hepatopetal\n flow. Appropriate flow is seen in the hepatic veins and the main hepatic\n artery. Forward flow is seen in the splenic vein and the SMV in the midline.\n There are numerous varices seen in the midline and also in the splenic hilum.\n\n IMPRESSION:\n 1. Patent hepatic vasculature and patent splenic vein with numerous varices\n seen in the splenic hilum and in the midline.\n 2. No focal liver lesion identified and no biliary dilatation seen.\n 3. Splenomegaly.\n 4. Trace of ascites.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-06-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1194411,
"text": " 8:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: plea reassess pulm status\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CHRONIC PULM DISEASE;PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with Sob, hypoxic, please assess pulm status.\n REASON FOR THIS EXAMINATION:\n plea reassess pulm status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath.\n\n FINDINGS: In comparison with the study of , the endotracheal tube and\n nasogastric tube have been removed. There are slightly lower lung volumes\n with continued evidence of pulmonary vascular congestion in a patient with\n substantial emphysema. An area of possible coalescent opacification at the\n right base laterally could represent a supervening pneumonia in the\n appropriate clinical setting.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2159-06-22 00:00:00.000",
"description": "Report",
"row_id": 202272,
"text": "Sinus rhythm. Frequent atrial premature beats versus wandering atrial\npacemaker. Compared to the previous tracing there is no change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2159-06-19 00:00:00.000",
"description": "Report",
"row_id": 202273,
"text": "Normal sinus rhythm with frequent atrial premature beats. Compared to the\nprevious tracing of no diagnostic interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2159-06-18 00:00:00.000",
"description": "Report",
"row_id": 202274,
"text": "Same as tracing #1 with no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2159-06-18 00:00:00.000",
"description": "Report",
"row_id": 202275,
"text": "Sinus tachycardia. Low voltages in the limb leads. Compared to the previous\ntracing of no significant change.\nTRACING #1\n\n"
}
] |
87,197 | 176,931 | #Delirium - The patient's altered mental status was most attributable to polypharmacy with psychotropic and narcotic medications post-operatively. The patient was initially admitted to the ICU for close monitoring, but her mental status had returned to baseline and she was stable for transfer to the floor on the 2nd hospital day. She was evaluted by psychiatry who felt that her condition was most consistent with delirium/toxic encephalopathy and that there was no evidence of active suicidality. Her mental status improved to baseline quickly. All her meds were initially held but then outpt psych meds were resumed and per psych, she can fu with her oupt psychiatrist. #Cellulitis - The patient developed a cellulitis overlying the left knee surgical site. There was no evidence of wound dehiscence, discharge, or abscess. Synovial fluid analysis was not consistent with septic arthritis. The patient will continue on antibiotics to complete a 10 day course. . #Depression - Outpatient medications were resumed on the 2nd hospital day, as above, when the patient's mental status had returned to baseline. Psychiatry did not feel as if there were any acute psychiatric issues requiring hospitalization. She will follow up with her mental health provider in . . #s/p left knee arthroscopy and open correction of patellofemoral instability- The patient was seen in consultation by orthopaedic surgery who recommended that the patient continue with routine post-operative care and follow up with her surgeon on . She was evaluated by physical therapy who recommended that the patient ambulate with crutches after discharge, which the patient confirmed she had at home. . #Nutrition - Regular diet. . #Prophylaxis - Subcutaneous heparin. | o Toxicology consulted o We are holding her medications o Has waxed and waned presently improved. She was found to be tachycardic with extremely dry MM, concerning for anticholinergic syndrome in setting of flexeril use. She was found to be tachycardic with extremely dry MM, concerning for anticholinergic syndrome in setting of flexeril use. - Hold medications including oxycodone, ambien, effexor, celexa until can confirm meds and doses - DC CIWA scale since has not required - Appreciate toxicology recs, continue supportive care - F/U Psychiatry recommendations re: medications, antidepressants . BCx x2 and Ucx were sent Ortho was paged, evaluated pt and performed arthrocentesis and got back serosanguinous fluid. BCx x2 and Ucx were sent Ortho was paged, evaluated pt and performed arthrocentesis and got back serosanguinous fluid. BCx x2 and Ucx were sent Ortho was paged, evaluated pt and performed arthrocentesis and got back serosanguinous fluid. BCx x2 and Ucx were sent Ortho was paged, evaluated pt and performed arthrocentesis and got back serosanguinous fluid. Also seen by Psych, recommended 1:1 sitter, avoidiing benzos, Haldol 2.5 qhs. Also seen by Psych, recommended 1:1 sitter, avoidiing benzos, Haldol 2.5 qhs. Pt was transferred from osh to ED and in ed her hr was 120, bp 90/56, o2 sats 100% temp 98.9. pt received 4l NS in ed now c sbp >100 hr down to 80 Pain control (acute pain, chronic pain) Assessment: Pt c/o pain in knee Action: Rn tried to give pt Tylenol pt refused Response: Pt continues to be in pain Plan: Continue to Altered mental status (not Delirium) Assessment: Action: Response: Plan: Hypotension (not Shock) Assessment: Action: Response: Plan: Impaired Skin Integrity Assessment: Action: Response: Plan: Risk for Injury Assessment: Action: Response: Plan: She was given narcan by EMS with subsequent agitation. She was given narcan by EMS with subsequent agitation. Pt taking oxycodone, flexeril, and darvocet for pain relief post-op. Pt was transferred from osh to ED and in ed her hr was 120, bp 90/56, o2 sats 100% temp 98.9. pt received 4l NS in ed now c sbp >100 hr down to 80 Pain control (acute pain, chronic pain) r/t knee surgery Assessment: Pt c/o pain in knee Action: Rn tried to give pt Tylenol pt refused Response: Pt continues to be in pain Plan: Continue to monitor for worsening pain Altered mental status (not Delirium) Assessment: Ct of neg, pt very paranoid and untrusting of medical staff, pt crying and yelling at all medical staff. left knee was assess by ortho left knee swollen and red and outlined c marker knee may need to be drained ------ Protected Section Addendum Entered By: , RN on: 17:13 ------ Pt refused rn to obtain labs ------ Protected Section Addendum Entered By: , RN on: 17:14 ------ haldol for panic episodes Hypotension (not Shock) Assessment: Bp low , high hr, mouth dry Action: Ns fluid infusion Response: Bp >100, hr 80s pt less thirsty now Plan: Continue to monitor for dehydration Impaired Skin Integrity r/t knee surgery Assessment: Left knee surgery leg has ace wrap around incision site, pt refused to let rn or md assess. haldol for panic episodes Hypotension (not Shock) Assessment: Bp low , high hr, mouth dry Action: Ns fluid infusion Response: Bp >100, hr 80s pt less thirsty now Plan: Continue to monitor for dehydration Impaired Skin Integrity r/t knee surgery Assessment: Left knee surgery leg has ace wrap around incision site, pt refused to let rn or md assess. Non-specific ST-T wave changes and slowing of the rate ascompared with prior tracing of . Pt was transferred from osh to ED and in ed her hr was 120, bp 90/56, o2 sats 100% temp 98.9. pt received 4l NS in ed now c sbp >100 hr down to 80 Pain control (acute pain, chronic pain) r/t knee surgery Assessment: Pt c/o pain in knee Action: Rn tried to give pt Tylenol pt refused Response: Pt continues to be in pain Plan: Continue to monitor for worsening pain Altered mental status (not Delirium) Assessment: Ct of neg, pt very paranoid and untrusting of medical staff, pt crying and yelling at all medical staff. Pt was transferred from osh to ED and in ed her hr was 120, bp 90/56, o2 sats 100% temp 98.9. pt received 4l NS in ed now c sbp >100 hr down to 80 Pain control (acute pain, chronic pain) r/t knee surgery Assessment: Pt c/o pain in knee Action: Rn tried to give pt Tylenol pt refused Response: Pt continues to be in pain Plan: Continue to monitor for worsening pain Altered mental status (not Delirium) Assessment: Ct of neg, pt very paranoid and untrusting of medical staff, pt crying and yelling at all medical staff. | 29 | [
{
"category": "Physician ",
"chartdate": "2109-11-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 417617,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt had restraints placed because she was being combative and pulling at\n her lines.\n She had the restraints removed later in the evening when she became\n more calm and oriented.\n Ortho consulted, saw pt. Recommended no abx at that time, CRP and ESR\n sent, AP and Lateral xray, and call if develops fever.\n Pt had a fever of 101.2 last night at 11pm.\n BCx x2 and Ucx were sent\n Ortho was paged, evaluated pt and performed arthrocentesis and got back\n serosanguinous fluid. No abx were started overnight.\n Also seen by Psych, recommended 1:1 sitter, avoidiing benzos, Haldol\n 2.5 qhs.\n This am, c/o knee pain, stable. Reports she did not remember coming to\n hospital. Feels thinking clear now.\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 09:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.6\nC (99.7\n HR: 88 (73 - 113) bpm\n BP: 100/57(67) {81/49(57) - 108/70(78)} mmHg\n RR: 16 (12 - 31) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,050 mL\n 65 mL\n PO:\n 800 mL\n TF:\n IVF:\n 250 mL\n 65 mL\n Blood products:\n Total out:\n 3,050 mL\n 80 mL\n Urine:\n 3,050 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,000 mL\n -15 mL\n Respiratory support\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n General Appearance: Anxious, interactive, appropriate\n Eyes / Conjunctiva: PERRL. Sclera anicteric\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal) . No m/r/g\n Peripheral Vascular: DP/PT 2+ BL\n Respiratory / Chest: CTAB\n Abdominal: Soft. NT/ND. +BS. No HSM\n Extremities: L knee with sutures, erythema surrounding incision with\n some warmth on skin, not around joint. No purulent drainage. Minimal\n tenderness. Erythema within written outline\n Skin: Warm\n Neurologic AAO x 3. Speaking clearly, appropriately.\n Labs / Radiology\n 183 K/uL\n 9.9 g/dL\n 74 mg/dL\n 0.6 mg/dL\n 19 mEq/L\n 3.2 mEq/L\n 7 mg/dL\n 115 mEq/L\n 141 mEq/L\n 28.0 %\n 5.5 K/uL\n [image002.jpg] CRP 83 ESR 26 UA neg Lactate 2.9\n Joint fluid: WBC 244 HCT 5 No crystals. Gam stain 2+ polys No\n organisms. Blood cx x 4 NGTD\n 10:49 PM\n WBC\n 5.5\n Hct\n 28.0\n Plt\n 183\n Cr\n 0.6\n Glucose\n 74\n Other labs: PT / PTT / INR:12.8/28.2/1.1, ALT / AST:16/17, Alk Phos / T\n Bili:43/0.3, Lactic Acid:2.9 mmol/L, Albumin:3.0 g/dL, LDH:151 IU/L,\n Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n A/P: Pt is a 55y/o F with PMH of depression and EtOH abuse admitted\n with mental status changes in setting of benzodiazepine, opiate and\n flexeril use.\n .\n # MS Changes - Pt with significant psychiatric history, on multiple\n medications which may contribute to delirium including oxycodone,\n ambien, flexeril and darvocet for migraines. Only new medication\n Oxycodone from knee surgery . Also given tachycardia, hypovolemia\n consider anticholingeric effect related to flexeril use vs serotonin\n syndrome from celexa. Pt also with evidence of pressured speech on exam\n with reports of auditory hallucinations, increased energy, decreased\n need for sleep concerning for element of mania, however difficult to\n fully assess given possible medication effects. Unclear if pt also has\n taken excessive doses of celexa and effexor given her reports of\n outpatient dosage.\n - Hold medications including oxycodone, ambien, effexor, celexa until\n can confirm meds and doses\n - DC CIWA scale since has not required\n - Appreciate toxicology recs, continue supportive care\n - F/U Psychiatry recommendations re: medications, antidepressants\n .\n # Depression - holding meds as above, no current SI/HI\n .\n # Hx EtOH abuse\n has not scored on CIWA scale as above, will DC,\n especially given Psych recs to avoid benzos\n .\n # Migraine Headache - holding topamax as above\n .\n # L Knee Arthroscopy - pt c/o pain, no limitation of mobility. Had\n recent surgery . Pain most likely wound cellulitis given\n surrounding erythema, joint aspirate not c/w septic joint\n - pain control with Tylenol and motrin prn\n - - avoiding narcs given recent mental status changes\n .\n #Fever: Spiked fever overnight. Most likely source wound cellulitus.\n Knee tap negative for infection with WBC 244. CXR neg, blood cx, urine\n cx No growth\n - Will start Ancef per ortho recs while inpatient, change to\n Keflex for 7 day course as outpt\n - F/U cultures\n .\n # FEN - regular diet, replete lytes PRN\n .\n # Access\n PIV\n .\n #PPX: Hep SC, Colace\n .\n # Code\n Full, call out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:16 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2109-11-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417600,
"text": "Pt was admitted to from OSH for change in mental status. Pt had\n knee surgery on Thursday this past week. She was sent home on Oxycodone\n for pain. Pt already had been taking pain med for her chronic migraines\n Darvacet. She may have taken both and husband thought she was acting\n bizarre and EMS was called .On arrival pt received Narcan and per\n husband pt awoke very agitated. She was seen at OSH and it was thought\n she would benefit coming to . On arrival to ED she had hr\n 120\ns, sbp <90 pt received 4 L NS which good effects sbp>100 and hr\n down to 80-90\ns. Pt was then very confused and paranoid and combative.\n Pt arrived to ccu in four point restraints. Pt continue to act out in\n CCU she received 5mg Haldol with good effect. Pt slept and when she\n awoke that evening she was alert and oriented x3 cooperating c medical\n staff. Pt received 2.5mg HS Haldol and slept well overnight. This am pt\n is alert and oriented. Pt was found to have some cellulites around knee\n incision and will be tx c Ancef.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain\n Action:\n Tylenol 650mg po, legs elevated on pillows\n Response:\n Pt felt better, less swelling at knee site.\n Plan:\n Continue to monitor pain and swelling, observe for worsening skin\n infection more red and swollen, keep leg elevated, and give pain meds\n no narcotics or benzo\n Risk for Injury\n Assessment:\n Pt has a difficult time standing on leg with knee surgery\n Action:\n Support to take pressure off leg when moving pt was sent home from osh\n after her surgery crutch\n Response:\n Pt was able to stand and pivot into chair and commode several times\n Plan:\n Pt needs a crutch before she goes home to help walk\n"
},
{
"category": "Physician ",
"chartdate": "2109-11-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 417615,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt had restraints placed because she was being combative and pulling at\n her lines.\n She had the restraints removed later in the evening when she became\n more calm and oriented.\n Ortho consulted, saw pt. Recommended no abx at that time, CRP and ESR\n sent, AP and Lateral xray, and call if develops fever.\n Pt had a fever of 101.2 last night at 11pm.\n BCx x2 and Ucx were sent\n Ortho was paged, evaluated pt and performed arthrocentesis and got back\n serosanguinous fluid. No abx were started overnight.\n Also seen by Psych, recommended 1:1 sitter, avoidiing benzos, Haldol\n 2.5 qhs.\n This am, c/o knee pain, stable. Reports she did not remember coming to\n hospital. Feels thinking clear now.\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 09:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.6\nC (99.7\n HR: 88 (73 - 113) bpm\n BP: 100/57(67) {81/49(57) - 108/70(78)} mmHg\n RR: 16 (12 - 31) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,050 mL\n 65 mL\n PO:\n 800 mL\n TF:\n IVF:\n 250 mL\n 65 mL\n Blood products:\n Total out:\n 3,050 mL\n 80 mL\n Urine:\n 3,050 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,000 mL\n -15 mL\n Respiratory support\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: No(t) Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Clear : )\n Abdominal: No(t) Soft, No(t) Non-tender, No(t) Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, pressured speech, tearful\n Labs / Radiology\n 183 K/uL\n 9.9 g/dL\n 74 mg/dL\n 0.6 mg/dL\n 19 mEq/L\n 3.2 mEq/L\n 7 mg/dL\n 115 mEq/L\n 141 mEq/L\n 28.0 %\n 5.5 K/uL\n [image002.jpg]\n 10:49 PM\n WBC\n 5.5\n Hct\n 28.0\n Plt\n 183\n Cr\n 0.6\n Glucose\n 74\n Other labs: PT / PTT / INR:12.8/28.2/1.1, ALT / AST:16/17, Alk Phos / T\n Bili:43/0.3, Lactic Acid:2.9 mmol/L, Albumin:3.0 g/dL, LDH:151 IU/L,\n Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n A/P: Pt is a 55y/o F with PMH of depression and EtOH abuse admitted\n with mental status changes in setting of benzodiazepine, opiate and\n flexeril use.\n .\n # MS Changes - Pt with significant psychiatric history, on multiple\n medications which may contribute to delirium including oxycodone,\n ambien, flexeril and question of darvocet. Also given tachycardia,\n hypovolemia consider anticholingeric effect related to flexeril use vs\n serotonin syndrome from celexa. Pt also with evidence of pressured\n speech on exam with reports of auditory hallucinations, increased\n energy, decreased need for sleep concerning for element of mania,\n however difficult to fully assess given possible medication effects.\n Unclear if pt also has taken excessive doses of celexa and effexor\n given her reports of outpatient dosage.\n - Hold medications including oxycodone, ambien, effexor, celexa\n - Maintain on CIWA scale\n - Monitor QT interval\n - Appreciate toxicology recs, continue supportive care\n - Consider Psychiatry consultation for recommendations re. medication\n toxicity, depression vs mania\n .\n # Depression - holding meds as above, no current SI/HI\n .\n # Hx EtOH abuse - maintain on CIWA scale as above\n .\n # Migraine Headache - holding topamax as above\n .\n # L Knee Arthroscopy - pt c/o pain, no limitation of mobility, holding\n pain meds as above\n .\n # FEN - regular diet, replete lytes PRN\n .\n # Access - PIV\n .\n # Code - Full\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:16 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2109-11-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417592,
"text": "Pt was admitted to from OSH for change in mental status. Pt had\n knee surgery on Thusday this past week. She was sent home on Oxycodone\n for pain. Pt already had been taking pain med for her chronic migrains\n Darvacet. She may have taken both and husband thought she was acting\n bizarre and EMS was called .On arrival pt received Narcan and per\n husband pt awoke very agitated. She was seen at OSH and it was thought\n she would benefit coming to . On arrival to ED she had hr\n 120\ns, sbp <90 pt received 4 L NS which good effects sbp>100 and hr\n down to 80-90\ns. Pt was then very confused and paranoid and combative.\n Pt arrived to ccu in four poit restrsints. Pt continue to act out in\n CCU she received 5mg Haldol with good effect. Pt slept and when she\n awoke that evening she was alert and oriented x3 cooperating c medical\n staff. Pt received 2.5mg HS Haldol and slept well overnight. This am pt\n is alert and oriented. Pt was found to have some cellulitis around knee\n incision and will be tx c Ancef.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain\n Action:\n Tylenol 650mg po, legs elevated on pillows\n Response:\n Pt felt better, less swelling at knee site.\n Plan:\n Continue to monitor pain and swelling , observe for worsening skin\n infection more red and swollen, keep leg elevated, give pain meds no\n narcotics ot benzo\n Assessment:\n Action:\n Response:\n Plan:\n Risk for Injury\n Assessment:\n Pt has a difficult time standing on leg with knee surgery\n Action:\n Support to take pressure off leg when moving pt was sent home from osh\n after her surgery crutch\n Response:\n Pt was able to stand and pivot into chair and commode several times\n Plan:\n Pt needs a crutch before she goes home to help walk\n"
},
{
"category": "Physician ",
"chartdate": "2109-11-17 00:00:00.000",
"description": "ICU Attending Addendum",
"row_id": 417590,
"text": "CRITICAL CARE STAFF ADDENDUM\n 12:45p\n I saw and examined the patient with the ICU team today. Dr. \n note from today reflects my input. I would add/emphasize that Ms.\n \n mental status has improved markedly. She states that she\n feels much better. Her exam is notable for markedly improved mental\n status; otherwise, exam is stable (including her knee with erythema).\n She was seen by orthopedics; arthrocentesis was reassuring. As\n recommended by orthopedics, we will start Ancef. Other issues as\n detailed in ICU team note from today. She is ready for transfer to the\n floor.\n"
},
{
"category": "Nursing",
"chartdate": "2109-11-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417591,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Risk for Injury\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2109-11-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417631,
"text": "Pt was admitted to from OSH for change in mental status. Pt had\n knee surgery on Thursday this past week. She was sent home on Oxycodone\n for pain. Pt already had been taking pain med for her chronic migraines\n Darvacet. She may have taken both and husband thought she was acting\n bizarre and EMS was called .On arrival pt received Narcan and per\n husband pt awoke very agitated. She was seen at OSH and it was thought\n she would benefit coming to . On arrival to ED she had hr\n 120\ns, sbp <90 pt received 4 L NS which good effects sbp>100 and hr\n down to 80-90\ns. Pt was then very confused and paranoid and combative.\n Pt arrived to ccu in four point restraints. Pt continue to act out in\n CCU she received 5mg Haldol with good effect. Pt slept and when she\n awoke that evening she was alert and oriented x3 cooperating c medical\n staff. Pt received 2.5mg HS Haldol and slept well overnight. This am pt\n is alert and oriented. Pt was found to have some cellulites around knee\n incision and will be tx c Ancef.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain\n Action:\n Tylenol 650mg po, legs elevated on pillows\n Response:\n Pt felt better, less swelling at knee site.\n Plan:\n Continue to monitor pain and swelling, observe for worsening skin\n infection more red and swollen, keep leg elevated, and give pain meds\n no narcotics or benzo\n Risk for Injury\n Assessment:\n Pt has a difficult time standing on leg with knee surgery\n Action:\n Support to take pressure off leg when moving pt was sent home from osh\n after her surgery crutch\n Response:\n Pt was able to stand and pivot into chair and commode several times\n Plan:\n Pt needs a crutch before she goes home to help walk\n ------ Protected Section ------\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n 63 Inch\n Admission weight:\n 74 kg\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history: left knee arthroscopy recently\n depression\n distant hx of alcohol abuse\n abdominoplasty\n MRSA +\n Surgery / Procedure and date: left knee arthroscopy recently in the\n past week\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:99\n D:60\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 100 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 222 mL\n 24h total out:\n 2,365 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 01:34 PM\n Potassium:\n 3.3 mEq/L\n 01:34 PM\n Chloride:\n 115 mEq/L\n 01:34 PM\n CO2:\n 21 mEq/L\n 01:34 PM\n BUN:\n 9 mg/dL\n 01:34 PM\n Creatinine:\n 0.9 mg/dL\n 01:34 PM\n Glucose:\n 131 mg/dL\n 01:34 PM\n Hematocrit:\n 34.0 %\n 01:34 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash Amount: 20.00\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: ccu\n Transferred to: \n Date & time of Transfer: 12:00 AM\n ------ Protected Section Addendum Entered By: , RN\n on: 17:14 ------\n"
},
{
"category": "Nursing",
"chartdate": "2109-11-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417421,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Risk for Injury\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2109-11-16 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 417408,
"text": "Chief Complaint: Change in Mental Status\n HPI:\n Pt is a 55y.o F trasferred from OSH with overdose of pain medication\n taken for post knee arthroscopy pain. Pt taking oxycodone, flexeril,\n and darvocet for pain relief post-op. Her family called EMS out of\n concern for altered mental status. She was given narcan by EMS with\n subsequent agitation. Urine tox at OSH was positive for benzos and\n opiates. She was given ativan, rocephine and vancomycin. Her OSH\n report, her family stated that she takes oxycodone 1,2 or 3 tablets\n every 4-6 hrs and that 8 tablets were missing from her bottle. She was\n increasing lethargic with a decrease in consciouness but arousable to\n stimulation.\n .\n On arrival to ED, initial vitals T 98.9, HR 120, BP 90/56, RR 18,\n O2 sat 100% RA. The pt very confused, with waxing and coherence.\n She was found to be tachycardic with extremely dry MM, concerning for\n anticholinergic syndrome in setting of flexeril use. This am she\n dropped pressure to systolic of 60s which responded to a 500cc fluid\n bolus. She was given levaquin and flagyl.\n .\n On arrival to the MICU, the patient was agitated and tearful with\n conversation. She became increasingly frustrated when asked questions\n about her medication history. She states that she did not take any\n darvocet and took her oxycodone as prescribed. Denies flexeril use over\n past 24hrs but may have taken one tablet the day prior. She states she\n does not remember the events bringing her into the hospital. She states\n she had been with good energy over the last few months. She lost her\n job approx 3 months ago due to a harrassment claim but states her\n employer is being supportive in attempting to find her a new job. She\n has had excellent energy levels, increased from baseline with decreased\n need for sleep but she attempts to sleep 8 hours nightly. She has\n gained 15lbs due to increased appetite. Denies visual hallucinations\n but states she hears things that others do not but \"only in my very\n deepest head\" and when her \"very good friend speaks to her.\"\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 09:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n L knee arthroscopy\n Depression\n Hx of EtOH abuse - states sober for 14 years\n Abdominoplasty\n Migraine headache\n MRSA\n s/p Hysterectomy\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married, states husband is supportive, he also has a hx of EtOH\n abuse and attends AA. Currently unemployed, lost job secondary to\n harrassment claim. Sober X 14 years, denies tobacco, denies IVDU.\n States she feels quite safe at home.\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: 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\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Musculoskeletal: No(t) Joint pain\n Heme / Lymph: No(t) Lymphadenopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 12:25 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 103 (103 - 105) bpm\n BP: 95/59(66) {95/59(66) - 107/68(76)} mmHg\n RR: 19 (12 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 133 mL\n PO:\n TF:\n IVF:\n 133 mL\n Blood products:\n Total out:\n 0 mL\n 1,190 mL\n Urine:\n 1,190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -1,057 mL\n Respiratory\n SpO2: 100%\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: No(t) Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Clear : )\n Abdominal: No(t) Soft, No(t) Non-tender, No(t) Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, pressured speech, tearful\n Labs / Radiology\n 212\n 102\n 0.9\n 15\n 23\n 112\n 4.0\n 142\n 32.6\n 7.2\n [image002.jpg]\n Other labs: Lactic Acid:2.9 mmol/L\n Fluid analysis / Other labs: Serum and Urine Tox negative\n ECG: ECG - ST 110bpm, nl axis and intervals, biphasic T waves\n v2-v4\n Radiology: CXR - my read - no effusion, no infiltrate\n Assessment and Plan\n A/P: Pt is a 55y/o F with PMH of depression and EtOH abuse admitted\n with mental status changes in setting of benzodiazepine, opiate and\n flexeril use.\n .\n # MS Changes - Pt with significant psychiatric history, on multiple\n medications which may contribute to delirium including oxycodone,\n ambien, flexeril and question of darvocet. Also given tachycardia,\n hypovolemia consider anticholingeric effect related to flexeril use vs\n serotonin syndrome from celexa. Pt also with evidence of pressured\n speech on exam with reports of auditory hallucinations, increased\n energy, decreased need for sleep concerning for element of mania,\n however difficult to fully assess given possible medication effects.\n Unclear if pt also has taken excessive doses of celexa and effexor\n given her reports of outpatient dosage.\n - Hold medications including oxycodone, ambien, effexor, celexa\n - Maintain on CIWA scale\n - Monitor QT interval\n - Appreciate toxicology recs, continue supportive care\n - Consider Psychiatry consultation for recommendations re. medication\n toxicity, depression vs mania\n .\n # Depression - holding meds as above, no current SI/HI\n .\n # Hx EtOH abuse - maintain on CIWA scale as above\n .\n # Migraine Headache - holding topamax as above\n .\n # L Knee Arthroscopy - pt c/o pain, no limitation of mobility, holding\n pain meds as above\n .\n # FEN - regular diet, replete lytes PRN\n .\n # Access - PIV\n .\n # Code - Full\n ICU Care\n Nutrition:\n Comments: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 09:16 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2109-11-16 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 417413,
"text": "Chief Complaint: Change in Mental Status\n HPI:\n Pt is a 55y.o F trasferred from OSH with overdose of pain medication\n taken for post knee arthroscopy pain. Pt taking oxycodone, flexeril,\n and for pain relief post-op. Her family called EMS out of\n concern for altered mental status. She was given narcan by EMS with\n subsequent agitation. Urine tox at OSH was positive for benzos and\n opiates. She was given ativan, rocephine and vancomycin. Her OSH\n report, her family stated that she takes oxycodone 1,2 or 3 tablets\n every 4-6 hrs and that 8 tablets were missing from her bottle. She was\n increasing lethargic with a decrease in consciouness but arousable to\n stimulation.\n .\n On arrival to ED, initial vitals T 98.9, HR 120, BP 90/56, RR 18,\n O2 sat 100% RA. The pt very confused, with waxing and coherence.\n She was found to be tachycardic with extremely dry MM, concerning for\n anticholinergic syndrome in setting of flexeril use. This am she\n dropped pressure to systolic of 60s which responded to a 500cc fluid\n bolus. She was given levaquin and flagyl.\n .\n On arrival to the MICU, the patient was agitated and tearful with\n conversation. She became increasingly frustrated when asked questions\n about her medication history. She states that she did not take any\n and took her oxycodone as prescribed. Denies flexeril use over\n past 24hrs but may have taken one tablet the day prior. She states she\n does not remember the events bringing her into the hospital. She states\n she had been with good energy over the last few months. She lost her\n job approx 3 months ago due to a harrassment claim but states her\n employer is being supportive in attempting to find her a new job. She\n has had excellent energy levels, increased from baseline with decreased\n need for sleep but she attempts to sleep 8 hours nightly. She has\n gained 15lbs due to increased appetite. Denies visual hallucinations\n but states she hears things that others do not but \"only in my very\n deepest head\" and when her \"very good friend speaks to her.\"\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 09:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Pt Reports Meds:\n Oxycodone 10mg 1-3 tabs Q 4PRN\n Flexeril PRN\n \n - pt states she has not taken\n Topamax - 100mg daily\n Effexor - 375mg daily ?\n Celexa - 100mg daily ?\n MA List\n Effexor 75mg 5tab QAM\n Celexa\n not on\n Topamax 25mg daily\n Prempro\n Hydromorphone\n \n Hydrocodone\n Oxycodone/APAP 5/325mg Q3-4\n HCTZ 25mg daily\n Abilify 20mg daily\n now off\n Past medical history:\n Family history:\n Social History:\n L knee arthroscopy\n Depression\n Hx of EtOH abuse - states sober for 14 years\n Abdominoplasty\n Migraine headache\n MRSA\n s/p Hysterectomy\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married, states husband is supportive, he also has a hx of EtOH\n abuse and attends AA. Currently unemployed, lost job secondary to\n harrassment claim. Sober X 14 years, denies tobacco, denies IVDU.\n States she feels quite safe at home.\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: 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\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Musculoskeletal: No(t) Joint pain\n Heme / Lymph: No(t) Lymphadenopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 12:25 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 103 (103 - 105) bpm\n BP: 95/59(66) {95/59(66) - 107/68(76)} mmHg\n RR: 19 (12 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 133 mL\n PO:\n TF:\n IVF:\n 133 mL\n Blood products:\n Total out:\n 0 mL\n 1,190 mL\n Urine:\n 1,190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -1,057 mL\n Respiratory\n SpO2: 100%\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: No(t) Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Clear : )\n Abdominal: No(t) Soft, No(t) Non-tender, No(t) Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, pressured speech, tearful\n Labs / Radiology\n 212\n 102\n 0.9\n 15\n 23\n 112\n 4.0\n 142\n 32.6\n 7.2\n [image002.jpg]\n Other labs: Lactic Acid:2.9 mmol/L\n Fluid analysis / Other labs: Serum and Urine Tox negative\n ECG: ECG - ST 110bpm, nl axis and intervals, biphasic T waves\n v2-v4\n Radiology: CXR - my read - no effusion, no infiltrate\n Assessment and Plan\n A/P: Pt is a 55y/o F with PMH of depression and EtOH abuse admitted\n with mental status changes in setting of benzodiazepine, opiate and\n flexeril use.\n .\n # MS Changes - Pt with significant psychiatric history, on multiple\n medications which may contribute to delirium including oxycodone,\n , flexeril and question of . Also given tachycardia,\n hypovolemia consider anticholingeric effect related to flexeril use vs\n serotonin syndrome from celexa. Pt also with evidence of pressured\n speech on exam with reports of auditory hallucinations, increased\n energy, decreased need for sleep concerning for element of mania,\n however difficult to fully assess given possible medication effects.\n Unclear if pt also has taken excessive doses of celexa and effexor\n given her reports of outpatient dosage.\n - Hold medications including oxycodone, , effexor, celexa\n - Maintain on CIWA scale\n - Monitor QT interval\n - Appreciate toxicology recs, continue supportive care\n - Consider Psychiatry consultation for recommendations re. medication\n toxicity, depression vs mania\n .\n # Depression - holding meds as above, no current SI/HI\n .\n # Hx EtOH abuse - maintain on CIWA scale as above\n .\n # Migraine Headache - holding topamax as above\n .\n # L Knee Arthroscopy - pt c/o pain, no limitation of mobility, holding\n pain meds as above\n .\n # FEN - regular diet, replete lytes PRN\n .\n # Access - PIV\n .\n # Code - Full\n ICU Care\n Nutrition:\n Comments: Regular diet\n Glycemic Control:\n Lines:\n 18 Gauge - 09:16 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2109-11-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417422,
"text": "55 yo female underwent knee surgery about one week ago. Pt had been\n taking multiple pain meds for knee pain. Husband called ems r/t mental\n status changes. EMS arrived and gave pt Narcan and per pt husband this\n is when she became wild according to husband. Pt was transferred from\n osh to ED and in ed her hr was 120, bp 90/56, o2 sats 100% temp\n 98.9. pt received 4l NS in ed now c sbp >100 hr down to 80\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain in knee\n Action:\n Rn tried to give pt Tylenol pt refused\n Response:\n Pt continues to be in pain\n Plan:\n Continue to\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Risk for Injury\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2109-11-16 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 417415,
"text": "Chief Complaint:\n HPI:\n 55 y/o woman underwent knee surgery about a week ago. Since then,\n taking multiple meds for pain. Husband was concerned b/c of increased\n somnolence. EMS --> Narcan --> agitation. At OSH tox (+) BZD,\n opiates, TCAs --> rx ativen, ctx, vanco. Transferred to . In ED:\n 98.9, 120, 90/56, 100% r/a, confused, looked very dry. Tox consult\n recommended supportive rx. This morning, had episode of\n fluid-responsive HOTN --> levo/flagyl.\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 09:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n see resident note (reviewed: there is disagreement between her reports\n and her pharmacy's reports)\n Past medical history:\n Family history:\n Social History:\n left knee arthroscopy (recent)\n depression\n distant history of alcohol abuse (states sober x 14 years)\n abdominoplasty\n MRSA+\n nc\n Occupation: recently lost her job\n Drugs: denies\n Tobacco: denies\n Alcohol: former\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Nutritional Support: NPO\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Psychiatric / Sleep: reports markedly increased energy and appetite.\n Some ?auditory hallucinations.\n Signs or concerns for abuse : No\n Flowsheet Data as of 01:48 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 90 (90 - 105) bpm\n BP: 107/59(69) {95/59(66) - 107/68(76)} mmHg\n RR: 21 (12 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 546 mL\n PO:\n 400 mL\n TF:\n IVF:\n 146 mL\n Blood products:\n Total out:\n 0 mL\n 1,190 mL\n Urine:\n 1,190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -644 mL\n Respiratory\n SpO2: 97%\n ABG: ////\n Physical Examination\n Presently sedated (after Haldol); previously very agitated\n Pupils symmetric\n Mucous membranes now moist\n Abdomen soft\n Knee with staples and some erythema\n Scant edema\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:2.9 mmol/L\n Fluid analysis / Other labs: Per OMR (reviewed)\n ECG: QRS not widenedl QT OK.\n Assessment and Plan\n 55 y/o woman with\n Altered mental status\n o CT head at OSH reassuring\n o BZD, opiates, and Flexeril\n appears to have had a mix of\n toxidromes from these over her course. SSRI toxicity also possible.\n Will also need to keep alcohol withdrawal in mind, though seems less\n likely.\n o Toxicology consulted\n o We are holding her medications\n o Has waxed and waned\n presently improved.\n o There is no clinical evidence of meningitis\n Subacute issues raise concern for bipolar\n consult\n psychiatry\n Knee does not look completely reassuring, and staples\n document an open procedure. Check plain film and consult orthopedics\n regarding possible infection. Low threshold to cover.\n Communication with husband.\n ICU \n Nutrition: NPO\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 09:16 AM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU for now\n Total time spent: 30 min\n"
},
{
"category": "Physician ",
"chartdate": "2109-11-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 417535,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt had restraints placed because she was being combative and pulling at\n her lines.\n She had the restraints removed later in the evening when she became\n more calm and oriented.\n Ortho consulted, saw pt. Recommended no abx at that time, CRP and ESR\n sent, AP and Lateral xray, and call if develops fever.\n Pt had a fever of 101.2 last night at 11pm.\n BCx x2 and Ucx were sent\n Ortho was paged, evaluated pt and performed arthrocentesis and got back\n serosanguinous fluid. No abx were started.\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 09:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.6\nC (99.7\n HR: 88 (73 - 113) bpm\n BP: 100/57(67) {81/49(57) - 108/70(78)} mmHg\n RR: 16 (12 - 31) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,050 mL\n 65 mL\n PO:\n 800 mL\n TF:\n IVF:\n 250 mL\n 65 mL\n Blood products:\n Total out:\n 3,050 mL\n 80 mL\n Urine:\n 3,050 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,000 mL\n -15 mL\n Respiratory support\n SpO2: 97%\n ABG: ///19/\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 183 K/uL\n 9.9 g/dL\n 74 mg/dL\n 0.6 mg/dL\n 19 mEq/L\n 3.2 mEq/L\n 7 mg/dL\n 115 mEq/L\n 141 mEq/L\n 28.0 %\n 5.5 K/uL\n [image002.jpg]\n 10:49 PM\n WBC\n 5.5\n Hct\n 28.0\n Plt\n 183\n Cr\n 0.6\n Glucose\n 74\n Other labs: PT / PTT / INR:12.8/28.2/1.1, ALT / AST:16/17, Alk Phos / T\n Bili:43/0.3, Lactic Acid:2.9 mmol/L, Albumin:3.0 g/dL, LDH:151 IU/L,\n Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:16 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2109-11-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 417536,
"text": "Chief Complaint:\n 24 Hour Events:\n Pt had restraints placed because she was being combative and pulling at\n her lines.\n She had the restraints removed later in the evening when she became\n more calm and oriented.\n Ortho consulted, saw pt. Recommended no abx at that time, CRP and ESR\n sent, AP and Lateral xray, and call if develops fever.\n Pt had a fever of 101.2 last night at 11pm.\n BCx x2 and Ucx were sent\n Ortho was paged, evaluated pt and performed arthrocentesis and got back\n serosanguinous fluid. No abx were started.\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 09:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.6\nC (99.7\n HR: 88 (73 - 113) bpm\n BP: 100/57(67) {81/49(57) - 108/70(78)} mmHg\n RR: 16 (12 - 31) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,050 mL\n 65 mL\n PO:\n 800 mL\n TF:\n IVF:\n 250 mL\n 65 mL\n Blood products:\n Total out:\n 3,050 mL\n 80 mL\n Urine:\n 3,050 mL\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,000 mL\n -15 mL\n Respiratory support\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: No(t) Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Clear : )\n Abdominal: No(t) Soft, No(t) Non-tender, No(t) Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed, pressured speech, tearful\n Labs / Radiology\n 183 K/uL\n 9.9 g/dL\n 74 mg/dL\n 0.6 mg/dL\n 19 mEq/L\n 3.2 mEq/L\n 7 mg/dL\n 115 mEq/L\n 141 mEq/L\n 28.0 %\n 5.5 K/uL\n [image002.jpg]\n 10:49 PM\n WBC\n 5.5\n Hct\n 28.0\n Plt\n 183\n Cr\n 0.6\n Glucose\n 74\n Other labs: PT / PTT / INR:12.8/28.2/1.1, ALT / AST:16/17, Alk Phos / T\n Bili:43/0.3, Lactic Acid:2.9 mmol/L, Albumin:3.0 g/dL, LDH:151 IU/L,\n Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n A/P: Pt is a 55y/o F with PMH of depression and EtOH abuse admitted\n with mental status changes in setting of benzodiazepine, opiate and\n flexeril use.\n .\n # MS Changes - Pt with significant psychiatric history, on multiple\n medications which may contribute to delirium including oxycodone,\n ambien, flexeril and question of darvocet. Also given tachycardia,\n hypovolemia consider anticholingeric effect related to flexeril use vs\n serotonin syndrome from celexa. Pt also with evidence of pressured\n speech on exam with reports of auditory hallucinations, increased\n energy, decreased need for sleep concerning for element of mania,\n however difficult to fully assess given possible medication effects.\n Unclear if pt also has taken excessive doses of celexa and effexor\n given her reports of outpatient dosage.\n - Hold medications including oxycodone, ambien, effexor, celexa\n - Maintain on CIWA scale\n - Monitor QT interval\n - Appreciate toxicology recs, continue supportive care\n - Consider Psychiatry consultation for recommendations re. medication\n toxicity, depression vs mania\n .\n # Depression - holding meds as above, no current SI/HI\n .\n # Hx EtOH abuse - maintain on CIWA scale as above\n .\n # Migraine Headache - holding topamax as above\n .\n # L Knee Arthroscopy - pt c/o pain, no limitation of mobility, holding\n pain meds as above\n .\n # FEN - regular diet, replete lytes PRN\n .\n # Access - PIV\n .\n # Code - Full\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:16 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2109-11-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417430,
"text": "55 yo female underwent knee surgery about one week ago. Pt had been\n taking multiple pain meds for knee pain. Husband called ems r/t mental\n status changes. EMS arrived and gave pt Narcan and per pt husband this\n is when she became wild according to husband. Pt was transferred from\n osh to ED and in ed her hr was 120, bp 90/56, o2 sats 100% temp\n 98.9. pt received 4l NS in ed now c sbp >100 hr down to 80\n Pain control (acute pain, chronic pain) r/t knee surgery\n Assessment:\n Pt c/o pain in knee\n Action:\n Rn tried to give pt Tylenol pt refused\n Response:\n Pt continues to be in pain\n Plan:\n Continue to monitor for worsening pain\n Altered mental status (not Delirium)\n Assessment:\n Ct of neg, pt very paranoid and untrusting of medical staff, pt crying\n and yelling at all medical staff. Pt confused at times and forgetful.\n When pt awakes from nap she appears to be panicing and tries to get oob\n and starts to pull at foley, iv\ns and ekg lines. Pt had four point\n leather restraints on arrival to ccu which were removed r/t red wrist\n soft restraints put on pt.\n Action:\n Haldol 5mg, reaasurance from medical staff that she is safe 1:1 time\n with pt.\n Response:\n Pt calmer and able to focus more and listen to rn\n Plan:\n Continue to provide calm environment , ativan ? haldol for panic\n episodes\n Hypotension (not Shock)\n Assessment:\n Bp low , high hr, mouth dry\n Action:\n Ns fluid infusion\n Response:\n Bp >100, hr 80\ns pt less thirsty now\n Plan:\n Continue to monitor for dehydration\n Impaired Skin Integrity r/t knee surgery\n Assessment:\n Left knee surgery leg has ace wrap around incision site, pt refused to\n let rn or md assess.\n Action:\n Leg elevated when pt allows\n Response:\n Less painfull in knee\n Plan:\n Keep leg elevated, try to assess leg when pt is more calmer\n acooperative\n Risk for Injury r/t alerteration in mental status\n Assessment:\n Pt very combative and trying to pull out iv\ns and trying to get oob\n Action:\n Soft wrist restraint, circulation checked frequently sitter 1:1 in room\n bed alarm\n Response:\n Pt is not pulling at lines iv\ns and she is not trying to get oob\n Plan:\n Keep in wrist restriaint and with sitter emotional support for pt and\n family\n ------ Protected Section ------\n Pt refused rn to obtain temp. left knee was assess by ortho left knee\n swollen and red and outlined c marker knee may need to be drained\n ------ Protected Section Addendum Entered By: , RN\n on: 17:13 ------\n"
},
{
"category": "Nursing",
"chartdate": "2109-11-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417431,
"text": "55 yo female underwent knee surgery about one week ago. Pt had been\n taking multiple pain meds for knee pain. Husband called ems r/t mental\n status changes. EMS arrived and gave pt Narcan and per pt husband this\n is when she became wild according to husband. Pt was transferred from\n osh to ED and in ed her hr was 120, bp 90/56, o2 sats 100% temp\n 98.9. pt received 4l NS in ed now c sbp >100 hr down to 80\n Pain control (acute pain, chronic pain) r/t knee surgery\n Assessment:\n Pt c/o pain in knee\n Action:\n Rn tried to give pt Tylenol pt refused\n Response:\n Pt continues to be in pain\n Plan:\n Continue to monitor for worsening pain\n Altered mental status (not Delirium)\n Assessment:\n Ct of neg, pt very paranoid and untrusting of medical staff, pt crying\n and yelling at all medical staff. Pt confused at times and forgetful.\n When pt awakes from nap she appears to be panicing and tries to get oob\n and starts to pull at foley, iv\ns and ekg lines. Pt had four point\n leather restraints on arrival to ccu which were removed r/t red wrist\n soft restraints put on pt.\n Action:\n Haldol 5mg, reaasurance from medical staff that she is safe 1:1 time\n with pt.\n Response:\n Pt calmer and able to focus more and listen to rn\n Plan:\n Continue to provide calm environment , ativan ? haldol for panic\n episodes\n Hypotension (not Shock)\n Assessment:\n Bp low , high hr, mouth dry\n Action:\n Ns fluid infusion\n Response:\n Bp >100, hr 80\ns pt less thirsty now\n Plan:\n Continue to monitor for dehydration\n Impaired Skin Integrity r/t knee surgery\n Assessment:\n Left knee surgery leg has ace wrap around incision site, pt refused to\n let rn or md assess.\n Action:\n Leg elevated when pt allows\n Response:\n Less painfull in knee\n Plan:\n Keep leg elevated, try to assess leg when pt is more calmer\n acooperative\n Risk for Injury r/t alerteration in mental status\n Assessment:\n Pt very combative and trying to pull out iv\ns and trying to get oob\n Action:\n Soft wrist restraint, circulation checked frequently sitter 1:1 in room\n bed alarm\n Response:\n Pt is not pulling at lines iv\ns and she is not trying to get oob\n Plan:\n Keep in wrist restriaint and with sitter emotional support for pt and\n family\n ------ Protected Section ------\n Pt refused rn to obtain temp. left knee was assess by ortho left knee\n swollen and red and outlined c marker knee may need to be drained\n ------ Protected Section Addendum Entered By: , RN\n on: 17:13 ------\n Pt refused rn to obtain labs\n ------ Protected Section Addendum Entered By: , RN\n on: 17:14 ------\n"
},
{
"category": "Nursing",
"chartdate": "2109-11-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417499,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Temp spike 101.2po blood and urine cultures sent. C/o left knee pain\n . Left knee swollen and painful, lightly wrapped in ace bandage.\n Action:\n Ortho surgery notified and bedside aspirated 20cc serosang liquid under\n local. Spec sent for culture\n Received Tylenol 650mg po and elevated left knee on pillow.\n Response:\n Pt tolerated procedure well. Temperature came down 99po. Pain\n tolerable as pt slept through the night.\n Plan:\n Continue to follow temperature curve. Medicate with Tylenol as needed.\n Observe for changes in surgical site, increase swelling, pain or\n drainage.\n Altered mental status (not Delirium)\n Assessment:\n Pt awake and answering questions with one word response. At 2100\n crying and did not understand\nwhy she was tied up like an animal\n Action:\n Explanation that the restraints were to protect herself and to protect\n the nurses and doctors as she was very combative Denies memory of any\n of this behavior. Restraints were removed. Sitter maintained through\n out the night. Received Haldol 2.5mg IVB at HS.\n Response:\n Pt was calmer after restraints were removed. Showed no further signs of\n agitation or combative behavior.\n Plan:\n Continue to assess pt for further agitation, delirium, paranoia or\n delusional symptoms. Sitter until psychiatry reevaluates in the am.\n Continue to keep pt and family aware of POC as discussed in multi\n disciplinary rounds.\n"
},
{
"category": "Nursing",
"chartdate": "2109-11-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417425,
"text": "55 yo female underwent knee surgery about one week ago. Pt had been\n taking multiple pain meds for knee pain. Husband called ems r/t mental\n status changes. EMS arrived and gave pt Narcan and per pt husband this\n is when she became wild according to husband. Pt was transferred from\n osh to ED and in ed her hr was 120, bp 90/56, o2 sats 100% temp\n 98.9. pt received 4l NS in ed now c sbp >100 hr down to 80\n Pain control (acute pain, chronic pain) r/t knee surgery\n Assessment:\n Pt c/o pain in knee\n Action:\n Rn tried to give pt Tylenol pt refused\n Response:\n Pt continues to be in pain\n Plan:\n Continue to monitor for worsening pain\n Altered mental status (not Delirium)\n Assessment:\n Ct of neg, pt very paranoid and untrusting of medical staff, pt crying\n and yelling at all medical staff. Pt confused at times and forgetful.\n When pt awakes from nap she appears to be panicing and tries to get oob\n and starts to pull at foley, iv\ns and ekg lines. Pt had four point\n leather restraints on arrival to ccu which were removed r/t red wrist\n soft restraints put on pt.\n Action:\n Haldol 5mg, reaasurance from medical staff that she is safe 1:1 time\n with pt.\n Response:\n Pt calmer and able to focus more and listen to rn\n Plan:\n Continue to provide calm environment , ativan ? haldol for panic\n episodes\n Hypotension (not Shock)\n Assessment:\n Bp low , high hr, mouth dry\n Action:\n Ns fluid infusion\n Response:\n Bp >100, hr 80\ns pt less thirsty now\n Plan:\n Continue to monitor for dehydration\n Impaired Skin Integrity r/t knee surgery\n Assessment:\n Left knee surgery leg has ace wrap around incision site, pt refused to\n let rn or md assess.\n Action:\n Leg elevated when pt allows\n Response:\n Less painfull in knee\n Plan:\n Keep leg elevated, try to assess leg when pt is more calmer\n acooperative\n Risk for Injury r/t alerteration in mental status\n Assessment:\n Pt very combative and trying to pull out iv\ns and trying to get oob\n Action:\n Soft wrist restraint, circulation checked frequently sitter 1:1 in room\n bed alarm\n Response:\n Pt is not pulling at lines iv\ns and she is not trying to get oob\n Plan:\n Keep in wrist restriaint and with sitter emotional support for pt and\n family\n"
},
{
"category": "Nursing",
"chartdate": "2109-11-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417629,
"text": "Pt was admitted to from OSH for change in mental status. Pt had\n knee surgery on Thursday this past week. She was sent home on Oxycodone\n for pain. Pt already had been taking pain med for her chronic migraines\n Darvacet. She may have taken both and husband thought she was acting\n bizarre and EMS was called .On arrival pt received Narcan and per\n husband pt awoke very agitated. She was seen at OSH and it was thought\n she would benefit coming to . On arrival to ED she had hr\n 120\ns, sbp <90 pt received 4 L NS which good effects sbp>100 and hr\n down to 80-90\ns. Pt was then very confused and paranoid and combative.\n Pt arrived to ccu in four point restraints. Pt continue to act out in\n CCU she received 5mg Haldol with good effect. Pt slept and when she\n awoke that evening she was alert and oriented x3 cooperating c medical\n staff. Pt received 2.5mg HS Haldol and slept well overnight. This am pt\n is alert and oriented. Pt was found to have some cellulites around knee\n incision and will be tx c Ancef.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain\n Action:\n Tylenol 650mg po, legs elevated on pillows\n Response:\n Pt felt better, less swelling at knee site.\n Plan:\n Continue to monitor pain and swelling, observe for worsening skin\n infection more red and swollen, keep leg elevated, and give pain meds\n no narcotics or benzo\n Risk for Injury\n Assessment:\n Pt has a difficult time standing on leg with knee surgery\n Action:\n Support to take pressure off leg when moving pt was sent home from osh\n after her surgery crutch\n Response:\n Pt was able to stand and pivot into chair and commode several times\n Plan:\n Pt needs a crutch before she goes home to help walk\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-16 00:00:00.000",
"description": "L KNEE( (SINGLE VIEW) LEFT",
"row_id": 1037874,
"text": ", C. MED CCU 2:40 PM\n KNEE( (SINGLE VIEW) LEFT Clip # \n Reason: eval for hardware\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with recent L knee surgery at OSH, unknown procedure, please\n eval if hardware present\n REASON FOR THIS EXAMINATION:\n eval for hardware\n ______________________________________________________________________________\n PFI REPORT\n No hardware is present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037963,
"text": " 7:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with recent knee surgery and new fever, please eval for\n infiltrate.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 3:07 PM\n No pneumonia. Minimal atelectasis is in the left base.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Postoperative fever.\n\n Comparison is made with prior study performed a day earlier.\n\n Cardiomediastinal contours are normal. Aside from minimal atelectasis in the\n left base, the lungs are clear. There is no pleural effusion or pneumothorax.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2109-11-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037964,
"text": ", C. MED CCU 7:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with recent knee surgery and new fever, please eval for\n infiltrate.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n PFI REPORT\n No pneumonia. Minimal atelectasis is in the left base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-16 00:00:00.000",
"description": "L KNEE( (SINGLE VIEW) LEFT",
"row_id": 1037873,
"text": " 2:40 PM\n KNEE( (SINGLE VIEW) LEFT Clip # \n Reason: eval for hardware\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with recent L knee surgery at OSH, unknown procedure, please\n eval if hardware present\n REASON FOR THIS EXAMINATION:\n eval for hardware\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 5:36 PM\n No hardware is present.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Recent left knee surgery at outside hospital, unknown\n procedure; evaluate if hardware is present.\n\n SINGLE AP PORTABLE VIEW OF THE KNEE: No hardware is present. Swelling of the\n lateral soft tissues of the thigh is noted.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2109-11-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037795,
"text": " 7:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for PNA, CHF\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 55-year-old woman with altered mental status.\n\n COMPARISON: Not available.\n\n FINDINGS: Lung volumes are low. The cardiomediastinal silhouette is\n unremarkable. There is a mild atelectasis at the left lung base. There is no\n consolidation, pleural effusion or pneumothorax. Pulmonary vascularity is\n normal.\n\n IMPRESSION: Low lung volumes, left basal atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-11-16 00:00:00.000",
"description": "L KNEE( (SINGLE VIEW) LEFT",
"row_id": 1037895,
"text": " 6:16 PM\n KNEE( (SINGLE VIEW) LEFT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please obtain lateral film that was not obtained previously\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p unknown type of left knee surgery, no with moderate\n erythema at surgical site.\n REASON FOR THIS EXAMINATION:\n Please obtain lateral film that was not obtained previously\n ______________________________________________________________________________\n WET READ: SBNa SAT 7:02 PM\n No hardware. Metallic skin staples unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Please obtain lateral film for a patient with prior knee surgery and\n moderate erythema at surgical site.\n\n A lateral cross-table portable view of the left knee was obtained. Bony\n alignment is within normal limits. There is soft tissue swelling anterior to\n the patella and along the suprapatellar soft tissues. ? joint effusion. Skin\n staples present. No osteolysis or orthopedic hardware is identified on the\n current image.\n\n"
},
{
"category": "ECG",
"chartdate": "2109-11-16 00:00:00.000",
"description": "Report",
"row_id": 224150,
"text": "Submitted late and out of sequence\nSinus rhythm\nAnterior T wave changes are nonspecific\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2109-11-17 00:00:00.000",
"description": "Report",
"row_id": 224385,
"text": "Sinus rhythm. Non-specific ST-T wave changes and slowing of the rate as\ncompared with prior tracing of . No diagnostic interim change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2109-11-16 00:00:00.000",
"description": "Report",
"row_id": 224386,
"text": "Sinus tachycardia. Diffuse non-specific ST-T wave changes. Compared to the\nprevious tracing of no apparent diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2109-11-16 00:00:00.000",
"description": "Report",
"row_id": 224387,
"text": "Sinus tachycardia. The tracing is marred by somatic tremor baseline artifact.\nDiffuse non-specific ST-T wave changes. A repeat tracing of diagnostic quality\nis suggested. No previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
59,411 | 151,021 | HOSPITAL COURSE 66yo man with past medical history of congestive heart failure, end-stage renal disease on dialysis, HTN, who initially presented with respiratory distress and was intubated in the ED, found to have STEMI, s/p cardiac catheterization demonstrating mid-RCA lesion 70-80% that was not intervened upon, was subsequently extubation, course complicated by pancreatitis, now improved. . # STEMI, Hyperkalemia, Acute Systolic CHF, End-stage Renal Disease Patient initially presented hypoxic, thought to be due to acute systolic heart failure and fluid overload. In the ED, in the setting of hyperkalemia, the patient developed wide-complex tachycardia with ST changes concerning for a STEMI, and the pt was urgently transferred to cath lab. On cardiac catheterization an 80% occlusion of the RCA was found, and the pt was noted to have markedly elevated right-sided pressures and wedge pressure. The cardiology team opted for medical management of the RCA lesion, and the patient was transfered to the CCU for urgent dialysis. Patient was dialyzed with improvement in pulmonary status and quickly extubated. A subsequent ECHO showed EF 30-35%. The pt was continued on atorvastatin, plavix, ASA. Continued HD Tues/Thurs/Saturday, nephrocaps. #COLD RIGHT FOOT WITH SURGERY CONSULT: During cardiac catheterization, a right femoral line was placed and shortly after the pt developed blueness and mottling of his foot; Surgery was called who recommended STAT removal of sheath and heparinization, with which the leg turned pink. #BLOWN PUPIL WITH NEUROLOGY CONSULT Following cardiac catheterization, patient was found to have a blown right pupil which was not present on previous admission. The patient CT head for the blown right pupil which showed no intracranial hemorrhage. The neurology team was consulted, reviewed the CT head, and felt he had not had an acute stroke. His dilated right pupil resolved and was felt due to albuterol exposure of the right eye. Another potential etiology that was entertained was cholesterol emboli which would unite the cold right foot and pancreatitis with this condition. #ACUTE PANCREATITIS: On after transfer to the medical floor, the patient developed abdominal pain, was noted to have elevated lipase >200. The pt did endorse drinking whiskey and beer daily prior to admission. CT c/w diagnosis of acute pancreatitis w/o signs of complications including no gallstones of biliary dilation. Patient was transferred to ICU to receive fluids in concert with dialysis. Patient was made NPO and was started on dilaudid PCA. Pain improved over 24 hours; diet was slowly adanced. There was question of ileus on KUB although no clinical signs were apparent. Diet was advanced with transition from PCA to oral analgesia. On discharge, patient was taking PO and was moving his bowels, but still requiring occasional (twice daily) oral narcotics. | There is a trivial/physiologic pericardial effusion. FINDINGS: NON-CONTRAST HEAD CT: There are mild areas of hypodensity in the left pon and left parietal cortex, acuity uncertain. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.PERICARDIUM: Trivial/physiologic pericardial effusion. There is mild symmetric left ventricular hypertrophy. Right ventricular chamber size isnormal. Mild distention of transverse colon is consistent with colonic ileus. There is an anteriorspace which most likely represents a fat pad, though a loculated anteriorpericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Probable patchy opacities at the lung bases. NOn-contrast CT Head: Small hypodense focus in the left side of pons, new since and studies; more conspicuous fromr ecent CT Head- etiology uncertain. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There is mild symmetric left ventricularhypertrophy. Mild calcific and non-calcific plaque in the vertical canalicular and cavernous portions of the bilateral carotids is nonocclusive. The tricuspid valve leaflets are mildlythickened. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basalanteroseptal - akinetic; mid anteroseptal - akinetic; basal inferoseptal -akinetic; mid inferoseptal - akinetic; basal inferior - akinetic; mid inferior- akinetic; anterior apex - akinetic; septal apex- akinetic; inferior apex -akinetic; lateral apex - akinetic;RIGHT VENTRICLE: Normal RV chamber size. Probable small bilateral pleural effusions persist. Mild global RV free wall hypokinesis.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Mild calcific and non-calcific plaque is noted throughout the course of the aortic arch vessels. The left adrenal gland appears bulky but the right adrenal gland is within normal limits (4a:46). with focal hypokinesis of the apical free wall. A femoral central line is noted. A focal noncalcified plaque is noted in the bilateral common carotid arteries just proximal to the bifurcation. Left femoral catheter. IMPRESSION: Unchanged cardiomegaly and moderate-to-severe pulmonary edema. CT OF HEAD WITHOUT CONTRAST: The study is limited by motion-related artifacts. Differential diagnosis includes ileus or early vs partial small bowel obstruction. Trivialmitral regurgitation is seen. The severity of the pre-existing mostly gas-filled and mildly dilated bowel loops is unchanged. Mild tortuosity of thoracic aorta and borderline heart size is unchanged. Shortness of breath.BP (mm Hg): 150/90HR (bpm): 125Status: InpatientDate/Time: at 08:59Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Elongated LA.LEFT VENTRICLE: Mild symmetric LVH. Suboptimalimage quality - ventilator.Conclusions:The left atrium is elongated. Slightly dense right transverse sinus is noted, of equivocal significance. Otherwise, the ventricles and sulci are normal in caliber and configuration other than previously noted area in the left frontoparietal infarct. There is a trivial/physiologicpericardial effusion.Views limited and not suitable for comparison to prior (complete) studyperformed on . Right ventricular function. Doppler parameters are most consistent with GradeIII/IV (severe) left ventricular diastolic dysfunction. Definity to evaluate for LV thrombus. Otherwise, atherosclerotic changes are visualized throughout the aorta but the aorta is of normal caliber and contour. Compared to the previous tracingcardiac rhythm is now sinus mechanism and intraventricular conduction delayis no longer present.TRACING #4 FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. Sinus tachycardia versus atrial flutter with 2:1 atrio-ventricular block.Compared to the previous tracing there is no major change.TRACING #3 Unchanged bilateral parenchymal opacities, unchanged size of the cardiac silhouette. Clinical correlation is suggested.Compared to the previous tracing of there is no diagnostic change. Sinus tachycardia with intraventricular conduction delay. Left atrialabnormality. IMPRESSION: Unchanged atelectasis. No pneumothorax has developed and the previously existing plethoric appearance of the pulmonary vasculature has further regressed. Possible anteroseptal myocardial infarction of indeterminateage. There has been removal of an OG tube. The course of the line is unremarkable, the tip of the line projects over the right atrium. Compared to the previous tracing of no diagnostic interval change. Sinus tachycardia versus atrial flutter with 2:1 atrio-ventricular block.Compared to the previous tracing atrial flutter may now be present.TRACING #2 FINDINGS: As compared to the previous radiograph, there is no relevant change. PTX, mainstem intubation FINAL REPORT CHEST RADIOGRAPH: INDICATION: Chest wall distention following recent intubation, questionable pneumothorax. FINAL REPORT CHEST RADIOGRAPH INDICATION: PICC line placement. Atelectatic changes are seen at the left base without evidence of acute pneumonia. Sinus rhythm with diffuse non-diagnostic repolarization abnormalities.Compared to the previous tracing multiple abnormalities as previously describedpersist without major change.TRACING #5 Continued enlargement of the cardiac silhouette without definite vascular congestion. Marked repolarization abnormalities. Unchanged borderline size of the cardiac silhouette without evidence of pulmonary edema. Compared to the previous tracing of marked QRS widening with secondary repolarization abnormalities are nowpresent.TRACING #1 FINDINGS: AP single view of the chest has been obtained with patient in sitting semi-upright position. ST-T wave changessuggetive of ischemia. Again seen is a left PICC line whose tip terminates within the SVC. FINDINGS: Single portable frontal view of the chest shows no progression of the atelectasis seen in the left lung base and right minor fissure. Sinus tachycardia. Voltage criteria for left ventricular hypertrophy withextensive ST-T wave abnormalities which may represent secondary repolarizationabnormalities and/or myocardial ischemia. The main portal vein is patent with hepatopetal flow. Available for comparison is the next preceding portable chest examination of . Sinus rhythm. The heart size is unchanged. The gallbladder is normal without evidence of stones. The echogenicity of the pancreas is within normal limits, and no peri-pancreatic fluid collection is identified. 11:34 AM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: ? Markedrepolarization abnormalities. Thus, no evidence of reoccurrence of the patient's previously established pulmonary edema most marked on examination of . | 29 | [
{
"category": "Radiology",
"chartdate": "2161-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1202045,
"text": " 5:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for fluid overload\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with shortness of breath\n REASON FOR THIS EXAMINATION:\n eval for fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male with dyspnea.\n\n COMPARISON: .\n\n CHEST, AP: Mild vascular congestion has developed, along with diffuse\n bilateral interstitial and airspace pulmonary opacities. Probable small\n bilateral pleural effusions persist. Mild cardiomegaly is present.\n\n IMPRESSION: New bilateral interstitial and airspace opacities, most\n consistent with congestive heart failure. Concurrent pneumonia cannot be\n excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1202046,
"text": " 6:31 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with respiratory distress\n REASON FOR THIS EXAMINATION:\n eval tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male with respiratory distress, intubated.\n\n COMPARISON: at 5:56.\n\n CHEST, AP SUPINE: New endotracheal tube terminates 5 cm above the carina, and\n nasogastric tube courses into the stomach, with tip just beyond the\n gastroesophageal junction. There is continued mild cardiomegaly, vascular\n congestion, and worsening moderately severe pulmonary edema.\n\n IMPRESSION:\n 1. ETT 5 cm from carina.\n 2. NGT in proximal stomach.\n 3. Worsening pulmonary edema probably due to recurrent congestive heart\n failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-22 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1202089,
"text": " 12:33 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: ?anneurysm\n Admitting Diagnosis: RESPIRATORY FAILURE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with newly blown R. Pupil, 7mm non-responsive. Concern for\n compression from an anneurysm\n REASON FOR THIS EXAMINATION:\n ?anneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf TUE 5:13 PM\n 1. Multiple areas of calcific and non-calcific atherosclerotic plaque causing\n narrowing of the right internal carotid artery at the bulb with a short area\n of severe narrowing of the right external carotid artery just past its origin.\n No aneurysms noted.\n\n 2. Bilateral large consolidations with multiple enlarged lymph nodes noted\n within the mediastinum.\n\n 3. Focal area of hypodensity in the left pons is unchanged and age\n indeterminate. An MR may be obtained for further evaluation.\n\n 4. Moderate proptosis of both globes could be related to disease.\n\n NOn-contrast CT Head:\n Small hypodense focus in the left side of pons, new since and \n studies; more conspicuous fromr ecent CT Head- etiology uncertain. COnsider MR\n to exclude ischemia/infarction. Consider MR if not contra-indicated.\n Dense appearance of the transverse and superior sagittal sinuses- ? slow flow-\n no prior contrast injected. However, enhance on CTA.\n\n 2. CTA: Sigf. atherosclerotic disease in the common carotid bif. and px\n cervical ICA and cavernous carotid segments. Pending 3D ref. No obvious\n aneurysm.\n\n D/w Dr. by Dr. on soon after the study\n WET READ VERSION #1\n WET READ VERSION #2 NPw TUE 1:29 PM\n NOn-contrast CT Head:\n Small hypodense focus in the left side of pons, new since and \n studies; more conspicuous fromr ecent CT Head- etiology uncertain. COnsider MR\n to exclude ischemia/infarction. Consider MR if not contra-indicated.\n Dense appearance of the transverse and superior sagittal sinuses- ? slow flow-\n no prior contrast injected. However, enhance on CTA.\n\n 2. CTA: Sigf. atherosclerotic disease in the common carotid bif. and px\n cervical ICA and cavernous carotid segments. Pending 3D ref. No obvious\n aneurysm.\n\n D/w Dr. by Dr. on soon after the study\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with newly blown right pupil 7 mm, nonresponsive.\n (Over)\n\n 12:33 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: ?anneurysm\n Admitting Diagnosis: RESPIRATORY FAILURE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Concern for compression from an aneurysm.\n\n COMPARISON: Head CT from .\n\n TECHNIQUE: MDCT images were acquired through the head and neck with and\n without IV contrast. Maximal intensity projections, multiplanar reformations,\n volume-rendered images, and curved multiplanar reformations were obtained and\n reviewed.\n\n FINDINGS:\n\n NON-CONTRAST HEAD CT: There are mild areas of hypodensity in the left pon and\n left parietal cortex, acuity uncertain. Also noted is moderate proptosis of\n both globes related to prominent retrobulbar fat. The extraocular muscles\n appear normal.\n\n CTA:\n\n No aneurysms are noted in the intracranial vessels. Mild calcific and\n non-calcific plaque is noted throughout the course of the aortic arch vessels.\n A focal noncalcified plaque is noted in the bilateral common carotid arteries\n just proximal to the bifurcation. There is severe mixed plaque in the right\n internal carotid artery just past the bifurcation. Also noted is severe\n narrowing of a short segment of the external carotid artery on the right. Mild\n plaque is noted in the carotid bulb on the left. Mild calcific and\n non-calcific plaque in the vertical canalicular and cavernous portions of the\n bilateral carotids is nonocclusive. The intracranial vessels are patent with\n no thrombosis, dissection or aneurysm. Both vertebral arteries are patent.\n\n The minimal diameter of the right internal carotid artery at its site of\n maximal stenosis measures 2.2 mm while the minimal distal cervical internal\n carotid artery measures 3.6 mm corresponding to a stenosis of 40%. The area\n of maximal stenosis within the left internal carotid artery measures 3 mm\n while the distal reference measures 3.2 mm corresponding to a 7% stenosis.\n\n The partially imaged lungs show severe bilateral consolidations with multiple\n enlarged lymph nodes in the neck. The ET tube and NG tube are appropriate.\n Nasopharyngeal fluid is likely related to intubation.\n\n IMPRESSION:\n\n 1. Multiple areas of calcific and non-calcific atherosclerotic plaque causing\n 40% narrowing of the right internal carotid artery at the bulb with a short\n area of severe narrowing of the right external carotid artery just past its\n origin. No aneurysms noted.\n (Over)\n\n 12:33 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: ?anneurysm\n Admitting Diagnosis: RESPIRATORY FAILURE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Bilateral large consolidations with multiple enlarged lymph nodes noted\n within the mediastinum.\n\n 3. Focal area of hypodensity in the left pons is unchanged and age\n indeterminate. An MR may be obtained for further evaluation.\n\n 4. Moderate proptosis of both globes could be related to disease\n although the extraocular muscles are normal in morphology.\n\n"
},
{
"category": "Echo",
"chartdate": "2161-09-22 00:00:00.000",
"description": "Report",
"row_id": 61676,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction. Right ventricular function. Shortness of breath.\nBP (mm Hg): 150/90\nHR (bpm): 125\nStatus: Inpatient\nDate/Time: at 08:59\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\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Severe regional LV\nsystolic dysfunction. Doppler parameters are most consistent with Grade III/IV\n(severe) LV diastolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - akinetic; mid anteroseptal - akinetic; basal inferoseptal -\nakinetic; mid inferoseptal - akinetic; basal inferior - akinetic; mid inferior\n- akinetic; anterior apex - akinetic; septal apex- akinetic; inferior apex -\nakinetic; lateral apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size. Focal apical hypokinesis of RV free\nwall.\n\nAORTIC VALVE: Aortic valve not well seen. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. There is an anterior\nspace which most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - ventilator.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. There is severe\nregional left ventricular systolic dysfunction with septal, inferior and\napical akinesis. Views suboptimal for assessment of regional wall motion;\nestimated left ventricular ejection fraction ?20-25%. Cannot exclude left\nventricular apical thrombus. Doppler parameters are most consistent with Grade\nIII/IV (severe) left ventricular diastolic dysfunction. Right ventricular\nchamber size is normal. with focal hypokinesis of the apical free wall. The\naortic valve is not well seen. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial\nmitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is a trivial/physiologic pericardial effusion. There is an\nanterior space which most likely represents a prominent fat pad.\n\nCompared with the prior study (images reviewed) of , regional wall\nmotion abnormalities are now more extensive (previously there was basal\ninferoseptal and basal inferior hypokineiss/akinesis and mid to apical\nanterior hypokinesis/akinesis).\n\n\n"
},
{
"category": "Echo",
"chartdate": "2161-09-23 00:00:00.000",
"description": "Report",
"row_id": 61751,
"text": "PATIENT/TEST INFORMATION:\nIndication: 20 percent drop in ejection fraction last month after ultrafiltration. Definity to evaluate for LV thrombus. Congestive heart failure.\nHeight: (in) 64\nWeight (lb): 153\nBSA (m2): 1.75 m2\nBP (mm Hg): 105/58\nHR (bpm): 111\nStatus: Inpatient\nDate/Time: at 09:01\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild symmetric LVH. Suboptimal technical quality, a focal LV\nwall motion abnormality cannot be fully excluded. Moderately depressed LVEF.\nNo LV mass/thrombus.\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews. Suboptimal image quality - poor subcostal views. Suboptimal image\nquality as the patient was difficult to position. Suboptimal image quality -\npatient unable to cooperate.\n\nConclusions:\nFOCUSED STUDY for evaluation of left ventricular thrombus. Only subcostal\nviews obtained. There is mild symmetric left ventricular hypertrophy. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Overall ejection fraction moderate to severely depressed.No masses\nor thrombi are seen in the left ventricle. Right ventricular chamber size is\nnormal. with mild global free wall hypokinesis. There is a trivial/physiologic\npericardial effusion.\n\nViews limited and not suitable for comparison to prior (complete) study\nperformed on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-25 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1202644,
"text": " 7:08 PM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate for dilated bowel loops or free air\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with acute pancreatitis\n REASON FOR THIS EXAMINATION:\n evaluate for dilated bowel loops or free air\n ______________________________________________________________________________\n WET READ: ENYa FRI 10:44 PM\n Diffuse gas-distended bowel loops, could represent pancreatitis-related ileus.\n The degree of distention has mildly decreased from prior study. No definite\n evidence of free air.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66 year-old man with acute pancreatitis.\n PORTABLE ABDOMEN\n\n Both views are likely supine. There is some mild blurring due to motion. Air\n is seen in multiple loops of large and small bowel. Small bowel loops are\n mildly dilated. No free air beneath the diaphragm. Scattered stool present.\n Probable patchy opacities at the lung bases. A femoral central line is noted.\n Scattered vascular calcification is present.\n\n IMPRESSION:\n\n Several mildly dilated loops of small bowel. Differential diagnosis includes\n ileus or early vs partial small bowel obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-23 00:00:00.000",
"description": "UNILAT UP EXT VEINS US",
"row_id": 1202266,
"text": " 2:16 PM\n UNILAT UP EXT VEINS US Clip # \n Reason: ? LUE thrombus\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with LUE edema, ? thrombus\n REASON FOR THIS EXAMINATION:\n ? LUE thrombus\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old male with left upper extremity edema.\n\n COMPARISON: None available in the system.\n\n LEFT UPPER EXTREMITY DOPPLER ULTRASOUND: Grayscale and doppler son of\n the bilateral subclavian, left internal jugular, left axillary, left brachial,\n left basilic veins were obtained. There is normal flow, compressibility, and\n augmentation. The left cephalic vein was not visualized.\n\n IMPRESSION: No evidence of DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-28 00:00:00.000",
"description": "ART EXT (REST ONLY)",
"row_id": 1202918,
"text": " 10:13 AM\n ART EXT (REST ONLY) Clip # \n Reason: COLD LEFT HAND S/P PICC LINE PLACEMENT, ASSESS PERFUSION\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with pancreatitis s/p left sided PICC placement today. Hand\n was swollen before but now is cool to touch and cyanotic.\n REASON FOR THIS EXAMINATION:\n adequate perfusion following PICC placement?\n ______________________________________________________________________________\n FINAL REPORT\n UPPER EXTREMITY DOPPLER AND PULSE VOLUME RECORDINGS OF THE UPPER EXTREMITIES\n\n INDICATION: 66-year-old man with pancreatitis, status post left-sided PICC\n placement. The hand was swollen before the placement, but currently is cool\n to touch and cyanotic. Evaluation of adequate perfusion following PICC\n placement.\n\n No studies available for comparison.\n\n TECHNIQUE: Doppler waveforms and segmental blood pressures were acquired from\n the upper extremities bilaterally.\n\n FINDINGS: Normal triphasic flow is seen on the Doppler recordings from\n bilateral upper extremities at the level of the brachial, radial and ulnar\n arteries. Pulse volume recordings are symmetrical at the forearm, wrist and\n the digit level.\n\n IMPRESSION: No significant arterial obstruction in the upper extremities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-24 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 1202429,
"text": " 12:58 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: eval for mesenteric ischemia v. perforation v. obstruction v\n Admitting Diagnosis: RESPIRATORY FAILURE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old male prior smoker with CAD, ESRD on HD, with recent cardiac cath\n c/b ischemic foot which revascularized after sheath pull, who has acute\n abdominal pain and peritoneal signs.\n REASON FOR THIS EXAMINATION:\n eval for mesenteric ischemia v. perforation v. obstruction v. aortic\n dissection. please do CTA. please call with questions\n CONTRAINDICATIONS for IV CONTRAST:\n please see study request\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with abdominal pain.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis prior to administration of IV contrast. Following the administration\n of 150 cc of Optiray nonionic intravenous contrast, MDCT-acquired axial images\n were obtained through the abdomen and pelvis as per mesenteric CTA protocol.\n Multiplanar reformatted images were prepared.\n\n FINDINGS:\n\n There are bibasilar atelectatic changes along with a small left pleural\n effusion with adjacent airspace atelectasis.\n\n The pancreas appears diffusely enlarged, heterogeneous, and with surrounding\n fat stranding and free fluid consistent with acute pancreatitis. There is no\n evidence of distinct hypodense foci to represent significant necrosis at this\n time.\n\n Otherwise, atherosclerotic changes are visualized throughout the aorta but the\n aorta is of normal caliber and contour. Evidence of possible stenosis at the\n origin of the celiac trunk; otherwise, the major celiac vessels are patent.\n The SMA is patent.\n\n There is a 12 x 12 mm hypodense focus in segment V/VI of the liver with\n Hounsfield units which are too high for a simple cyst. Otherwise, the liver\n is normal with no evidence of intra- or extra-hepatic biliary ductal\n dilatation. The branches of the hepatic artery appear widely patent. The\n main portal vein is patent.\n\n Gallbladder is normal. The stomach, visualized loops of small and large bowel\n are normal. The left adrenal gland appears bulky but the right adrenal gland\n is within normal limits (4a:46).\n\n Bilateral kidneys appear atrophic consistent with chronic kidney disease.\n (Over)\n\n 12:58 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: eval for mesenteric ischemia v. perforation v. obstruction v\n Admitting Diagnosis: RESPIRATORY FAILURE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Multiple hypodense structures are visualized throughout bilateral kidneys and\n likely representative of dialysis related cyst. The spleen is within normal\n limits with an adjacent splenule. No free air is throughout the abdomen.\n Multiple prominent retroperitoneal lymph nodes are visualized, none of which\n meet criteria for pathologic enlargement. No mesenteric lymphadenopathy.\n\n CTA OF THE PELVIS: The bladder, prostate, rectum, and sigmoid colon are\n within normal limits. No free fluid or free air throughout the pelvis. No\n pelvic or inguinal lymphadenopathy by CT size criteria.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n 1. Diffusely enlarged and heterogeneous pancreas with surrounding stranding\n and free fluid, is consistent with acute pancreatitis.\n 2. No evidence of mesenteric ischemia.\n 3. Hypodense structure is visualized in the right lobe of the liver with\n Hounsfield units which are too high for a simple cyst. A dedicated MRI on a\n non-emergent setting is recommended.\n 4. The left adrenal gland appears bulky. A dedicated MRI is recommended in a\n non-emergent setting.\n\n These findings were discussed by Dr. with via telephone at 4\n p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-27 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1202793,
"text": " 8:58 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ? bowel perforation\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with abd pain, pancreatitis question ileus, question bowel\n perforation.\n REASON FOR THIS EXAMINATION:\n ? bowel perforation\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL RADIOGRAPH\n\n INDICATION: Abdominal pain, pancreatitis, questionable bowel perforation.\n\n COMPARISON: .\n\n FINDINGS: On the three images acquired at today's examination, there is no\n evidence of free intraperitoneal air. The severity of the pre-existing mostly\n gas-filled and mildly dilated bowel loops is unchanged. The left lateral\n decubitus shows several small air-fluid levels. No pathological\n calcifications, small phleboliths in the pelvis. Left femoral catheter.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-22 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1202051,
"text": " 8:07 AM\n CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # \n Reason: recheck tube place, ptx?\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with intub, asym chest mvt\n REASON FOR THIS EXAMINATION:\n recheck tube place, ptx?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: 66-year-old man with intubation, asymmetric chest post tube\n placement, to look for pneumothorax.\n\n TECHNIQUE: Frontal radiograph of chest.\n\n Comparison was made with prior chest radiographs through with\n the most recent from .\n\n FINDINGS: Endotracheal tube is 4.8 cm above the carina and is adequately\n placed. Distal end of orogastric tube including the sidehole appears to be\n within the stomach and adequately placed. Cardiomegaly and moderate-to-severe\n pulmonary edema is unchanged since . There is no pneumothorax.\n\n IMPRESSION: Unchanged cardiomegaly and moderate-to-severe pulmonary edema.\n No evidence of pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-27 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1202845,
"text": " 5:38 PM\n PORTABLE ABDOMEN Clip # \n Reason: NG tube correctly placed?\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with Pancreatitis, just had NG tube placed.\n REASON FOR THIS EXAMINATION:\n NG tube correctly placed?\n ______________________________________________________________________________\n WET READ: MXAk SUN 6:01 PM\n NG tube with tip in the stomach. Several dilated loops of small bowel persist\n with the differential including ileus or small bowel obstruction. Enlarged\n cardiac silhouette with prominence of lung vasculature and fluid in the\n fissure is indicative of increased central venous pressure.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation after placement of NG tube.\n\n COMPARISON: .\n\n TECHNIQUE: Portable upright abdomen radiograph.\n\n FINDINGS: Tip of NG tube is observed in the stomach, but the side port is\n approximately at the level of the gastroesophageal junction. The transverse\n colon is mildly distended with a diameter of 6.4 cm. Bowel gas pattern is\n normal. No soft tissues calcifications are seen.\n\n IMPRESSION:\n 1. Sided port of NG tube is at the level of the gastroesophageal junction.\n Recommend advancing the tube approximately 2 cm.\n 2. Mild distention of transverse colon is consistent with colonic ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1202050,
"text": " 7:55 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with respiratory arrest\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw TUE 6:06 PM\n 1. Small 4-mm hypodensity in the left aspect of the pons, not seen in the\n previous studies. If there are no contraindications, consider MR study to\n further evaluate this lesion.\n 2. Volume loss associated with previously documented stroke in the left\n frontoparietal area. No other changes in the ventricles or sulci are noted.\n\n Please note, this study is limited by motion-related artifacts.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: Respiratory arrest, evaluation for CVA.\n\n COMPARISON EXAM: MRI of the head, and CT of the head without\n contrast, .\n\n TECHNIQUE: Multidetector CT-acquired axial images from the vertex to the\n level of C1 were displayed with 5-mm slice thickness. Coronally and\n sagittally reformatted images were displayed with 2-mm slice thickness.\n\n CT OF HEAD WITHOUT CONTRAST:\n\n The study is limited by motion-related artifacts. Seen in the left posterior\n aspect of the frontal lobe is volume loss with encephalomalacic changes which\n correlate with previously documented watershed infarct in .\n\n In the left side of the pons, there is a small spherical hypodensity, not\n previously seen on prior studies. It measures approximately 4-mm in diameter\n and is seen best in image 2A:8. If there are no contraindications, consider\n MR study for further evaluation of this lesion to exclude an acute infarct.\n\n There are stable periventricular hypoattenuation foci noted in previous\n studies, especially in the left frontal lobe consistent with chronic small\n vessel ischemic disease. Otherwise, the ventricles and sulci are normal in\n caliber and configuration other than previously noted area in the left\n frontoparietal infarct. Slightly dense right transverse sinus is noted, of\n equivocal significance.\n\n IMPRESSIONS:\n 1. Small 4-mm hypodensity in the left side of the pons, not seen in the\n previous studies. If there are no contraindications, consider MR study to\n further evaluate this lesion to exclude acute infarct.\n\n (Over)\n\n 7:55 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Slightly dense right transverse sinus, of equivocal significance- attention\n on close followup.\n\n Please note, this study is limited by motion-related artifacts.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1202195,
"text": " 7:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Is there inverval change in pulmonary congestion/edema?\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with admission for volume overload in the setting of needing\n dialysis. Now s/p first dialysis session and wanted to assess effect.\n REASON FOR THIS EXAMINATION:\n Is there inverval change in pulmonary congestion/edema?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male with fluid overload. Evaluate for change status\n post diuresis via dialysis.\n\n EXAMINATION: Single frontal chest radiograph.\n\n COMPARISONS: and .\n\n FINDINGS: An endotracheal tube and enteric feeding tube have been removed.\n Pulmonary edema is improved, and is minimal if any, with mild residual\n asymmetric right-sided opacification. There are no pleural effusions or\n pneumothorax. Mild tortuosity of thoracic aorta and borderline heart size is\n unchanged.\n\n IMPRESSION: Improvement in asymmetric interstitial pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-28 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1202916,
"text": " 9:47 AM\n PORTABLE ABDOMEN Clip # \n Reason: KUB for increased distension\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ESRD on dialysis, now with pancreatitis\n REASON FOR THIS EXAMINATION:\n KUB for increased distension\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN.\n\n INDICATION: 66-year-old man with ESRD on dialysis, now with pancreatitis.\n Evaluate for increased distention.\n\n ABDOMEN, PORTABLE: Air is identified in the small and large bowel. The\n transverse colon is now dilated to 7.6 cm (previously 7.3 cm). Air is\n identified in the rectum.\n\n IMPRESSION: Increasing adynamic ileus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203116,
"text": " 12:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Acute pulmonary process?\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ESRD, now with low sats.\n REASON FOR THIS EXAMINATION:\n Acute pulmonary process?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Desaturation.\n\n COMPARISON: .\n\n FINDINGS: Single portable frontal view of the chest shows no progression of\n the atelectasis seen in the left lung base and right minor fissure. No\n pleural effusion or pneumothorax. The heart size is unchanged. Again seen is\n a left PICC line whose tip terminates within the SVC. There has been removal\n of an OG tube.\n\n IMPRESSION: Unchanged atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1202811,
"text": " 12:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 52cm left picc. tip?\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 52cm left picc. tip?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n new PICC line. The course of the line is unremarkable, the tip of the line\n projects over the right atrium. The line should be pulled back by\n approximately 5 cm.\n\n No evidence of complications, notably no pneumothorax.\n\n Unchanged borderline size of the cardiac silhouette without evidence of\n pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1202867,
"text": " 1:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube placement\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with pancreatitis with possible ileus\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pancreatitis and possible ileus, for NG tube placement.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n nasogastric tube that extends to the fundus of the stomach. Left PICC line\n remains in place. Continued enlargement of the cardiac silhouette without\n definite vascular congestion. Atelectatic changes are seen at the left base\n without evidence of acute pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1202428,
"text": " 12:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: correct placement of NG tube.\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ESRD, now with NG tube placed.\n REASON FOR THIS EXAMINATION:\n correct placement of NG tube.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 66-year-old male patient with end-stage renal disease, now with\n new NG tube placed, assess correct position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. Available for comparison is the next preceding\n portable chest examination of . An NG tube has been placed.\n Special enhanced contrast imaging identifies the NG tube very well seen to\n reach into the body of the stomach and this includes the side port. No\n pneumothorax has developed and the previously existing plethoric appearance of\n the pulmonary vasculature has further regressed. Thus, no evidence of\n reoccurrence of the patient's previously established pulmonary edema most\n marked on examination of . Previously described left-sided old rib\n fractures remain unchanged.\n\n IMPRESSION: Correct position of NG tube.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1202081,
"text": " 11:34 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? PTX, mainstem intubation\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with asymetrical L> chest wall distension following recent\n intubation\n REASON FOR THIS EXAMINATION:\n ? PTX, mainstem intubation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH:\n\n INDICATION: Chest wall distention following recent intubation, questionable\n pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The monitoring and support devices are in unchanged position. No\n evidence of pneumothorax. Unchanged bilateral parenchymal opacities,\n unchanged size of the cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-09-25 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1202582,
"text": " 1:43 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: ?Gallbladder disease\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with ESRD, sCHF, COPD admitted for pancreatitis, has history of\n alcohol use but evaluate for causes of pancreatitis\n REASON FOR THIS EXAMINATION:\n ?Gallbladder disease\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old male admitted with pancreatitis. Evaluation for\n cholelithiasis.\n\n COMPARISON: CT abdomen from .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver demonstrates homogeneous\n echogenicity without suspicious focal lesion. The main portal vein is patent\n with hepatopetal flow. The gallbladder is normal without evidence of stones.\n The common bile duct measures 5 mm and is not dilated. The echogenicity of\n the pancreas is within normal limits, and no peri-pancreatic fluid collection\n is identified. The spleen is enlarged measuring 15 cm. The kidneys appear\n echogenic and atrophic, measuring 8.1 cm each. There is no stone,\n hydronephrosis or suspicious renal mass. A 1.5 x 1.3 cm simple cyst is\n identified in the upper pole of the left kidney.\n\n IMPRESSION:\n 1. Normal gallbladder without evidence of stones or sludge.\n 2. Atrophic echogenic kidneys consistent with end-stage renal disease.\n 3. Splenomegaly.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2161-09-22 00:00:00.000",
"description": "Report",
"row_id": 111253,
"text": "Sinus tachycardia with intraventricular conduction delay. Marked\nrepolarization abnormalities. Compared to the previous tracing of \nmarked QRS widening with secondary repolarization abnormalities are now\npresent.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2161-09-22 00:00:00.000",
"description": "Report",
"row_id": 111254,
"text": "Probable sinus tachycardia at a rate of 150 beats per minute. Left atrial\nabnormality. Poor R wave progression in leads V1-V4. ST-T wave changes\nsuggetive of ischemia. Compared to the previous tracing of the heart\nrate has increased from 90 to 150 and ST-T wave changes are more pronounced.\n\n"
},
{
"category": "ECG",
"chartdate": "2161-09-30 00:00:00.000",
"description": "Report",
"row_id": 111247,
"text": "Normal sinus rhythm. Voltage criteria for left ventricular hypertrophy with\nextensive ST-T wave abnormalities which may represent secondary repolarization\nabnormalities and/or myocardial ischemia. Clinical correlation is suggested.\nCompared to the previous tracing of there is no diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2161-09-24 00:00:00.000",
"description": "Report",
"row_id": 111248,
"text": "Marked baseline artifact. Sinus tachycardia. Left ventricular hypertrophy.\nExtensive ST-T wave changes. Compared to the previous tracing of \nno diagnostic interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2161-09-23 00:00:00.000",
"description": "Report",
"row_id": 111249,
"text": "Sinus rhythm with diffuse non-diagnostic repolarization abnormalities.\nCompared to the previous tracing multiple abnormalities as previously described\npersist without major change.\nTRACING #5\n\n"
},
{
"category": "ECG",
"chartdate": "2161-09-22 00:00:00.000",
"description": "Report",
"row_id": 111250,
"text": "Sinus rhythm. Possible anteroseptal myocardial infarction of indeterminate\nage. Marked repolarization abnormalities. Compared to the previous tracing\ncardiac rhythm is now sinus mechanism and intraventricular conduction delay\nis no longer present.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2161-09-22 00:00:00.000",
"description": "Report",
"row_id": 111251,
"text": "Sinus tachycardia versus atrial flutter with 2:1 atrio-ventricular block.\nCompared to the previous tracing there is no major change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2161-09-22 00:00:00.000",
"description": "Report",
"row_id": 111252,
"text": "Sinus tachycardia versus atrial flutter with 2:1 atrio-ventricular block.\nCompared to the previous tracing atrial flutter may now be present.\nTRACING #2\n\n"
}
] |
51,446 | 116,410 | Assessment and Plan 73 year old Albanian speaking only male with hx of CAD, HTN, HL, CVA, PVD, and ESRD on HD T/Th/S sent in from clinic with concern for a clotted right UE HD AV graft. | An 035 glidewire was advanced through the thrombosed graft through the venous anastamosis into the right brachiocephalic vein. Patient presented on with a clotted fistulla and subsequently underwent a declotting procedure. Using ultrasound guidance, the patent left femoral vein was accessed using a micropuncture needle, through which a 0.018 guide nitinol wire was advanced into the IVC under fluoroscopic guidance. A hand injection of contrast demonstrated a clot filling the graft. Over the wire, a 4F straight flush catheter was advanced to the region of the axillary vein and digital subtraction venogram was performed which redemonstrated two areas of apparent narrowing in the left brachiocephalic vein and upper SVC, though without significant collateral flow noted suggesting that they may not be hemodynamically significant. Following anesthesia timeout, anesthesia was initiated. Additional digital subtraction venogram was performed with catheter tip in the proximal arm veins. Purse-string sutures were applied at both access points in the graft and the sheaths were removed and the access points were held for adequate hemostasis. Tip of the catheter is placed in the IVC and ready to use. With ultrasound guidance, the AV loop graft was accessed using a micropuncture needle close to the arterial side and directed towards the venous side. Embolectomy at the level of the arterial anastomosis. We then crossed into the brachial artery proximal to the graft take off using a glide wire and performed a digital subtraction angiogram. REASON FOR THIS EXAMINATION: please evaluate AV graft, perform thrombectomy if feasible FINAL REPORT INDICATION: Recurrent thrombosis of the right upper extremity AV graft, suspect prominent venous anastomosis. The catheter was secured to the skin using a 0 silk suture and sterile dressings were applied. The micropuncture sheath was removed and the soft tissue tract was dilated using a 12 and 14 French dilators. The tip of the catheter was positioned in the IVC. With the catheter, a further 4mg TPA was instilled into the graft at the arterial side. The graft was then accessed in a retrograde fashion with a micropuncture set and ultrasound guidance and a 6 French sheath was placed. A digital subtraction venogram performed more distally in the arm demonstrated areas of narrowing in the outflow vein, despite prior venoplasty Attention was first turned to the central veins. The mechanised cleaner device was intermittently used for mechanical thrombolysis within the graft. MEDICATIONS: General anesthesia was given by the anesthesiologist. US demonstrated thrombosed right femoral vein, as well as left internal jugular. AV fistulagram with catheter-directed TPA injection, 2. Needle was exchanged for a micropuncture sheath and the wire upsized to wire, which was navigated into the IVC for stability. The level of the arterial inflow anastamosis and the venous outflow anastamosis were marked on the patients skin.Bruising from a prior intervention or access was noted. (Over) 8:25 AM AV FISTULOGRAM SCH Clip # Reason: please evaluate AV graft, perform thrombectomy if feasible Admitting Diagnosis: HYPERKALEMIA;FISTULA OBSTRUCTION Contrast: OPTIRAY Amt: 250 FINAL REPORT (Cont) CONCLUSION: Uncomplicated AV fistulagram with extensive intervention as above including chemical and mechanical thrombectomy, balloon dilatation of central venous strictures, dilatation and stenting of venous anastomosis, and removal of organized thrombus at the arterial anastomosis. IMPRESSION: Uncomplicated placement of a temporary left femoral line, for hemodialysis access. Metallic stenting of the venous anastamosis. Today, patient presents again with a thrombosed AV fistula. Now patient comes in for a temporary line. Multiple sweeps were made with a 5.5F embolectomy balloon catheter which successfully removed two firm plugs of organized thrombus from the arterial anastomotic site. PHYSICIAN: , .D., attending, was present and supervising, , M.D., fellow, was performing the procedure. At this point, 3 mg of TPA (Over) 8:25 AM AV FISTULOGRAM SCH Clip # Reason: please evaluate AV graft, perform thrombectomy if feasible Admitting Diagnosis: HYPERKALEMIA;FISTULA OBSTRUCTION Contrast: OPTIRAY Amt: 250 FINAL REPORT (Cont) was infused via a catheter into the graft. This demonstrated a persistant filling defect in the graft near the arterial anastomosis. When inflated at the venous anastomosis, there was a significant waist which improved on post plasty runs. This demonstrated some persistent narrowing of the venous anastomosis despite plasty and an 8 mm x 4 cm Wallstent was then deployed at the venous anastomosis and post-dilated with an 8-mm balloon to good result. Pre-procedure timeout was performed as per protocol. | 5 | [
{
"category": "Radiology",
"chartdate": "2196-06-28 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 1250657,
"text": " 3:10 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: CLOTTED GRAFT\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS MOD SEDATION, FIRST 30 MIN. *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n TEMPORARY DIALYSIS LINE'\n\n INDICATION: 73-year-old male with history of end-stage renal disease, on\n hemodialysis since , with a right-sided AV graft. Patient presented on\n with a clotted fistulla and subsequently underwent a declotting\n procedure. Today, patient presents again with a thrombosed AV fistula. Now\n patient comes in for a temporary line.\n\n OPERATORS: Dr. (IR fellow) and Dr. (IR attending).\n Dr was present in the room and supervised the entire procedure.\n\n ANESTHESIa:\n Moderate sedation was provided by administering divided doses of fentanyl\n (total of 50 mcg) throughout the total intraservice time of 1 hour, during\n which patient's hemodynamic parameters were continuously monitored. Local 1%\n anesthesia was also used.\n\n PROCEDURE:\n After explaining risks and benefits and alternatives of the procedure with an\n interpreter, written informed consent was obtained. The patient was brought\n to the angiography suite and placed supine on the imaging table. The left\n groin was prepped and draped in standard sterile fashion. Pre-procedure\n timeout was performed as per protocol.\n\n US demonstrated thrombosed right femoral vein, as well as left internal\n jugular. Using ultrasound guidance, the patent left femoral vein was accessed\n using a micropuncture needle, through which a 0.018 guide nitinol wire was\n advanced into the IVC under fluoroscopic guidance. Needle was exchanged for a\n micropuncture sheath and the wire upsized to wire, which was navigated\n into the IVC for stability. The micropuncture sheath was removed and the soft\n tissue tract was dilated using a 12 and 14 French dilators. A 14 French 24-cm\n catheter was then advanced over the wire. The tip of the catheter was\n positioned in the IVC. The guidewire was removed. Both lines were aspirated\n and flushed easily and subsequently capped. The catheter was secured to the\n skin using a 0 silk suture and sterile dressings were applied.\n\n The patient tolerated the procedure well and there were no procedure or\n immediate complications.\n\n IMPRESSION: Uncomplicated placement of a temporary left femoral line, for\n hemodialysis access. Tip of the catheter is placed in the IVC and ready to\n use.\n (Over)\n\n 3:10 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: CLOTTED GRAFT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "ECG",
"chartdate": "2196-06-29 00:00:00.000",
"description": "Report",
"row_id": 206443,
"text": "Atrial fibrillation with slow ventricular response. Compared to the previous\ntracing of there is no diagnostic change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2196-06-28 00:00:00.000",
"description": "Report",
"row_id": 206444,
"text": "Artifact is present. Atrial fibrillation with slow ventricular response.\nCompared to the previous tracing of the same day there is no significant\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2196-06-28 00:00:00.000",
"description": "Report",
"row_id": 206445,
"text": "Artifact is present. Atrial fibrillation with slow ventricular response.\nCompared to the previous tracing of the rate is slower.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-06-30 00:00:00.000",
"description": "INTRO DIALYSIS FISTULA",
"row_id": 1250868,
"text": " 8:25 AM\n AV FISTULOGRAM SCH Clip # \n Reason: please evaluate AV graft, perform thrombectomy if feasible\n Admitting Diagnosis: HYPERKALEMIA;FISTULA OBSTRUCTION\n Contrast: OPTIRAY Amt: 250\n ********************************* CPT Codes ********************************\n * INTRO DIALYSIS FISTULA PTA VENOUS *\n * PTA VENOUS THROMBOCTMY, PERC AVF *\n * TRANSCATH PLCMT INTRAVAS STENT INTRO INTRAVASCULAR STENT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with recurrent thrombosis of RUE AVG, ?problem at site of\n venous anastasmosis.\n REASON FOR THIS EXAMINATION:\n please evaluate AV graft, perform thrombectomy if feasible\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recurrent thrombosis of the right upper extremity AV graft,\n suspect prominent venous anastomosis.\n\n PHYSICIAN: , .D., attending, was present and supervising, \n , M.D., fellow, was performing the procedure. , M.D.,\n attending.\n\n MEDICATIONS: General anesthesia was given by the anesthesiologist. We\n administered 250 cc of Optiray 320 contrast media as well as 7000 units of\n intravenous heparin and 7 mg of intra graft TPA during the case.\n\n FLUOROSCOPY TIME: 46.3 minutes.\n\n PROCEDURES:\n 1. AV fistulagram with catheter-directed TPA injection,\n 2. Mechanical thrombolysis,\n 3. Balloon venoplasty of multiple strictures in central veins as well as at\n the venous anastomosis.\n 4. Embolectomy at the level of the arterial anastomosis.\n 5. Metallic stenting of the venous anastamosis.\n\n PROCEDURE DETAILS: Informed consent was obtained from the patient with the\n use of an Albanian translator. The patient was positioned supine. Following\n anesthesia timeout, anesthesia was initiated. The area was prepped and draped\n in sterile fashion. We then had appropriate procedural timeout. Fluoroscopy\n was used intermittently.\n\n Limited ultrasound of the graft demonstrates complete thrombosis with no\n demonstrable flow on Doppler evaluation. The level of the arterial inflow\n anastamosis and the venous outflow anastamosis were marked on the patients\n skin.Bruising from a prior intervention or access was noted.\n With ultrasound guidance, the AV loop graft was accessed using a micropuncture\n needle close to the arterial side and directed towards the venous side.\n Ultimately, a 7 French sheath was placed in this location. A hand injection\n of contrast demonstrated a clot filling the graft. At this point, 3 mg of TPA\n (Over)\n\n 8:25 AM\n AV FISTULOGRAM SCH Clip # \n Reason: please evaluate AV graft, perform thrombectomy if feasible\n Admitting Diagnosis: HYPERKALEMIA;FISTULA OBSTRUCTION\n Contrast: OPTIRAY Amt: 250\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n was infused via a catheter into the graft. An 035 glidewire was advanced\n through the thrombosed graft through the venous anastamosis into the right\n brachiocephalic vein. Over the wire, a 4F straight flush catheter was advanced\n to the region of the axillary vein and digital subtraction venogram was\n performed which redemonstrated two areas of apparent narrowing in the left\n brachiocephalic vein and upper SVC, though without significant collateral flow\n noted suggesting that they may not be hemodynamically significant.\n A digital subtraction venogram performed more distally in the arm demonstrated\n areas of narrowing in the outflow vein, despite prior venoplasty\n\n\n Attention was first turned to the central veins. An Amplatz wire with the use\n of the catheter was positioned into the inferior vena cava and over this wire,\n a 12-mm diameter balloon was advanced . This was inflated at both sites of\n narrowing in the central veins with good angiographic result. An 8-mm balloon\n was then used more proximally into the arm veins to the site of the venous\n anastomosis. When inflated at the venous anastomosis, there was a significant\n waist which improved on post plasty runs. The balloon was inflated twice in\n this location. The balloon was then pulled into the graft and inflated to\n macerate the clot within. Additional digital subtraction venogram was\n performed with catheter tip in the proximal arm veins. This demonstrated some\n persistent narrowing of the venous anastomosis despite plasty and an 8 mm x 4\n cm Wallstent was then deployed at the venous anastomosis and post-dilated with\n an 8-mm balloon to good result. After this, there was no significant residual\n narrowing. Attention was then turned to the arterial side. The graft was\n then accessed in a retrograde fashion with a micropuncture set and ultrasound\n guidance and a 6 French sheath was placed. With the catheter, a further 4mg\n TPA was instilled into the graft at the arterial side. We then crossed into\n the brachial artery proximal to the graft take off using a glide wire and\n performed a digital subtraction angiogram. This demonstrated a persistant\n filling defect in the graft near the arterial anastomosis. Multiple sweeps\n were made with a 5.5F embolectomy balloon catheter which successfully\n removed two firm plugs of organized thrombus from the arterial anastomotic\n site. DSA was repeated after each sweep, two additional times, which\n demonstrated improvement each time. Finally, there was no residual filling\n defect at the anastomosis.\n The mechanised cleaner device was intermittently used for mechanical\n thrombolysis within the graft. At the end of the procedure, there was a\n palpable thrill in the graft and other evidence of improved blood flow.\n\n Purse-string sutures were applied at both access points in the graft and the\n sheaths were removed and the access points were held for adequate hemostasis.\n The patient was extubated in the room and transferred to the PACU in stable\n condition without any immediate complication.\n\n (Over)\n\n 8:25 AM\n AV FISTULOGRAM SCH Clip # \n Reason: please evaluate AV graft, perform thrombectomy if feasible\n Admitting Diagnosis: HYPERKALEMIA;FISTULA OBSTRUCTION\n Contrast: OPTIRAY Amt: 250\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CONCLUSION:\n Uncomplicated AV fistulagram with extensive intervention as above including\n chemical and mechanical thrombectomy, balloon dilatation of central venous\n strictures, dilatation and stenting of venous anastomosis, and removal of\n organized thrombus at the arterial anastomosis.\n Following the procedure the graft had a palpable thrill and may be used for\n dialysis immediately.\n\n"
}
] |
29,483 | 136,829 | GI was consulted. EGD on demonstrated a non-bleeding erosion in D2. On , he developed hypotension, hematochezia, and was transferred to the SICU. Repeat EGD demonstrated a clot adherent to the GJ tube, but no active bleeding. Angiogram was recommended, and was also negative. His PTC was exchanged at that time. On , pt developed hematemesis, hematochezia, hypotension, and desaturation. He was transferred to the SICU, intubated, and started on pressors. Repeat angiogram demonstrated a thrombosed GDA, but no source of bleed. Vancomycin and Zosyn were started for presumptive aspiration pneumonia. He was in ARDS and was oliguric. On , diltiazem gtt was started for a-fib. Vanc was changed to linezolid on . On , antibiotics were changed to cefepime only, and TPN was started. Diuresis was begun. He was gradually weaned off pressors. Tube feeds were started on . TPN and antibiotics were d/c'd on . CXR on demonstrated complete L lung white-out. CT chest demonstrated R peribronchial infiltrates and b/l pleural effusions. Fluc was started for yeast in urine. On , his GJ tube was changed as the J tube was clogged. The PTC was also exchanged as the pigtail was cracked. Lasix gtt was started. A CT head was performed as the CT chest had demonstrated infarcts in the liver; there were no infarcts in the brain. On , a L pigtail was placed in the chest. On , a pigtail was placed in the R chest. On , he was febrile to 102.2. CT torso demonstrated multifocal pulmonary opacities. He was started on vanc/Zosyn/Flagyl for presumptive pneumonia and C.diff prophylaxis. CT incidentally demonstrated a RIJ thrombus. Bronchoscopy was performed on . All sputum and BAL cultures eventually grew E.coli. ID was consulted and recommending d/c'ing fluc. A RIJ U/S demonstrated a non-occlusive thrombus. Vascular was consulted; anticoagulation was unnecessary. On , the R chest pigtail was d/c'd. On , ID recommended d/c'ing vanc and Flagyl. Patient underwent percutaneous tracheostomy at the bedside by the Red Surgery team. On , the L chest tube was d/c'd. Zosyn was d/c'd on , completing a 7 day course. He had persistent high stool output. C.diff was negative several times. On , pancreatic enzymes were started. G tube was capped on . For the remainder of the hospital stay, patient was diuresed to near baseline weight and his vent was weaned. Lasix gtt was changed to PO on . On discharge, he was tolerating trach collar intermittently. He was afebrile with stable vital signs, tolerating tube feeds, and getting out of bed to chair with PT. He is being discharged to vent rehab. | FINDINGS: In the interim, a right internal jugular sheath has been placed which is sharply angulated at its proximal portion. Percutaneous gastrostomy and percutaneous transhepatic catheter, again both terminate in proximal jejunum. Peripheral and wedge-shaped hypodensities along right hepatic lobe and spleen, new compared to CT torso from , consistent with infarct. FINDINGS: There is interval considerable opacification of the left hemithorax, most likely secondary to atelectasis versus effusion. REASON FOR THIS EXAMINATION: assess fluid status FINAL REPORT SINGLE PORTABLE AP CHEST RADIOGRAPH INDICATION: Intubated, resuscitated for GI bleed, shortness of breath. In the interim, slight reexpansion of the left upper lung region has occurred with persistent moderate left pleural effusion. There is patchy atelectasis at the right lung base. Right subclavian catheter terminates in the superior vena cava. In addition, there is a slight decrease in the opacification of the right hemithorax, which is a combination of atelectasis and right pleural effusion. Persistent moderate right pleural effusion and adjacent atelectasis. There is continued bibasilar atelectasis, small right and moderate left pleural effusion. Slight improvement characterized by reexpansion of a portion of the left upper lung, with persistent moderate left pleural effusion. A right IJ catheter terminates in the cavoatrial junction. New right-sided small pleural effusion. + GENERALIZED EDEMA.RESP: LS CLEAR, DIMINISHED BASES. TEAM MADE AWARE.R: FEBRILE, HYPOTENSIVE, REQUIRING FLUID BOLUS, ? Albuterol and Atrovent MDIs as ordered. condition updatedS/P GI BLEED W/RESP COMPROMISEEvents overnoc: temp spikeFor detail info please refer to carevue flowsheetTemp spike to 101.2, ^resp rate, and periods anxiety.tylenol given and cultured (peripheral BC x2 and urine). Pt on Vancomycin, Zosyn, and Flagyl. Dsg over left pigtail drain chest tube changed x1. NGT with drb draining in small amts. BLBS diminished suctioned for sm amt thick secretions mdis given per order. BRONCH DONE, BAL SENT. BRONCH DONE, BAL SENT. BS clear bilaterally w diminished LLL. FLUID BOLUS X1 GIVEN, AND THEN TO TREAT WITH PRESSORS IF NEEDED. tube out and MD's aware. NGT in right nare to LCWS with BRB return. Continue to moniter respiratory status. Continue to diurese as tolertated. Pt tmax 99.9.PLAN-Monitor respiratory status and wean as tolerated. Bronchodilators given x3 with good effect noted. Albuterol/Atrovent MDI given Q4hr. Maxed out on neo, can go up on levoif needed. N - Patient on propofol gtt but responding to questions appropriately. NGT in place and conts on LCS with BRB out. Intubated in unit w/c. Hematocrit stable. Pt continues to be hypotensive, neo to max, started on levophed gtt and titrated to max with concurrent transfusions x 4 completed. RESP CARE NOTEPT CONTINUES ON VENTILATOR: A/C 22 550 .4 +20.LAST ABG @0400 :7.45/28/98/20/-2. Generalized edema noted, +DP/PT pulses. DP/PT pulses dopplerable. Resp care,Pt. Pt tachypneic (RR 30s); Dr. aware. Pt with generalized anasarca. Per Dr. , vasopressin gtt off. Left GJ tube clamped. BLBS slightly wheezey, suctioned for small amt thick tan and mdis given per order. + DP/PT pulses. Abdomen soft, distended, +BS. Abdomen soft, distended, +BS. G-tube to gravity with scant amounts of old bloody drainage. CXR done. RUQ gauze dressing changed wet-dry dressing. Sx for small tan secretions.Last ABG 7.44/33/153/23/0Will continue to follow. CT APPEARS PLUGGED. J-tube with greeen output. pt remains NPO, replete with fiber tube feeds infusing via J tube at 70 cc/hr. See CareVue for ABG results. NGT and Gtube to gravity with minimum abouts of old bloodly drainage. NEO WEANED OFF. Resp care,Pt. Resp Care,Pt. CONDITION UPDATE AFEBRILE. ABG revealed resp alka. Vasopressin and levophed weaning. Denies pain.CV: afebrile, HR 70's NSR with occasional PVC. Last ABG 7.44/32/129/22/0. Sx for small to mod amts of thk wht secr. Last ABG WNL with good oxygenation noted on present settings. PT BECOMING HYPOTENSIVE REQUIRING NEO DRIP. Abd is distended and slightly firm, BS are absent. ABG: 119/32/7.48/25/1. ABG acceptable, continue to wean IPS/peep as tol. PRIOR TO EGD PT ELECTIVELY INTUBATED - STARTED ON PPF DRIP. R Pedal and dorsal pulses strong following IR.RESP: lungs clear to diminished at bases. GENERALIZED EDEMA THROUGHOUT.RESP: LS CLEAR. on levophed gtt and titrated. Generalized edema, scrotal edema improving. Currently J-tube is instilled with . ABG acceptable this am.GI: tol tube feed at goal. ABG show adequte oxygenation and compensated respiratory acidosis.7.38,57,83 Repeat CXR done. Pt with generalized anasarca. Per Dr. , albumin ordered. Pt with generalized edema (pitting pedal and BUE edema). NGT to LWCS with bilious drainage, G-tube to gravity with bilious drainage. Scrotal edema improving (Critic-Aid clear applied and scrotum elevated). Pt hypertensive (SBP 160-170s) and tachycardic (HR 100s) during activity. Left femoral artline site has dressing CDI. abg 7.41-35-104-23. vap mouth care done as per protocol. +scrotal edema; elevated. LR bolus for hypotension and low u/o midmorning.+ BS x4 abd firm, distended. lytes repleated.RESP: lungs clear through out. Continue with diuresis. K+ repleted, KPhos administered and IV KCL administered. Cont on lasix with adequate diuresis. Keep SBP < 160, Pulmonary toilet as tolerated.PRN Versed/Ativan if needed post extubation. Restarted at MN for hypotensive periods. Tachypenia resolving with postive reinforcement. CHEST X-RAY DONE POST PIGTAIL PLACEMENT AND EFFUSION REDUCED, ETT IN ACCEPTABLE POSITION.GI: G TUBE TO GRAVITY, J TUBE WITH TUBE FEEDS NOW RUNNING @ 70 CC'S/HR. Has generalized anasarca. Lungs coarse; clear after suctioning. Right pigtail drain (in biliary system per Dr. ) capped; small amount of bilious drainage noted from around pigtail drain (dsg changed x1). MOUTH CARE DONE.GI-ABD DISTENDED. Trivialmitral regurgitation is seen. Mild mitralannular calcification. Effusion is loculated. Non-specificdiffuse T wave flattening. The ascending aorta is mildlydilated. +SCROTAL EDEMA.ENDO-SSRI. +PP VIA DOPPLER. Resp Care,Pt. The right ventricular cavity isdilated with depressed free wall contractility. The effusionappears loculated subtending the right atrial free wall. Mild [1+] TR. PEEP and rate weaned as noted. Trace aortic regurgitation is seen. pt continues on lasix gtt at 1mg/hr.gi: abd soft, distended, positive bowelsounds. Abdomen softly distended. Weaning sedation. aline waveform dampened, follow cuff pressures. Normal tricuspid valvesupporting structures. RV function depressed.AORTA: Normal aortic diameter at the sinus level. ABG on vent changes is 7.46/34/112/25/0. Heparin sq restarted. | 166 | [
{
"category": "Radiology",
"chartdate": "2124-06-06 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1019089,
"text": " 9:28 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Eval lungs for effusion/infectious process, eval abd for pos\n Admitting Diagnosis: GI BLEED\n Field of view: 42\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with fever.\n REASON FOR THIS EXAMINATION:\n Eval lungs for effusion/infectious process, eval abd for position of biliary\n catheter and possible infectious process. Please perform abd only with\n contrast, remainder of exam without contrast. thanks.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old male with fever.\n\n COMPARISON: CT chest of and CT torso from .\n\n TECHNIQUE: MDCT axial imaging was performed through the chest, abdomen, and\n pelvis after administration of oral contrast and 130 mL of IV Optiray.\n Multiplanar reformatted images were then obtained.\n\n CT CHEST: Rounded filling defect in the right jugular vein may represent a\n thrombus. A left subclavian central venous catheter terminates at the\n cavoatrial junction. Atherosclerotic calcifications are noted along the\n aortic arch and the coronary arteries. Heart size is top normal, and there is\n no pericardial effusion. Scattered mediastinal lymph nodes are again noted,\n measuring up to 9 mm in short axis in the pretracheal region.\n\n ET tube tip which was previously seen within the right main stem bronchus is\n now 2.3 cm above the carina. There is improved aeration of the left upper\n lobe. Multifocal ground-glass opacities remain particularly in the right\n middle lobe and now also in the left upper lobe. Bilateral moderate-sized\n pleural effusions are slightly improved from the CT chest of . Both\n lower lobes remain collapsed. Since , there is interval placement of\n two percutaneous pigtail catheters at the level of the diaphragms which appear\n to terminate in the pleural spaces bilaterally.\n\n CT ABDOMEN: A percutaneous transhepatic catheter coils in the gallbladder\n fossa and terminates in the proximal jejunum. Patient is status post\n cholecystectomy. New hypodensities along the dome of the right liver are\n better defined than that seen on CT chest from five days prior; peripheral\n location and wedge-shaped appearance is suggestive of infarct. Rounded\n hypodensity along the inferior tip of the liver is also new compared to the CT\n torso of , and may also represent region of infarct versus extension of\n adjacent fluid collection. Wedge-shaped hypodense regions along the periphery\n of the spleen are also consistent with splenic infarcts which were not present\n on the CT; hypodensity along the medial aspect of the spleen may\n represent infarct versus extension of adjacent fluid collection.\n\n While there is increase in ascites compared to the CT torso from , the\n (Over)\n\n 9:28 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Eval lungs for effusion/infectious process, eval abd for pos\n Admitting Diagnosis: GI BLEED\n Field of view: 42\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n amount of ascites is little changed from the limited views of the abdomen on\n CT chest from . Multiple fluid collections with enhancing rims in the\n abdomen are little changed compared to . Fluid collection anterior to\n the body of the pancreas is little changed and may communicate with the fluid\n collection that extends posterior to the stomach and adjacent to the spleen.\n Loculated rim-enhancing collections along the right paracolic gutter are\n little changed, again containing bubbles of gas. Foci of gas are again noted\n within the collection anterior to the head of the pancreas. A percutaneous\n gastrostomy tube terminates in the jejunum. Soft tissue swelling and edema is\n noted along both the right posterior and left lateral abdominal wall\n subcutaneous soft tissues. Again, a soft tissue defect is noted along the\n right mid abdominal wall, with the defect measuring approximately 2.9 x 2.4\n cm.\n\n The pancreas is unchanged in appearance and enhances homogeneously. The\n adrenal glands appear normal. The kidneys are unremarkable; again 1-cm\n hypodense lesion in the inferior pole of the right kidney and 1.3-cm hypodense\n lesion in the interpolar region of the left kidney are consistent with cysts.\n Contrast opacifies small bowel and colon which appear unremarkable, as does\n the stomach. Stool is noted throughout the colon. The appendix appears\n normal. Atherosclerotic calcifications are noted along the abdominal aorta,\n without aneurysmal dilatation. No definite lymph node enlargement meeting CT\n size criteria for adenopathy is seen.\n\n CT PELVIS: Bladder is distended with fluid, and Foley catheter tip and\n balloon are noted to terminate within the inferior aspect of the prostate. The\n prostate is enlarged, measuring 6.5 x 6.5 x 7.0 cm. A rectal tube is in\n place. Sigmoid diverticula are noted, without definite inflammatory changes\n seen. Again free fluid tracks from the abdomen into the pelvis. No definite\n lymph node enlargement is seen meeting CT size criteria for adenopathy.\n\n OSSEOUS STRUCTURES: Multilevel degenerative changes are noted throughout the\n spine. Vertebral body heights are maintained, and there is no evidence of\n bony destruction that is concerning for malignancy.\n\n IMPRESSION:\n 1. Multifocal pulmonary opacities particularly in the right middle lobe and\n left upper lobe may represent multifocal pneumonia or aspiration. Moderate\n bilateral pleural effusions remain; pigtail catheters in place. Bilateral\n lower lobes remain collapsed.\n 2. Multiple rim-enhancing fluid collections in the abdomen are little\n changed. Fluid collections along the right paracolic gutter and also anterior\n to the pancreatic head again contain foci of gas. Infectious process cannot be\n excluded. Increased ascites compared to .\n (Over)\n\n 9:28 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Eval lungs for effusion/infectious process, eval abd for pos\n Admitting Diagnosis: GI BLEED\n Field of view: 42\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Peripheral and wedge-shaped hypodensities along right hepatic lobe and\n spleen, new compared to CT torso from , consistent with infarct.\n 4. Percutaneous gastrostomy and percutaneous transhepatic catheter, again\n both terminate in proximal jejunum.\n 5. Foley catheter with balloon and tip terminating in prostate, with fluid\n distended bladder.\n 6. Non-occlusive thrombus in right jugular vein partially visualized.\n\n Findings, including Foley position, were discussed with Dr. at 3\n p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018242,
"text": " 8:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with GI bleed,intubated, now with increased pressure support\n requirement\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 2:26 PM\n Dramatic interval increase in left atelectasis. Recommend withdrawing\n endotracheal tube 3 cm and bronchoscopy.\n ______________________________________________________________________________\n FINAL REPORT\n ^FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: GI bleed, intubated with increased respiratory distress.\n\n COMPARISON: .\n\n FINDINGS: There is interval considerable opacification of the left\n hemithorax, most likely secondary to atelectasis versus effusion. Endotracheal\n tube is again noted to be low lying approximately 2 cm from the carina in the\n head-up position. A small-to-moderate right pleural effusion is again noted.\n\n IMPRESSION: Interval dramatic increase in opacity of the left hemithorax,\n secondary either to atelectasis or effusion. Withdrawal of endotracheal tube\n by approximately 3 cm and bronchoscopy is recommended to evaluate for\n endobronchial mucus plugging versus endobronchial lesion.\n\n Findings relayed to Dr. at the time of dictation.\n\n \n"
},
{
"category": "Radiology",
"chartdate": "2124-06-01 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1018302,
"text": " 1:09 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess fluid vs. atelectasis\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with h/o Gi bleed, ARDS, with abnormal cxr\n REASON FOR THIS EXAMINATION:\n assess fluid vs. atelectasis\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 3:18 PM\n The endotracheal tube tip is in right main bronchus and needs to be retracted\n by at least 3 cm. This information was given to the referring physician.\n increase of bilateral pleural effusion with adjacent atelectasis and\n probable aspiration in the right lung. Bibasilar atelectasis.\n\n No ARDS.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT chest without contrast on .\n\n COMPARISON: CT chest on .\n\n TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to\n the subdiaphragmatic area without contrast. Thinner slice 5-mm and 1.25-mm\n images were reconstructed in the axial plane at different window algorithms.\n Sagittal/coronal reformatted images were also obtained for further evaluation.\n\n HISTORY: 76-year-old man with GI bleed; rule out ARDS, fluid versus\n atelectasis.\n\n FINDINGS:\n\n The endotracheal tube tip is at the origin of the right main bronchus with\n almost complete collapse of the left lung and right to left cardiomediastinal\n shift. The bilateral moderate-to-severe pleural effusion has worsened on\n today's examination with adjacent right basilar atelectasis. Peribronchial\n infiltrates are seen in the right upper lobe and right middle lobe and in the\n aerated portion of the right lower lobe.\n\n There are no pathologically enlarged lymph nodes in the mediastinal or hilar\n areas.\n\n There is no pericardial effusion. The heart size is top normal with\n atherosclerotic calcification of the aortic annulus.\n\n The bones do not show any lesions suspicious for malignancy and/or infection.\n\n The limited evaluation of the abdomen demonstrates a new hypodense area in the\n dome of the right lobe of the liver. Pockets of free fluid in the abdominal\n cavity are again demonstrated.\n\n (Over)\n\n 1:09 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess fluid vs. atelectasis\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. No evidence of ARDS. Multifocal peribronchial infiltrates are seen in\n the aerated portion of the right lung, likely infectious versus aspiration.\n 2. Endotracheal tube tip is in the right main bronchus resulting in almost\n complete collapse of the left lung. This needs to be retracted by at least 3\n cm.\n 3. Worsening bilateral moderate-to-severe pleural effusion with adjacent\n atelectasis.\n 4. A new hypodense area in the liver worrisome for infection given the known\n pancreatitis. A dedicated study such as ultrasound or dedicated CT scan\n examination of the abdomen is recommended.\n 5. In the presence of extensive intrabdominal infection the possibility of\n bilateral empyema could not be excluded, although the effusion appears simple\n with no loculations or hyperdense material. This report was discussed with Dr\n .\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-05-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1017749,
"text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man w/ GI bleed, hypotension, s/p resucitation.\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: 76-year-old male with GI bleed, hypotension.\n\n COMPARISON: .\n\n FINDINGS: Endotracheal tube is low riding, approximately 1 cm from the\n carina. Recommend withdrawing tube 3-4 cm for optimal positioning. Left\n internal jugular central venous catheter tip resides at the cavoatrial\n junction. Two feeding tubes course through the mediastinum with tip and side\n port in the expected region of the stomach.\n\n There is interval increase in bibasilar atelectasis and effusions. Mild\n intersitital sepatal markings are consistent with pulmonary edema. A\n percutaneous biliary catheter is noted in the right upper abdomen.\n\n IMPRESSION:\n 1. Low-riding endotracheal tube. Recommend withdrawal 3-4 cm for optimal\n positioning.\n\n 2. Increase in bibasilar atelectasis and effusions, left greater than right.\n\n 3. Mild interstitial pulmonary edema.\n\n Findings relayed to the ICU team at the time of dictation.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018243,
"text": ", P. SICU-A 8:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with GI bleed,intubated, now with increased pressure support\n requirement\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n PFI REPORT\n Dramatic interval increase in left atelectasis. Recommend withdrawing\n endotracheal tube 3 cm and bronchoscopy.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-01 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1018303,
"text": ", P. SICU-A 1:09 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess fluid vs. atelectasis\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with h/o Gi bleed, ARDS, with abnormal cxr\n REASON FOR THIS EXAMINATION:\n assess fluid vs. atelectasis\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n The endotracheal tube tip is in right main bronchus and needs to be retracted\n by at least 3 cm. This information was given to the referring physician.\n increase of bilateral pleural effusion with adjacent atelectasis and\n probable aspiration in the right lung. Bibasilar atelectasis.\n\n No ARDS.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-05-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1017338,
"text": " 6:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess fluid status\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man intubated, resuscitated for recurrent upper/lower gi bleed.\n REASON FOR THIS EXAMINATION:\n assess fluid status\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE PORTABLE AP CHEST RADIOGRAPH\n\n INDICATION: Intubated, resuscitated for GI bleed, shortness of breath.\n\n COMPARISON: and .\n\n FINDINGS: There is no significant change in the appearance of the chest.\n Body habitus and lack of penetration limits examination; however, no\n appreciable change is detected to the pulmonary vascularity. There is a\n probable small right pleural effusion. The cardiomediastinal silhouette is\n stable. Lines and tubes remain unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-05-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1017091,
"text": " 12:15 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please evaluate for interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with massive GI bleed with extremely poor oxygenation on\n ventilator\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP ON \n\n COMPARISON: Same day examination at 07:29.\n\n HISTORY: 76-year-old man with massive GI bleed, follow up.\n\n FINDINGS:\n\n Followup examination of the same day showing severe progression of pulmonary\n edema in both lungs along with worsening of bilateral now small-to-moderate\n pleural effusions, right more than left. The endotracheal tube, left\n subclavian line, right internal jugular sheath, and feeding tube are all\n unchanged since the prior study. Persistent multifocal pneumonia in both\n lungs is again seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018714,
"text": " 4:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate effusion for interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with worsening respiratory status\n REASON FOR THIS EXAMINATION:\n Please evaluate effusion for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Worsening respiratory status.\n\n Marked patient rotation limits assessment. Vast majority of findings appear\n unchanged, but there had been some apparent improved aeration in the left\n retrocardiac region.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018638,
"text": " 11:15 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess endotracheal tube placement ( had been 9 cm above car\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with upper GI bleed, ARDS, left plueral effusion s/p pigtail\n placement\n REASON FOR THIS EXAMINATION:\n assess endotracheal tube placement ( had been 9 cm above carina on last cxr,\n advanced). also, just placed left pigtail for pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST , 11:28 A.M.\n\n COMPARISON: Previous study at 12:51.\n\n INDICATION: Endotracheal tube advancement and placement of left pleural\n catheter.\n\n Endotracheal tube has been advanced, now terminating in standard position\n about 4.7 cm above the carina. Left pigtail pleural catheter has been placed\n into the periphery of the left lower lung at the thoracoabdominal junction,\n with resultant marked decrease in left pleural effusion with residual\n small-to-moderate effusion remaining. Atelectasis within the left lung has\n improved with residual atelectasis and/or consolidation in the left lower\n lobe. Moderate layering right pleural effusion appears unchanged, and note is\n again made of probable ascites.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-05-24 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1017042,
"text": " 7:16 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for RIJ placement, pna\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with gi bleed, pna\n REASON FOR THIS EXAMINATION:\n eval for RIJ placement, pna\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable for line placement on \n\n HISTORY: 76-year-old man with GI bleed and pneumonia. Evaluate for right\n internal jugular line placement and pneumonia.\n\n FINDINGS:\n\n In the interim, a right internal jugular sheath has been placed which is\n sharply angulated at its proximal portion. The endotracheal tube is 3 cm from\n the carina, relatively stable since the prior study. Stable position of the\n left subclavian line, which terminates at the distal portion of the SVC. A\n feeding tube has been placed with tip in the stomach. Persistent multifocal\n opacities consistent with pneumonia are again seen; however, on today's\n examination, there is slight worsening of the airspace disease seen in both\n lungs, compatible with newly developing edema. Stable bilateral small, left\n more than right, effusion with adjacent atelectasis are again noted.\n\n IMPRESSION:\n 1. Newly placed right internal jugular line with tip in the right internal\n jugular vein and is kinked at its proximal portion.\n 2. No change in the position of the endotracheal tube or left subclavian\n line.\n 3. Newly placed feeding tube in the stomach.\n 4. Persistent multifocal opacities consistent with pneumonia.\n 5. Worsening pulmonary edema.\n 6. Stable bilateral pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-05-24 00:00:00.000",
"description": "MOD SEDATION, EACH ADDL 15 MIN.",
"row_id": 1017055,
"text": " 8:31 AM\n MESSENERTIC Clip # \n Reason: Please attempt to localize GI hemorrhage\n Admitting Diagnosis: GI BLEED\n Contrast: OPTIRAY Amt: 130\n ********************************* CPT Codes ********************************\n * INITAL 2ND ORDER ABD/PEL/LOWER EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * VISERAL SEL/SUPERSEL 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 ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with GI bleed\n REASON FOR THIS EXAMINATION:\n Please attempt to localize GI hemorrhage\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION FOR EXAM: 76-year-old male with gastrointestinal bleeding.\n\n RADIOLOGISTS: The procedure was performed by Drs. , and ,\n the attending radiologist, who was present and supervising throughout.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained explaining the\n risks and benefits of the procedure, the patient was placed supine on the\n angiographic table and the right groin was prepped and draped in the standard\n sterile fashion. A preprocedure timeout was performed.\n\n Using sterile technique, and palpatory guidance, the right common femoral\n artery was punctured with a 19-gauge needle and a 0.035 wire was\n advanced into the abdominal aorta under fluoroscopic guidance. The needle was\n then exchanged over the wire for a 5 French vascular sheath which was\n connected to a continuous sidearm flush. Selective catheterization of the\n celiac trunk was performed with a SOS catheter and selective arteriogram was\n performed demonstrating patent celiac, common hepatic and splenic arteries.\n There was opacification of a small proximal portion of the GDA. A\n microcatheter was advanced through the SOS catheter into the common hepatic\n artery and selective arteriograms was performed confirming the occlusion of\n the GDA. Attempts to selectively catheterize the proximal portion of the GDA\n were unsuccessful.\n\n The microcatheter was removed and the SOS catheter was used to perform\n selective catheterization of the SMA. Arteriogram was performed with no signs\n of bleeding. The microcatheter was advanced into the SMA and an arteriogram\n demonstrated retrograde opacification of the GDA, with no sgins of active\n bleeding. Attempts to perform selective catheterization of this branch were\n unsuccessful. There is a small contrast collection adjacent to one of the\n small branchs of the pancreatico-duodenal vessels off the SMA, This is felt\n to represent partial retrograde filling of a segmant of the gastro-duodenal\n artery, rather than a tiny pseudoaneurysm.\n\n The catheter and the vascular sheath were removed and manual compression was\n (Over)\n\n 8:31 AM\n MESSENERTIC Clip # \n Reason: Please attempt to localize GI hemorrhage\n Admitting Diagnosis: GI BLEED\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n held until hemostasis was achieved. The patient tolerated the procedure well\n without immediate complications.\n\n Moderate sedation was provided by administering divided dose of 150 mcg of\n fentanyl throughout the total intra-service time of 1 hour and 15 minutes\n during which the patient's hemodynamic parameters were continuously monitored.\n\n IMPRESSION: Selective arteriograms were performed in the celiac and superior\n mesenteric arteries without signs of active bleeding.\n\n There are signs of occlusion of the GDA since the original arteriogram a few\n days ago.\n\n Because no obvious intervention was feasible, the procedure was terminated.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-05-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1017184,
"text": " 4:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with massive UGI bleed, s/p resuscitation with likely fluid\n overload\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after massive upper GI bleeding\n and resuscitation.\n\n AP chest radiograph was compared to .\n\n The ET tube tip is 5 cm above the carina. The NG tube tip is in the stomach.\n The Dobbhoff tube tip terminates proximally in the stomach at least 5 cm\n proximal to the NG tube tip. The left subclavian line tip terminates in mid\n distal SVC. The right internal jugular line tip is at the level of the right\n apex, in mid portion of internal jugular vein.\n\n Significant interval improvement in parenchymal opacities is demonstrated\n consistent with resolution of pulmonary edema. Still present left\n retrocardiac atelectasis and right lower lung opacities most likely represent\n remnants of the prior extensive involvement of the lungs by edema. Small\n bilateral pleural effusion cannot be excluded. No evidence of pleural\n effusion is present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018355,
"text": " 4:29 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: reassess left lung atelectasis, ett location\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man b/l effusions, ett pulled back 3cm\n REASON FOR THIS EXAMINATION:\n reassess left lung atelectasis, ett location\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 7:15 PM\n Adjusted ETT position. Small degree of re-aeration but extensive left-sided\n atelectasis remaining.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable, single view.\n\n INDICATION: Bilateral pleural effusions, ETT pulled back by 3 cm. Reassess\n left lung atelectasis.\n\n FINDINGS: AP single view of the chest obtained with patient in sitting semi-\n erect position is analyzed in direct comparison with a preceding supine AP\n chest examination obtained five hours earlier during the same date. The ETT\n has been withdrawn by a few centimeters and is now safe above the carina at a\n distance of cm. Thus, mechanical obstruction by the tube is not in\n question anymore. The left-sided total atelectasis remains, however, with\n perhaps some small amount of air appearing in the upper half of the left\n hemithorax. Continued shift of the mediastinum towards the left indicates\n persistent atelectatic component of the left lung. Evidence of right-sided\n pleural effusion is a rather unchanged.\n\n IMPRESSION: Small reoccurrence of air in central portion of left lung, but\n still extensive left lung atelectasis and presence of pleural effusion.\n Significant left-sided mediastinal shift remains. Consider to accelerate re-\n aeration. Also, remaining pleural effusion may be culprit for slow re-\n aeration. Suggest chest x-ray followup with short interval.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-07 00:00:00.000",
"description": "RP UNILAT UP EXT VEINS US RIGHT PORT",
"row_id": 1019280,
"text": " 12:51 PM\n UNILAT UP EXT VEINS US RIGHT PORT Clip # \n Reason: please evaluate Right jugular veins and Right subclavian vei\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with prolonged mechanical ventilation, ? RIJ thrombus\n REASON FOR THIS EXAMINATION:\n please evaluate Right jugular veins and Right subclavian vein for thrombus\n (seen on CT)\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KLMn WED 5:53 PM\n Nonocclusive thrombus in the right internal jugular vein.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old man with right IJ non-occlusive thrombus seen on CT.\n\n LIMITED UPPER EXTREMITY VENOUS ULTRASOUND: The study is compared to the CT of\n the torso from one day prior. As seen on that study there is non-occlusive\n thrombus in the right internal jugular vein. The subclavian veins bilaterally\n are patent, however the proximal right subclavian vein demonstrates marked\n elevation in velocity measuring up to 160 cm/s suggesting stenosis in this\n locale.\n\n IMPRESSION: Non-occlusive thrombus in the right internal jugular vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-07 00:00:00.000",
"description": "RP UNILAT UP EXT VEINS US RIGHT PORT",
"row_id": 1019281,
"text": ", P. SICU-A 12:51 PM\n UNILAT UP EXT VEINS US RIGHT PORT Clip # \n Reason: please evaluate Right jugular veins and Right subclavian vei\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with prolonged mechanical ventilation, ? RIJ thrombus\n REASON FOR THIS EXAMINATION:\n please evaluate Right jugular veins and Right subclavian vein for thrombus\n (seen on CT)\n ______________________________________________________________________________\n PFI REPORT\n Nonocclusive thrombus in the right internal jugular vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018356,
"text": ", P. SICU-A 4:29 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: reassess left lung atelectasis, ett location\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man b/l effusions, ett pulled back 3cm\n REASON FOR THIS EXAMINATION:\n reassess left lung atelectasis, ett location\n ______________________________________________________________________________\n PFI REPORT\n Adjusted ETT position. Small degree of re-aeration but extensive left-sided\n atelectasis remaining.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-02 00:00:00.000",
"description": "REINSERT TRANSHEPATIC T-TUBE",
"row_id": 1018510,
"text": " 1:47 PM\n BILIARY CATH REPLACE Clip # \n Reason: Please replace PTC drain, perform tube cholangiogram\n Admitting Diagnosis: GI BLEED\n Contrast: OPTIRAY Amt: 30\n ********************************* CPT Codes ********************************\n * REINSERT TRANSHEPATIC T-TUBE -78 RELATED PROCEDURE DURING POSTOPE *\n * PERC TRANSHEPATIC CHOLANGIOGRA -78 RELATED PROCEDURE DURING POSTOPE *\n * -51 MULTI-PROCEDURE SAME DAY CHANGE PERC TUBE OR CATH W/CON *\n * PERC TRANSHEPATIC CHOLANGIOGRA *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with PTC dual pigtail in place, dislodged, cracked\n REASON FOR THIS EXAMINATION:\n Please replace PTC drain, perform tube cholangiogram\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old male with necrotizing pancreatitis and partial\n cholecystectomy with history of bile leak and distal CBD stricture presents\n for replacement of internal-external right biliary drain due to\n malpositioning.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. , the\n attending radiologist, who was present and an active participant in the\n procedure.\n\n PROCEDURE AND FINDINGS: Informed consent was obtained from the \n healthcare proxy (wife) after the risks and benefits of the procedure were\n explained. A pre-procedure timeout was performed documenting the nature of\n the procedure and the patient's identity. The patient was placed supine on\n the angiographic table, and the right upper quadrant was prepped and draped in\n normal sterile fashion. Preprocedural scout radiographs demonstrated\n malpositioning of the indwelling right biliary drain with the proximal pigtail\n having been retracted external to the patient and the distal pigtail located\n in the region of the distal CBD/ampulla. Contrast was attempted to be\n injected through the indwelling catheter; however, none could be passed due to\n obstruction. Both a Glidewire and wire were attempted to be advanced\n through the indwelling catheter; however, the distal tip was blocked. Given\n the inability to pass the wire distally through the indwelling biliary drain,\n the catheter was cut and retracted, and a 12 French sheath was advanced over\n the indwelling catheter into the intra-hepatic biliary tree. A cholangiogram\n was performed demonstrating no intra-hepatic ductal dilatation, mild\n distal CBD stricture and known accessory variant biliary duct draining segment\n V/VI with its insertion near the cystic duct and unchanged appearance to\n remnant cystic duct and gallbladder fossa. No definite leak was identified on\n today's exam. A combination of a Glidewire and Kumpe catheter was then used to\n navigate through the intra- and extra- hepatic biliary tree with the wire and\n Kumpe catheter advanced into the distal jejunum. The Kumpe catheter was then\n removed and a new 22 cm 10 French NU stent (double pigtail) was advanced over\n the wire with the distal pigtail formed within the jejunum. The more proximal\n pigtail was not formed with the sideholes left in place near the intra-hepatic\n biliary confluence. Contrast was injected through the catheter documenting\n (Over)\n\n 1:47 PM\n BILIARY CATH REPLACE Clip # \n Reason: Please replace PTC drain, perform tube cholangiogram\n Admitting Diagnosis: GI BLEED\n Contrast: OPTIRAY Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appropriate positioning.\n\n The catheter was capped for internal drainage and secured with 2.0 silk suture\n and a StatLock device. 3 grams of Unasyn was give preprocedure.\n\n The patient tolerated the procedure well with no immediate postprocedural\n complications. No additional conscious sedation on top of the patient's\n normal floor medications was provided while in the radiology department.\n\n Total fluoroscopy: Including subsequent gastrostomy tube replacement was 3.7\n minutes.\n\n IMPRESSION:\n\n 1. Malpositioned and obstructed indwelling right percutaneous trans-hepatic\n biliary drain, which was successfully removed and replaced with a new 10\n French 22 cm double-pigtail internal-external biliary drain.\n\n 2. Unchanged appearance to mild-to-moderate distal CBD stricture and known\n variant biliary anatomy and remnant cystic duct/gallbladder. No definite\n leak noted on today's exam.\n\n PLAN:\n The patient can return in approximately three months for a repeat\n cholangiogram and possible catheter removal/exchange.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-02 00:00:00.000",
"description": "REPLACE GJ TUBE, ALL INCL.",
"row_id": 1018511,
"text": " 1:48 PM\n PERC G/J TUBE CHECK Clip # \n Reason: Please replace G-J tube over wires, as J-tube is hopelessly\n Admitting Diagnosis: GI BLEED\n Contrast: OPTIRAY Amt: 70\n ********************************* CPT Codes ********************************\n * REPLACE GJ TUBE, ALL INCL. -79 UNRELATED PROCEDURE/SERVICE DURI *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with G-J tube in place, non-functional\n REASON FOR THIS EXAMINATION:\n Please replace G-J tube over wires, as J-tube is hopelessly clogged.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Non-functioning GJ tube with obstruction of the jejunal port. Please\n replace the tube.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. , the\n attending radiologist who was an active participant in the procedure.\n\n PROCEDURE AND FINDINGS: Informed consent was obtained from the patient's\n wife, the healthcare proxy, after explaining the risks and benefits of the\n procedure. A preprocedural timeout was performed documenting the nature of\n the procedure and the patient identity. The patient was placed supine on the\n angiographic table and the left upper quadrant and indwelling GJ tube was\n prepped and draped in normal sterile fashion. An initial scout image\n demonstrated appropriate positioning of the catheter. Contrast was injected\n through the gastric port documenting appropriate positioning within the\n gastric lumen; however, the jejunal port could not be injected due to\n obstruction. A stiff Glidewire was attempted to be advanced through the\n jejunal port but was noted to exit through a crack in the tubing in the region\n of the gastric lumen and could not be successfully advanced distally through\n the tube into the jejunum. The indwelling sutures and the catheter were then\n cut and removed, and a 20 French peel-away sheath was placed in the\n subcutaneous tract over the existing catheter into the gastric lumen. A\n combination of a Kumpe catheter and Glidewire were then placed through the\n peel-away sheath and successfully advanced into the distal jejunum under\n fluoroscopic observation. The Kumpe catheter was then removed, and a new 18\n French MIC GJ tube was advanced over the indwelling Glidewire into the distal\n jejunum. 20 mL of sterile saline was used to inflate the balloon within the\n gastric lumen, and a small amount of Optiray contrast was injected through\n both gastric and jejunal ports documenting appropriate positioning. The\n external security \"waffle\" device was then advanced flushed to the skin at the\n 6 cm marking on the GJ tube. No sutures were used to secure the tube due to\n the friability of the underlying tissue with the catheter being secured using\n a Flexi-Trak device. An appropriate dressing was placed.The patient tolerated\n the procedure well with no immediate post- procedure complications. No\n additional conscious sedation on top of the patient's normal medications was\n given by the radiology department.\n\n Total fluoroscopy time including prior biliary drain replacement was 3.7\n minutes.\n (Over)\n\n 1:48 PM\n PERC G/J TUBE CHECK Clip # \n Reason: Please replace G-J tube over wires, as J-tube is hopelessly\n Admitting Diagnosis: GI BLEED\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n Obstructed native/indwelling GJ tube with crack in the jejunal tubing exiting\n into the stomach lumen. Successful replacement with new 18 French MIC GJ tube\n through the indwelling tract.\n\n The new GJ tube is appropriately positioned and ready to use.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019063,
"text": " 5:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess effusions\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with b/l pigtail chest tubes, b/l effusions\n REASON FOR THIS EXAMINATION:\n reassess effusions\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MEz TUE 12:28 PM\n Patient with bilateral pigtail chest tubes and bilateral effusion. Evaluate\n effusions.\n\n FINDINGS:\n\n Right and left pigtail catheters have been introduced with a slight decrease\n of the moderate-to-severe right pleural effusion and small-to-moderate left\n pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMPARISON: .\n\n HISTORY: 76-year-old male with bilateral pigtail chest tubes with bilateral\n effusions. Evaluate effusions.\n\n FINDINGS: The left pigtail drainage catheter is partially visualized on\n today's examination, however, with a slight decrease of a small-to-moderate\n left pleural effusion and persistent mild left lower lobe atelectasis. The\n right catheter may have a relatively short intrathoracic excursion. However,\n the moderate-to-severe right pleural effusion has decreased. The atelectasis\n at the right lung base has not improved.\n\n The heart size is indeterminant. Endotracheal tube is approximately 3.5 cm\n above the carina. A left central line still terminates at the\n caval/brachiocephalic junction.\n\n IMPRESSION: Improvement of a moderate-to-severe right pleural effusion and a\n small-to-moderate left pleural effusion after the placement of two pigtail\n catheters; the right-sided catheter might have only a very short intrathoracic\n excursion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019064,
"text": ", P. SICU-A 5:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess effusions\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with b/l pigtail chest tubes, b/l effusions\n REASON FOR THIS EXAMINATION:\n reassess effusions\n ______________________________________________________________________________\n PFI REPORT\n Patient with bilateral pigtail chest tubes and bilateral effusion. Evaluate\n effusions.\n\n FINDINGS:\n\n Right and left pigtail catheters have been introduced with a slight decrease\n of the moderate-to-severe right pleural effusion and small-to-moderate left\n pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-05-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1016368,
"text": " 5:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with recent PNA, now wheezing\n REASON FOR THIS EXAMINATION:\n eval PNA\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 76-year-old man with pneumonia, presenting with wheezing.\n\n COMPARISON: Multiple prior studies, most recent dated .\n\n FINDINGS: Cardiomediastinal silhouette is stable. In comparison to the prior\n radiograph of , the degree of pulmonary edema has improved. There are\n persistent bibasilar opacities. Given the history of left lower lobe\n consolidation, these could represent pneumonia. There is a small left pleural\n effusion.\n\n IMPRESSION:\n 1. Persistent left lower lobe consolidation/collapse.\n\n 2. Bibasilar opacities, in the setting of known left lower lobe\n consolidation, may also represent pneumonia.\n\n 3. Improving pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019885,
"text": " 11:40 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for PTX s/p L pleural pigtail removal\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with bilateral pleural effusion\n REASON FOR THIS EXAMINATION:\n eval for PTX s/p L pleural pigtail removal\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Left pleural pigtail removal.\n\n COMPARISON STUDY: Same day at 05:41.\n\n FINDINGS:\n\n There is no appreciable change since the prior study. There is continued\n bibasilar atelectasis, small right and moderate left pleural effusion.\n Tracheostomy is in the midline. Right subclavian catheter terminates in the\n superior vena cava.\n\n IMPRESSION:\n\n No change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018429,
"text": " 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with left sided whiteout\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 76-year-old man with left-sided white-out. Please evaluate for\n interval change.\n\n FINDINGS:\n\n The endotracheal tube tip is 3.5 cm from the carina in satisfactory location.\n In the interim, slight reexpansion of the left upper lung region has occurred\n with persistent moderate left pleural effusion. In addition, there is a\n slight decrease in the opacification of the right hemithorax, which is a\n combination of atelectasis and right pleural effusion.\n\n IMPRESSION:\n\n 1. Slight improvement characterized by reexpansion of a portion of the left\n upper lung, with persistent moderate left pleural effusion.\n\n 2. Persistent moderate right pleural effusion and adjacent atelectasis.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019596,
"text": " 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with bilateral pleural effusions\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral pleural effusions.\n\n COMPARISON: .\n\n SEMI-UPRIGHT CHEST RADIOGRAPH: An endotracheal tube and right subclavian\n central venous line are in unchanged positions. The cardiomediastinal\n silhouette is stable. There is stable mild pulmonary edema, as well as small\n bilateral pleural effusions and increasing left retrocardiac atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1020205,
"text": " 7:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia hx, eval for interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p GI bleed\n REASON FOR THIS EXAMINATION:\n pneumonia hx, eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: GI bleed with history of pneumonia.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Bibasilar opacifications are consistent with atelectasis and possible\n pleural fluid.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019754,
"text": " 5:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with PNA\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 06:19\n\n COMPARISON STUDY: \n\n CLINICAL INFORMATION: Pneumonia.\n\n FINDINGS:\n\n There is cardiomegaly. There is consolidation of the left lower lobe. There\n is a tracheostomy in the midline. A right IJ catheter terminates in the\n cavoatrial junction. There is patchy atelectasis at the right lung base.\n\n IMPRESSION:\n 1. Essentially no change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1019126,
"text": " 2:14 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval line placement (new R subclavian) / eval for pneumothor\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p R subclavian line placement\n REASON FOR THIS EXAMINATION:\n eval line placement (new R subclavian) / eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 76-year-old male status post right subclavian line\n placement. Evaluate for pneumothorax.\n\n AP chest radiograph compared to exam obtained nine hours prior demonstrate\n right basal pleural density which may be related to drainage via pleural\n catheter. Left pleural catheter remains in place. Lung volumes are\n diminished with plate atelectasis in the lung bases. The patient remains\n intubated with ET tube terminating 3.9 cm above the carina. Bilateral\n subclavian central venous catheter is present with tip overlying the distal\n SVC. No pneumothorax is identified. A drain overlies the abdomen.\n\n IMPRESSION: Satisfactory position of new right subclavian central venous\n catheter with tip positioned within the SVC. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-05-24 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1017034,
"text": " 5:29 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: tube placement\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with recent intubation\n REASON FOR THIS EXAMINATION:\n tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable for line placement on .\n\n COMPARISON: .\n\n HISTORY: 76-year-old man with recent intubation.\n\n FINDINGS:\n\n An endotracheal tube has been placed with the tip approximately 3.5 cm from\n the carina. Persistent right middle lobe and lingular infiltrates are again\n seen. Bibasilar left more than right effusions with adjacent atelectasis are\n also stable.\n\n IMPRESSION:\n 1. Newly placed endotracheal tube, left subclavian line are in satisfactory\n location.\n 2. Persistent multifocal pneumonia.\n 3. Stable small bilateral left more than right effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018890,
"text": " 10:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for resolution/change in effusion\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with pleural effusions, s/p Right thoracentesis/pigtail\n placement\n REASON FOR THIS EXAMINATION:\n please evaluate for resolution/change in effusion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MEz MON 3:41 PM\n R/O and evaluate effusion on a chest radiograph of .\n\n Placement of a right PICC catheter. There is no change in the status of the\n moderate-to-severe right pleural effusion and small to moderate left pleural\n effusion.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP on :\n\n COMPARISON: .\n\n HISTORY: 76-year-old man with pleural effusion status post right\n thoracocentesis/pigtail placement, evaluate for resolution or change.\n\n FINDINGS:\n\n The patient is status post placement of a right inferior pigtail catheter with\n no change in the moderate to severe right pleural effusion. Persistent small\n to moderate left pleural effusion is seen with a more slight worsening of air\n space disease in the right upper lung. No change in the status of the\n endotracheal tube, left subclavian line.\n\n IMPRESSION:\n\n 1) Status post placement of a right pigtail showing no dramatic change in the\n moderate to severe right pleural effusion.\n\n 2) Persistent small to moderate left pleural effusion with worsening left\n upper lobe air space disease likely edema, however, pneumonia cannot be\n completely excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-05-23 00:00:00.000",
"description": "B UNILAT UP EXT VEINS US BILAT",
"row_id": 1016991,
"text": " 4:17 PM\n UNILAT UP EXT VEINS US BILAT Clip # \n Reason: EDEMA PLEASE EVAL FOR DVT\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with bue edema\n REASON FOR THIS EXAMINATION:\n please eval for dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral upper extremity edema.\n\n COMPARISONS: None.\n\n BILATERAL UPPER EXTREMITY ULTRASOUND: 2D, color, and Doppler waveform imaging\n was obtained of bilateral internal jugular, subclavian, axillary, brachial,\n basilic and cephalic veins. Normal compressibility, waveforms, and\n augmentation were demonstrated. No intraluminal thrombus were identified.\n\n IMPRESSION: No evidence of bilateral upper extremity deep vein thrombosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018891,
"text": ", P. SICU-A 10:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for resolution/change in effusion\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with pleural effusions, s/p Right thoracentesis/pigtail\n placement\n REASON FOR THIS EXAMINATION:\n please evaluate for resolution/change in effusion\n ______________________________________________________________________________\n PFI REPORT\n R/O and evaluate effusion on a chest radiograph of .\n\n Placement of a right PICC catheter. There is no change in the status of the\n moderate-to-severe right pleural effusion and small to moderate left pleural\n effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1018500,
"text": " 1:24 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for possible ischemic foci.\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with viseral ischemic event\n REASON FOR THIS EXAMINATION:\n Please evaluate for possible ischemic foci.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMdb FRI 2:45 PM\n PFI - No acute abnormality.\n ______________________________________________________________________________\n FINAL REPORT\n ROUTINE UNENHANCED HEAD CT\n\n HISTORY: Assess for ischemia.\n\n No comparison studies.\n\n There is no acute intracranial hemorrhage or acute transcortical infarction.\n There is no hydrocephalus. There is age-appropriate volume loss.\n There is intracranial vascular calcification.\n\n There is a fluid level in the sphenoid sinus on the left. Scattered ethmoid\n and maxillary opacification is seen on the left with a left maxillary sinus\n fluid level.\n IMPRESSION:\n\n No acute abnormality.\n\n Sinus opacification as above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1018501,
"text": ", P. SICU-A 1:24 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for possible ischemic foci.\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with viseral ischemic event\n REASON FOR THIS EXAMINATION:\n Please evaluate for possible ischemic foci.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI - No acute abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019201,
"text": " 3:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with bilateral pleural effusions, fever\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bilateral pleural effusions and fever, to evaluate for change.\n\n FINDINGS: In comparison with study of , there are slightly better lung\n volumes. The endotracheal tube now measures only 2.5 cm above the carina. No\n change in the appearance of the right central catheter.\n\n Enlargement of the cardiac silhouette may in large part reflect the poor\n inspiration. Prominence of interstitial markings suggests some elevated\n pulmonary venous pressure. Some opacification behind the heart could reflect\n atelectatic change.\n\n The left subclavian catheter has been removed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019857,
"text": " 4:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with pna\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 05:41\n\n COMPARISON STUDY: \n\n CLINICAL INFORMATION: Assess interval change, pneumonia.\n\n FINDINGS:\n\n Tracheostomy is in the midline at the thoracic inlet. Since the prior study\n there has been interval worsening in the appearance of the chest. There are\n bilateral pleural effusions. There is now a small right pleural effusion\n which is new from the previous day. There is increased right-sided basilar\n atelectasis. On the left there is a small-to-moderate pleural effusion and\n left lower lobe atelectasis. There is probably an element of mild congestive\n failure. The heart is mildly enlarged. Mediastinum is within normal limits.\n\n IMPRESSION:\n 1. Interval worsening\n 2. New right-sided small pleural effusion. Continued left pleural effusion.\n 3. Increased atelectasis at both lung bases.\n 4. Mild congestive failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018910,
"text": " 11:57 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please repeat xray making sure to include left costophrenic\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with bilateral pigtail chest tubes, left pigtail and left\n costophrenic angle not visualized on last xray.\n REASON FOR THIS EXAMINATION:\n please repeat xray making sure to include left costophrenic angle\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS MON 8:01 PM\n AP CHEST, 12:23 P.M.\n\n Assess pigtail catheter.\n\n Left basal pigtail catheter unchanged at the level of the diaphragm. The\n lateral aspect right hemithorax is excluded from the examination, showing only\n a small portion of the right pigtail drain, probably unchanged in position\n since _____ a.m. Moderate right pleural effusion persists, left lung are very\n low in volume. ET tube in standard placement. Swan-Ganz catheter passes as\n far as the pulmonary outflow tract, but the tip is indistinct. No\n pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:23 P.M., \n\n HISTORY: Bilateral pigtail pleural tubes.\n\n IMPRESSION: AP chest read in conjunction with 11:25 a.m. today. The views,\n in aggregate, show the entire chest. Bilateral pigtail drainage catheters\n project over their respective hemidiaphragm locations, though localization is\n impossible on the single frontal view. The right catheter may have a\n relatively short intrathoracic excursion. Moderate to large right pleural\n effusion is unchanged. Atelectasis at the left lung base has improved. In\n the upper lung, there appears to be extensive consolidation. Heart size is\n indeterminate. Volume of left pleural effusion is also difficult to assess,\n slightly decreased since . ET tube is in standard placement at the\n thoracic inlet. A Swan-Ganz line entering from the left subclavian approach\n can be traced as far as the pulmonary outflow tract, but the tip is\n indistinct. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018911,
"text": ", P. SICU-A 11:57 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please repeat xray making sure to include left costophrenic\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with bilateral pigtail chest tubes, left pigtail and left\n costophrenic angle not visualized on last xray.\n REASON FOR THIS EXAMINATION:\n please repeat xray making sure to include left costophrenic angle\n ______________________________________________________________________________\n PFI REPORT\n AP CHEST, 12:23 P.M.\n\n Assess pigtail catheter.\n\n Left basal pigtail catheter unchanged at the level of the diaphragm. The\n lateral aspect right hemithorax is excluded from the examination, showing only\n a small portion of the right pigtail drain, probably unchanged in position\n since _____ a.m. Moderate right pleural effusion persists, left lung are very\n low in volume. ET tube in standard placement. Swan-Ganz catheter passes as\n far as the pulmonary outflow tract, but the tip is indistinct. No\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-05-20 00:00:00.000",
"description": "CHANGE PERC BILIARY DRAINAGE CATHETER",
"row_id": 1016618,
"text": " 4:37 PM\n MESSENERTIC Clip # \n Reason: assesss for bleeding source from UGIB\n Admitting Diagnosis: GI BLEED\n ********************************* CPT Codes ********************************\n * CHANGE PERC BILIARY DRAINAGE C -78 RELATED PROCEDURE DURING POSTOPE *\n * EA 1ST ORDER ABD/PEL/LOWER EXT -51 MULTI-PROCEDURE SAME DAY *\n * EA 1ST ORDER ABD/PEL/LOWER EXT -59 DISTINCT PROCEDURAL SERVICE *\n * CHANGE PERC TUBE OR CATH W/CON VISERAL SEL/SUPERSEL A-GRAM *\n * VISERAL SEL/SUPERSEL 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 * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 M Hx gallstone pancreatitis now w hypotension and raised WBC(17) s/p partial\n open Chole, Open Tracheostomy , Open G/J tube placement , and a\n Percutaneous Cholecystostomy tube placed on .\n REASON FOR THIS EXAMINATION:\n assesss for bleeding source from UGIB\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old male with new-onset upper GI bleeding (bright red blood\n per rectum and hematemesis) with endoscopy performed today noting clots\n adherent to the GJ tube, but no site of active bleeding. Evaluate for\n possible hepatic bleeding (hemobilia) as source. The patient has known PTBD\n drain in place for biliary drainage due to bile leak after partial open\n cholecystectomy.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. , the\n attending radiologist, who was an active participant during the procedure.\n\n PROCEDURE AND FINDINGS: Informed consent was obtained from the patient and\n the patient's wife (healthcare proxy) after the risks and benefits were\n explained. A preprocedural timeout was performed to verify patient identity\n and the nature of the procedure. The patient was placed supine on the\n angiographic table and the right and left groins as well as the right upper\n quadrant indwelling biliary drain were prepped and draped in normal sterile\n fashion.\n\n Initial fluoroscopic image demonstrated appropriate positioning of the biliary\n NU stent with its pigtail coiled within the jejunum and the biliary\n confluence. The catheter was cut to release the pigtails and an Amplatz\n catheter was inserted and coiled in the jejunum. The biliary catheter was\n then removed. Access was then gained to the right femoral artery wut a\n micropuncture kit. A micropuncture guidewire was advanced under fluoroscopic\n observation and needle removed and exchanged for a 5 French vascular sheath\n with its sidearm hooked to saline. A SOS catheter was then advanced into the\n aorta with its tip engaged within the SMA orifice. A dedicated SMA angiogram\n was then performed three times to allow appropriate and accurate coverage of\n the main and distal branches. The SMA itself displays conventional anatomy\n (Over)\n\n 4:37 PM\n MESSENERTIC Clip # \n Reason: assesss for bleeding source from UGIB\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n with no pseudoaneurysms or vascular blush appreciated. Attention was then\n turned to the celiac axis which was engaged with the Sos catheter. Multiple\n angiograms were then obtained of the celiac axis in AP and bilateral oblique\n projections which demonstrated conventional vascular anatomy and no evidence\n of active bleed, pseudoaneurysm or biliary vascular fistula connection.\n Multiple attempts were then made to advance the guidewire through the Sos\n catheter into the common/proper hepatic artery but initially unsuccessful\n given severe tortuosity of the hepatic artery. Subsequently, a Renegade Hi-\n Flow microcatheter and its native wire were successfully advanced through the\n Sos catheter into common and proper hepatic arteries and dedicated angiograms\n were attempted. These angiograms were suboptimal due to extensive respiratory\n motion and limited ability to inject high flow rates. The obtained angiograms\n in AP and oblique projections were unremarkable with no evidence again of\n active bleeding, pseudoaneurysm or biliary vascular fistulous connection.\n\n The catheter, guidewires and vascular sheath were then removed from the right\n inguinal region and manual compression was held for approximately 15 minutes\n with appropriate hemostasis obtained. Attention was then redirected to the\n biliary drain and a 12F x 24 cm nephroureteral (double-J) internal-external\n stent was advanced over the Amplatz wire with its distal tip terminating\n within the jejunum. A limited cholangiogram was performed through the\n catheter demonstrating appropriate sidehole placement within the biliary tree\n and prompt drainage into the intestines. No significant intrahepatic biliary\n dilatation was identified. The previously identified distal common bile duct\n stricture and variant anatomy was not well evaluated on this limited\n cholangiogram. Of note, no aberrant vascular connection was noted with\n contrast injection through the biliary tree. The pigtails were then deployed\n and the catheter was secured in a locked position. 2-0 silk sutures were used\n to secure the catheter to the skin which was covered with external dressing.\n Appropriate positioning of the two pigtails within the jejunum and biliary\n confluence was documented with fluoroscopic observation.\n\n 3 grams of Unasyn was given prior to the proceudre and 25 mcg of fentanyl and\n divided doses of 1 mg of Versed were given during the 2 hour and 20 minute\n intraservice time, during which time the patient's hemodynamic parameters were\n continuously monitored. Of note, the patient's heart rate and blood pressure\n were remarkably stable during the procedure and there was no evidence of\n active GI bleeding or hemobilia. .\n\n IMPRESSION:\n 1. Normal SMA and celiac trunk mesenteric angiograms with conventional\n anatomy and no evidence of active bleeding, pseudoaneurysm or vascular biliary\n fistulous connection. Limited dedicated angiogram of the common/proper\n hepatic arteries as described above was also unremarkable.\n\n 2. Replacement of right PTBD (double J) catheter with distal pigtail coiled\n (Over)\n\n 4:37 PM\n MESSENERTIC Clip # \n Reason: assesss for bleeding source from UGIB\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n in jejunum and proximal pigtail coiled within the biliary confluence. No\n hemobilia noted during examination. The catheter is capped for internal\n drainage. Of note, the insertion site does appear slightly indurated and\n tender to touch, consistent with a mild local infection.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-09 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1019679,
"text": " 2:28 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval trach placement\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p tracheostomy\n REASON FOR THIS EXAMINATION:\n eval trach placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy placement.\n\n FINDINGS: In comparison with the earlier study of this date, the endotracheal\n tube has been removed and replaced with a tracheostomy tube, the tip of which\n lies approximately 3.6 cm above the carina. Otherwise, little change in the\n appearance of the heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019466,
"text": " 11:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for ptx\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p right chest pigtail removal\n REASON FOR THIS EXAMINATION:\n assess for ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post right chest pigtail removal, to evaluate for\n pneumothorax.\n\n FINDINGS: In comparison with the study of , there are lower lung volumes.\n The tip of the endotracheal tube lies approximately 3.5 cm above the carina.\n Central catheter remains in place. Persistent enlargement of the cardiac\n silhouette, which in part may reflect poor inspiration. There is still some\n indistinctness of pulmonary vessels consistent with elevated pulmonary venous\n pressure. Opacification behind the heart again suggests some atelectatic\n change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2124-06-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018588,
"text": " 12:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for aeration\n Admitting Diagnosis: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with recent left lung collapse\n REASON FOR THIS EXAMINATION:\n Please evaluate for aeration\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Recent left lung collapse.\n\n Endotracheal tube terminates 9.3 cm above the carina, and the balloon of the\n endotracheal tube is markedly overdistended within the cervical region.\n Worsening atelectasis is present in the left lung with residual area of\n aerated lung in the perihilar region. Large left pleural effusion and\n moderate right pleural effusion are unchanged. Apparent ascites and anasarca.\n\n Position of endotracheal tube and overdistention of the cuff have been\n discussed by phone with Dr. on .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-08 00:00:00.000",
"description": "Report",
"row_id": 1644327,
"text": "Nursing Note 7a-7p:\nNursing assessment:\n\nTmax 101.2 po. Per sicu culture if >101.5 po. Pt is and following commands. At times gives a puzzled expression when being orientated. Nods no to pain. Moving arms in bed but does not assist in turning. Frequent turning/repositioning. Skin to coccyx intact/nonreddened.\nLungs are clear. Right pigtail CT with no drainage and discontinued this morning. CXR following. Per xray Left lower lobe worsening/more consolidation. Left pigtail CT with straw colored drg 150 cc for shift. Neg fluct/neg leak/ neg crepitus. Straw colored drg now oozing from old Right CT site. Attempted cpap 5/5 this morning but pt with increased work of breathing RR 30-40 and placed back to cpap 10/5. Per gold surgery and sicu team plan was to trach either today or tommorrow and no further attempts at vent weaning have been made today. ABG's followed with no significant changes. Pt is having frequent coughing fits and suctioning for thin white /frothy secretions.\nAbdomen is softly distended with present bowel sounds. Gtube to gravity draining bilious. Jtube feeding replete with fiber at goal. Flexiseal intact with soft brown stool (200cc/shift). Abdominal drg wet to dry changed. Biliary pigtail remains clamped.\nLasix gtt increased for goal even to negative for today. No fluid boluses to be given for any hypotension, rather levophed if needed. SBP 90s-120/40-50s. HR NSR 80s without ectopy. Lopressor dose decreased for hypotension this morning and to allow more room for diuresis. UO approx 80cc/hr clear yellow. No urine output for two hours despite flushing cath and foley advanced with good effect. MD notified. Potassium repleted as needed. Please refer to carevue for all further details: Plan: lasix gtt for goal even today. Trach tommorrow. Monitor for hypotension, levophed if necessary; please avoid bolusing fluid at this time. Emotional support for pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-14 00:00:00.000",
"description": "Report",
"row_id": 1644349,
"text": "RESP CARE NOTE\nPT REMAINS VENTED ON PSV . LAST ABG 7.53/36/131/7. RSBI 121. PLAN WEAN AS TOLERATED AND SCREEN FOR REHAB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-14 00:00:00.000",
"description": "Report",
"row_id": 1644350,
"text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nTmax 100 po. Pt is easily and following commands. MAE. Lungs clear, suctioned for thin white secretions. CPAP 5/5 however low tidal volumes and per RT back to orginal settings. Pt is now currently back on trial this morning. Abdomen softly distended with present bowel sounds. Tube feeds via jtube at goal. gtube to gravity. Lasix gtt continues and negative 1 liter at midnight. Plan: Physical therapy and rehab screening. Vent weaning as tolerated. Lasix gtt ?goal for today? Freq reorientation. Please see carevue for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-14 00:00:00.000",
"description": "Report",
"row_id": 1644351,
"text": "STATUS\nD: REMAINS ON LASIX GTT..FOLLOWS COMMANDS..MOVES ALL EXTREM'S\nA: VENT FIO2 TO 30%..SUCTIONED FOR SM AMT THIN WHITE..TRACH CARE DONE..TOL TF'S WELL..LASIX GTT @ 3MGM WITH GOOD HUO'S..LIQ BROWN STOOL FLEXI SEAL INTACT..SEEN BY PT SAT ON SIDE OF BED TOL FAIRLY WELL\nR: STABLE\nP: REHAB PLACEMENT..CONTINUE TO WEAN VENT AS TOL..TRACH CARE PER PROTOCOL..LABS PER HO..LASIX TO KEEP PT 1L NEG QD..CONTINUE WITH FAMILY/PATIENT SUPPORT\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-14 00:00:00.000",
"description": "Report",
"row_id": 1644352,
"text": "Resp care\nPt remians on PSV vent settings increased to this am due to tachypnia and vt <300. BLBS diminished suctioned for sm amt thick secretions mdis given per order. plan to continue on current settings overnight as toelrated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-15 00:00:00.000",
"description": "Report",
"row_id": 1644353,
"text": "condition updated\nS/P GI BLEED W/RESP COMPROMISE\n\nEvents overnoc: temp spike\n\nFor detail info please refer to carevue flowsheet\n\nTemp spike to 101.2, ^resp rate, and periods anxiety.\ntylenol given and cultured (peripheral BC x2 and urine). resp rate in high 20's most of night ^to mid thirties when stimulated. temp down after tylenol. ativan given x1 for sleep and slept in naps. AM abg's improved. WBC'S elevated to 13.6 this AM\nspoke at length w/wife who is concerned about temp, amount of ativan given and not notified of pending d'c to rehab. reassured and explained to wife the nature of his illness and the multiple reasons for new temp but we would monitor closely and keep on top of things. The issue w/ativan was she felt he was too \"sleepy\" everytime she visited and this lethargy would compromise his rehab. After discussion w/SICU resident order was changed to Q8hrs PRN with an attempt to use sparingly. Pt is , orientation but easily refocuses and calms down. In terms of rehab wife \"had no idea\" of the possibility of transfer to rehab today. It was explained to her that he was heading in the direction of improvement and we had begun the screening process but it was decided late in the day that the transfer would not take place until the earliest Monday and that would be contingent on how he progresses. She seemed satisfied and appreciative with all the explanations.\nPOC:\nfollow temp closely\nincrease activity w/PT\nuse ativan sparingly\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-07 00:00:00.000",
"description": "Report",
"row_id": 1644318,
"text": "SICU NPN\nHypotensive\n\nHR 80-90s, NSR, few PVCs, SBPs 70-130s. Tm 101.9 Tc 100.6. Worsening rash from head to toe with focus around torso. Flat red/pink patches, spread out. Vanco and Zosyn started . WBC 11(8). HUO 80-400cc/hr. (-)750cc for 24hrs.\n\n2L of NS boluses, transfused with 1u PRBC. Levophed infusion on standby. SBPs 90-100s. Potassium, Calcium, and Magnesium repleted. Benadryl 25mg IV once.\n\nMonitor hemodynamics closely, Keep SBP > 90, Follow up w/ labs during day. Follow temp curve. Follow up w/ culture data.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-07 00:00:00.000",
"description": "Report",
"row_id": 1644319,
"text": "Respiratory Therapy\nPt presents orally intubated on PSV. BS clear bilaterally w diminished LLL. Sx moderate amounts thin to thick white secretions. PS increased to 10 overnight as pt became febrile and hypotensive W increased RR. ABG: 7.40/48/138/31. Plan: continue ventilatory support, wean as tol. Please see carevue for specifics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-26 00:00:00.000",
"description": "Report",
"row_id": 1644270,
"text": "condition update\nD: pt sedated on propofol and fentanyl. propofol and fentanyl increased during the shift due to pt opening eyes and moving head to painful stimuli. pt pupils are equal and reactive to light. pt does not move extremities.\ncardiac: pt nsr changed to afib at 2330 tonight hr 130's. sbp 106/60. pt seen by dr. and diltiazem 25mg bolus given and pt started on drip and titrated up to 15mg. pt seen by dr and hr still 115-125. sbp remains greater than 100. additional 25 mg given and pt remains at 15mg/hr. hr still afib at 102-116. labs sent and lytes unchanged. neo weaned down to 1.75mcg/kg/min before pt went into afib. since being in afib. no further weaning of pressors tolerated. levo remains at .3mcg/kg/min, vasopressin at 2.4units/min.\nresp: pt remains on ac with 20 of peep. see flowsheet for abgs. rate decreased to 22. pt suctioned for thick white sputum.\ngi: gt/jt to gravity. gt draining old dark bloody drainage. Dr. aware. jtube draining biliouos. ngt draining thick old bloody. abd distended, no bowel sounds. flexiseal intact with no drainage.\ngu; foley patent draining cloudy colored urine. output 28-34cc/hr.\nskin: allevyn dressing intact on coccyx. pt with total body edema. arms elevated on pillows. bruising present on right side of chest near cordis placement. abd pigtail with no drainage. open area(? skin tear from tape below cordis on neck. aquacel dressing applied.\na: continue to montior labs and fluid status. montior sedation level.\nr: pt still arousable to stimulation. abgs are unchanged po2 90's on 40% and 20 of peep. pt still with volume overload. urine output has improved. no further weaning of pressors at this time pt still in afib byt with better rate control.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-26 00:00:00.000",
"description": "Report",
"row_id": 1644271,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nPt remains sedated on fentanyl and propofol for vent control. Opening eyes to pain and not following commands. Remains vented on AC 40% Peep 20 rate 22 with improving abg. Lungs are coarse, clears with suctioning. ?pleural effusion on xray. Lungs are audible but diminished in the bases. Abdomen is firm and absent bowel sounds. NGT with drb draining in small amts. Nothing per ngt at this time. Gtube to gravity with scant drb out this shift. Jtube to gravity with bilious output in small amts. Flexiseal without output. Pigtail not draining. Drain near pigtail with scant amt of drb and changed d/t leaking. Abdominal dressing changed last night intact. Pt in afib 100-115 this morning on dilt gtt and then at 0745 converted to sinus brady. Dilt decreased and then discontinued MD . Pt takes po amiodorone at home but if converts back into afib will consider iv amiodorone vs diltizem. Pt remains brady all shift with a rate of 47-55 bpm. Pt weaned from neo gtt and remains on levophed and vasopressin at this time for goal map >65 sbp >90. Is bp drops levophed is to be titrated up before restarting neo MD . UO aprox 30cc/hr of cloudy yellow. VRE grew back from rectal swab per sicu team. monitoring continues as recorded in carevue. PLease see carevue for all further specifics. Monitor hct q 8 hours. Monitor abg on vent. Emotional support and updates to pt's wife. Further pressor weaning as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-07 00:00:00.000",
"description": "Report",
"row_id": 1644320,
"text": "Resp. Care Note\nPt received intubated and vented on PSV settings as charted on resp flowsheet. PSV level decreased from today with pt becoming more tachypneic to low 30's. PSV level increased back to 10. Pt also with fever spike today to 102. Pt bronched for BAL, secretions frothy white. Albuterol and Atrovent MDIs as ordered. Cont current settings, reeval in AM for readiness to wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-07 00:00:00.000",
"description": "Report",
"row_id": 1644321,
"text": "CONDITION UPDATE:\nD/A: TEMP SPIKE TO 102.2, TYLENOL GIVEN, HYPOTENSIVE WITH TEMP BREAK. BRONCH DONE, BAL SENT. CULTURES PENDING. ID CONSULT REQUESTED.\n\nNEURO: , FOLLOWS COMMANDS, DENIES PAIN, MAE'S, PERL.\n\nCV: HR 70'S-90'S NSR WITH PVC'S. BP UP TO 150'S/60'S WHEN FEBRILE, HYPOTENSIVE TO 80'S/40'S WITH BREAK IN FEVER. FLUID BOLUS X1 GIVEN, AND THEN TO TREAT WITH PRESSORS IF NEEDED. CVP ~ 16. FLUID BALANCE MN-1700 +1700CC'S. + GENERALIZED EDEMA.\n\nRESP: LS CLEAR, DIMINISHED BASES. CONSTANT WHITE FROTHY SECREATIONS. BRONCH DONE, BAL SENT. PT ON CPAP + PS, 5 PEEP, 5 PS WITH INCREASED WORK OF BREATHING. PS INCREASED TO 10 WITH ABG: 7.45, 38, 102, 27, 2. X2 PIGTAIL CATHETER BILAT PLEURAL EFFUSIONS WITH STRAW COLORED DRAINAGE.\n\nGI: TUBE FEEDS AT GOAL VIA JTUBE. GTUBE TO GRAVITY. FOUL SMELLING LIQUID BROWN STOOL WITH 1ST CDIFF SPECIMEN NEGATIVE, SECOND PENDING, CAN SEND 3RD AFTER MN.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nID: CONSULTED.\n\nSX: WIFE REQUESTING PRIMARY TEAM TOUCH BASE WITH HER. TEAM MADE AWARE.\n\nR: FEBRILE, HYPOTENSIVE, REQUIRING FLUID BOLUS, ? SEPTIC PICTURE.\n\nP: GOAL MAP > 60, USE PRESSORS IF NEEDED.\nVENTILATOR SUPPORT WHILE EXCESSIVE SECREATIONS.\nMONITOR CULTURE DATA.\nFOLLOW UP ON ID CONSULT.\nPT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-08 00:00:00.000",
"description": "Report",
"row_id": 1644322,
"text": "RESP CARE NOTE\nABG DRAWN RIGHT RADIAL. SITE HELD UNTIL BLEEDING STOPPED\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-08 00:00:00.000",
"description": "Report",
"row_id": 1644323,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt easily arousable to voice. Follows simple commands; squeezed RN's hands and moved toes to command. . Moves all extremities in bed. Pt lifts/holds BUE. Bilateral wrist restraints in place d/t pt attempts to pull at ETT and lines. Pt nods/shakes head to some questions. When asked if in pain, pt shook head \"no.\" Tmax 100.8; per Dr. , pan culture if temp >101.5. Pt on Vancomycin, Zosyn, and Flagyl. HR 60-80s (NSR; rare PVC's noted at beginning of the shift). MAP >60 off pressors. CVP 8-16. Pt with generalized edema. DP/PT pulses palpable. Venodyne boots on BLE. Multipodus boots off/on. 24hr net I&O balance was +2170 (Dr. aware). Per Dr. , start Lasix gtt at 1mg/hr; per , not give bolus. Lungs coarse; clear after suctioned. Pt suctioned for white, frothy secretions. No vent changes overnight. CPAP 40%, PEEP 5, PS 10. ABG showed compensated metabolic alkalosis. Bilateral pigtail drains to 20cm suction; straw colored drainage. Negative fluctuation/leak/crepitus. Abdomen softly distended with hypoactive bowel sound. TF at goal rate via J-tube. G-tube to gravity bag with bilious output. Flexi-seal intact with brown stool; guaiac positive. Stool sent for C.diff #3. Foley intact with clear, yellow urine. UO >/= 50cc/hr. No pressure sores noted. Pt on KinAir mattress. Aloe Vesta applied to bilateral heels and coccyx/buttocks. RUQ abdominal wet to dry dsg changed; no drainage noted. Dsg over left pigtail drain chest tube changed x1. Right pigtail drain chest tube dsg clean, dry, intact. Right pigtail drain capped; dsg intact. wife visited until 9PM and called x1 overnight; updated by RN on pt's condition and on plan of care.\n Plan: Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. Wean O2 setting as tolerated. Continue antibiotics; follow up result of cultures. Pan culture if temp >101.5. Keep MAP >60. Lasix gtt at 1mg/hr. Monitor output from wounds and drains. Change dsg as ordered. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-08 00:00:00.000",
"description": "Report",
"row_id": 1644324,
"text": "Addendum to NPN:\nPink rash noted on chest, abdomen, and bilateral upper thighs. Rash is not raised; blanches. Miconazole powder applied to groin area and under abdominal fold. RUQ abd wound bed is pink with yellow tissue; wet to dry dsg changed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-08 00:00:00.000",
"description": "Report",
"row_id": 1644325,
"text": "RESP CARE NOTE\nPT CONTINUES ON PSV 10/5/.4/+5. LAST ABG: 7045/38/91/27. RSBI 82 BUT RR IN LOW 30'S. PLAN TO EVALUATE THIS AM FOR EXTUBATIONTEMP 100.8.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-12 00:00:00.000",
"description": "Report",
"row_id": 1644343,
"text": "please see carevue for details of care\n\npt , non-verbal secondary to trach, able to mouth words to express needs. Complains of \"stomachache\" , Dr. aware, 0.5 mg dilaudid IV given as ordered with good relief of pain. pt states he is \"nervous\", 0.5 mg ativan iv given as ordered. pt moves all extremities, generalized weakness noted. T max 99.8. HR 60s-70s, SR, no ectopy. BP 100s-120s/50s-60s. Generalized edema noted, on lasix gtt, titrated to achieve neg 1-2L fluid balance, currently lasix infusing at 3 cc/hr with 1.7L off. CVP 2-5. +DP/PT pulses. Lungs CTA upper lobes, diminished at bases. #8 trach collar in place, on CPAP & PS 40% FiO2, 10 pressure support, 5 PEEP, tidal volumes ~ 400. RR 25-30. O2 sat >97%. Suctioned x3 white, frothy secretions. +cough. Abdomen soft, distended, +BS. pt NPO, replete with fiber full strength infusing via J tube at 70 cc/hr. G tube to gravity draining bilious fluid. Flexiseal draining loose brown stool. Foley catheter draining approx 150 cc/hr clear light yellow urine. Skin reddened trunk and back. RUQ abdominal wet to dry dressing changed. K,Mg and Ca repleted as ordered. Wife at bedside, updated re: plan of care.\n\nPlan: continue to monitor respiratory status, wean vent as tolerated, monitor hemodynamic status, monitor fluid status, monitor lab results, replete lytes as ordered, maintain skin integrity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-13 00:00:00.000",
"description": "Report",
"row_id": 1644344,
"text": "RESP CARE NOTE\nPT BEGAN TO FATIGUE DURING NIGHT WITH PERIODS LOW TIDAL VOLUMES AND PS WAS INCREASED TO 15. CURRENT SETTINGS PS 10/40/+5. RSBI THIS AM 117. SX THIN AND WATERY WHITE. MDI'S GIVEN. PLAN TO CONTINUE TO WEAN AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-13 00:00:00.000",
"description": "Report",
"row_id": 1644345,
"text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nTmax 100.9 po. Pt is awake and with puzzled expression when being reorientated. Following commands until this morning pt refusing mouth care despite reorientation. Ativan x 1 overnight for increased coughing on vent and increased respiratory rate. Vent pressure support increased by RT and MD notified. Unable to draw abg from arterial line and MD also notified, will attempt to rewire line this morning. Lungs are clear. Abdomen softly distended. Large amount of liquid stool via flexiseal following eight pm meds via jtube. Slowing overnight. Pt denies pain. Urine output adequate via foley cath. Lasix gtt continues with good results -2300 at midnight. Plan: Cont to wean vent as tolerated. Frequent reorientation and emotional support for pt and wife. Physical therapy consult and ? start oob with permission from team. Rewire aline. W-D dressing to abdomen. Continue to diurese as tolertated. Please see carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-13 00:00:00.000",
"description": "Report",
"row_id": 1644346,
"text": "Nursing note (0700-1900) 16:30.\n\nSee careview for details.\n\nEssentially unchanged condition since previous shift, A-line changed over wire successfuly, screened for rehab.\nSxn'd for moderate amounts of thin white secretions, able to cough to end of trach himself also. PS weaned back to 10, adequate abg since, LS clear to UL's coarse to LL's\nTylenol given for low grade temp, would recommend giving round the clock to help.\nDressing to abdomen changed, area granulating well.\nLasix gtt continues at 3mg/hr, plan is for -ve ltrs today.\nloose stool contained well with flexiseal.\n\nPlan.\nWean vent further if able.\nPT to see this afternoon.\n? send to rehab next day or so.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-25 00:00:00.000",
"description": "Report",
"row_id": 1644265,
"text": "(Continued)\nmosis noted to the right where his IJ cordis is in place. Upper chest has some mottled areas noted. Skin overall is intact, warm and dry. Pitting edema to extremities noted.\n\nLABS - ABGs done every 4 hours with improvement noted, lactates were trending down but have noted to increase. WBCs elevated in the high 40s, low 50s. Replaced magnesium, potassium and calcium per sliding scale orders. RSSI given for slightly elevated glucose levels.\n\nP/S - Family in during the night, support given and many questions answered. Dr. visited family and gave update. They were made aware on many occasions the critical condition of patient and his plan of care. Patient remains full code. Wife and children emotional at bedside, given much support and comfort.\n\nIV - Left subclavian TLC has meds infusing all three patent lumen. Right IJ cordis is positional but infusing adequately, dressing changed. Right radial artline with good waveform, good return and distal CSM noted to right hand, dressing changed. Left arm 18s intact, flush well, ? date placed.\n\nPLAN - hemodynamic monitoring, monitor labs, antibiotics, keep patient and family notified of plan of care, vent support, pressor support, fluid boluses.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-25 00:00:00.000",
"description": "Report",
"row_id": 1644266,
"text": "RESP CARE NOTE\n76 YO M ADMITTED FOR ARDS, GASTRIC PANCREATITIS is currently on a/c, 550. 40% +20. an esphogeal baloon was inserted. oxygenation has improved. last abg 741,28,141,178,-4,95. angio done yesterday showed that the bleeding has stopped. plan to continue continue slow wean.\n\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-25 00:00:00.000",
"description": "Report",
"row_id": 1644267,
"text": "BS coarse crackles. Suctioned for small amounts thick white secretions. Rate decreased with little change in ABG's. Esophageal balloon numbers show no requirement to change PEEP. Prognosis continues poor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-25 00:00:00.000",
"description": "Report",
"row_id": 1644268,
"text": "Please See Carevue for Details.\n\nNeuro: Pt remains sedated with pain control with Propfol and Fentanyl gtts. Pt with excessive stimuli withdrawing bilat lower exts. Does not obey commands. PERRLA.\n\nResp: Pt remains on ventilation. PEEP 20. Fi02 40. No changes to the ventilation settings this shift. Pt suctioned from ETT for scant white secretions. Moderate secretions from oral cavity. Bite block in place to prevent biting of ETT and to keep tongue with in the oral cavity.\n\nCardio: Pt continues to need x3 vasopressors. Tolerated minor wean on Neo from 4.5mcg/kg/min to 2.25 mcg/kg/min. Pt's femoral arterial line deemed more accurate then the radial arterial line (positional issues). PICCO2 placed by dr. for continuous cardiac output monitoring as well as fluid status assessment via SVV values.\nLab values with noted improvement. Repletion of CA as ordered by the sliding scale.\n\nGU: Minimal urine output. Approx 20-30 cc/hr. Yellow and cloudy. MD's aware. Minimal drainage in J/G/ and NGT. J tube with green bile and G and NGT with BRB to tinged. All have been irrigated to manage patency of drains.\n\nGI: Pt continues to have placement of Flexi Seal in case of additional GI bleed. No output since placement on . No BS. Abdomen firm and soft.\n\nIntegumentary: Pt now on a triadyne bed for turning compliance to assist pulmonary functioning and protection of integumentary. Pt's BP does not tolerate manual turns frequently. Is tolerating the Triadyne movement. Pt's backside and majority of torso with mottling. Buttocks red-purple but blanchable. Small skin tear treat with allevyn dsg. Complete head to toe skin exam completed. Pt is third spacing fluid and has small, minimal weeping areas to arms and legs. Scelera noted with increased edema as well.\n\nPlan: Continue aggressive medical treatment per wife and pt's request. Continue to attempt wean of vassopressors, neo the priority to wean. Continue to closely moniter hemodynamics and respiratory status. Continue to closely moniter C.O. and I/O's. Continue pt on Triadyne bed for improved ventilationa nd integumentary. If pt does re-bleed, it is probable that no invasive interventions (ie O.R., I.R.) will be implemented by MD's. Pt's family made aware by Attendings on . Ho and primary team aware of all above.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-26 00:00:00.000",
"description": "Report",
"row_id": 1644269,
"text": "RESP CARE NOTE\nPT CONTINUES ON VENTILATOR: A/C 22 550 .4 +20.LAST ABG @0400 :\n7.45/28/98/20/-2. plan to continue slow wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-11 00:00:00.000",
"description": "Report",
"row_id": 1644339,
"text": "Resp Care\nPt remains on PSV vent setting weaned to psv 5/5 from 8am-4pm when she was increased to due to tachypnia into mid to upper 30s. BLBS diinished suctioned for small amt thick secretions, mdis given per order. plan to continue on current settings overnight as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-12 00:00:00.000",
"description": "Report",
"row_id": 1644340,
"text": "7pm-7am Nursing Note\nSee CareVue for objective data and trends:\n\nPt , following commands appropriately and MAE. Pt mouthing words to communicate needs. HR running 60s-70s in NSR, BP 90s-120s/60s-80s. CVP ranging . Pt continues on lasix drip with goal to run 2 liters negative-pt negative 1850 at midnight. Lasix rate lowered for brief period as BP trending lower for period. Pt remains ventilated on CPAP 40% fio2, 5 PEEP, 10PS. Pt being suctioned for small to moderate amounts of frothy, white sputum. Pox maintaining 97-100%. LS clear and diminished at bases. Pt continues to have generalized edema although it is improving. Pt tmax 99.9.\nPLAN-Monitor respiratory status and wean as tolerated. Follow labs, continue lasix drip to diurese patient. ? plan for rehab when medically cleared.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-12 00:00:00.000",
"description": "Report",
"row_id": 1644341,
"text": "Respiratory Care:\n\nPatient with 8.0 Portex. Cuff pressure 25cm/H2O. BS clear bilaterally. Sx'd for sm amount of thin white secretions. Strong cough effort. Albuterol/Atrovent MDI given Q4hr. Tolerated well. Current vent settings PSV 10, Peep 5, Fio2 40%. Spont vols 400's with RR high 20's to 30. Pt. weaned yesterday to PSV 5 and rested on PSV 10. RSBI 113 this am. Increased from 87 yesterday. Fluid positive, lasix drip. No further changes made.\nPlan: Continue with PSV as tolerated. ? ^ PSV level if RR stays high.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-12 00:00:00.000",
"description": "Report",
"row_id": 1644342,
"text": "Resp Care\n\nPt remains with a #8 portex and currently vented on PSV 10/+5 tol well with no changes made this shift to parameter settings. Vt ranging from 400-450ml breathing in the high 20s low 30s at time with MV 10-12L. BS clear to course sxing for small to mod amts of thin white secretions. Bronchodilators given x3 with good effect noted. Will cont with vent support and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-24 00:00:00.000",
"description": "Report",
"row_id": 1644259,
"text": "Readmission to ICU\n0400 - Patient transferred to ICU from 11, he is lying supine on floor bed and is on their monitor. He is on 100% NRB. He is noted to be awake and oriented x 3, moving all extremities. He complains that he moved his bowels and needs to be cleaned. Patient transferred to ICU bed with 4 assist and tolerated well. SICU team at bedside. Patient mentating appropriately and denies SOB. VS as documented. Plan made to intubate patient for airway protection. At 0420 patient was ambu'd and then given etomidate 10mg IVP then Succinylcholine 100mg IVP, patient intubated with 7.5, 23 at lip, color change with CO2 detector, bilateral lung expansion and breath sounds heard bilaterally, patient tolerated well. Patient started on propofol gtt at 0430, 10mcg/kg/min and a right radial artline was placed by anesthesia while SICU resident Weeds placed a left subclavian TLC, during which patient had hypotension and neo gtt was initiated and NS/LR boluses ordered and administered peripherally. Patient's sats in the high 80s with good pleth noted. Once RSC TLC placed his ETT suctioned for small amounts of thin white secretions, ABG as documented and current vent settings, PCXR completed and verified that line and ETT in correct position. Pt continues to be hypotensive, neo to max, started on levophed gtt and titrated to max with concurrent transfusions x 4 completed. Propofol continued at 10mcg/kg/min for sedation. At 0620 patient vomited large amount of BRB emesis, NGT placed in right nare and placed to LCWS with BRB return, patient tolerated well. Throughout patient was responsive and trying to speak, support given throughout. SICU attending/team at bedside with multiple orders. Right IJ cordis placed, awaiting PCXR.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-24 00:00:00.000",
"description": "Report",
"row_id": 1644260,
"text": "Respiratory note:\nPt recently admitted to for gallstone pancreatitis. Readmitted for acute respiratory distress. Intubated in unit w/c. Line was placed. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-24 00:00:00.000",
"description": "Report",
"row_id": 1644261,
"text": "N - Patient on propofol gtt but responding to questions appropriately. Bilateral soft wrist restraints placed to maintain safety, explained to patient. Patient denies pain throughout. PERRL at 4mm bilaterally, moving all extremities and following commands.\n\nCV - HR NSR to ST in low/mid 100s, noted to be afebrile. Vasoactive gtts of neo and levo titrated for pressure support. 4 units of PRBCs infused per order due to continued bleeding. Pulses are palpable in radial, pedal and post tibial locations. Peripheral edema noted.\n\nR - Patient intubated with 7.5, 23 at the lip, lung sounds coarse with crackles on the left upper lobes noted, sats increased to mid to high 90s on current FiO2 of 100% and PEEP of 10cm, propofol for vent compliance. ABGs poor as documented, continue to monitor.\n\nGI - Patient has large, soft obese abdomen with bowel sounds present. NGT in right nare to LCWS with BRB return. Left GJ tube to gravity drainage. Right flank pigtail clamped. Right flank collection bag collecting blooding drainage. Midadbominal wound with steristrips intact, wet->dry dressing intact, not changed. Patient is NPO. Patient has large loose BRB stool with clots noted.\n\nGU - foley placed in patient, noted to have hypospadius, returned clear yellow urine.\n\nIV - Right arm 18G intact, patent with dressings intact. Left subclavian TLC intact with all three lumen patent and infusing multiple meds/ products. Right IJ cordis placed, awaiting pending CXR readings. Right radial artline intact with good waveform noted, dressing CDI.\n\nLABS - Patient given calcium gluconate 2grams IV as ordered for low ionized calcium. Lactate noted to be elevated. Transfused multiple units of PRBCs.\n\nP/S - Wife, , notified of patient's condition, awaiting her arrival.\n\nPatient remains on MRSA precautions, is a full code with NKDA.\n\nPLAN - obtain hemodynamic stability, replace products, monitor labs, keep patient/family informed on plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-24 00:00:00.000",
"description": "Report",
"row_id": 1644262,
"text": "Respiratory Care\nPatient remains intubated and on full mechanical ventilatory support, breath sounds bilaterally clear, suctioned for no secretions, after increase in frequency and in PEEP acid-base balance was good, but oxygenation still was not good, esophageal baloon inserted at 1325, PEEP was increased to 20 to compensate for the measured underpeep, still the follow-up ABGs showed mild hypoxemia on 100%, FiO2 dropped to 90%, since patient has been long enough on 100%, patient had a trip prior to esophageal baloon insertion to Angio, because of bleeding,no gastric source of bleeding was located and the bleeding seemed to have stopped, patient was paralysed during baloon insertion, right now SPO2 is 98%, has been around 95% most of the the day, had cardiac ultrasounds around midday, will continue to be followed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-24 00:00:00.000",
"description": "Report",
"row_id": 1644263,
"text": "Please see Carvue for Details.\n\nNeuro: Pt sedated on Propofol 30mcg/kg/min. Received Vecuronium Bromide for esophogeal ballon placement at approx 1300. Currently not obeying commands, not moving ext's to painful stimuli. Pupils 2mm bilat and sluggish. Pt also on a Fentanyl gtt for additional comfort (pt was fighting the ventilator) at 100 mcg/hr.\n\nResp: Patient intubated shortly after arrival to SICU this am. Has progressed to ARDS with worsening cxray and increasing Fio2 requirement and increasing PEEP to maintain pO2>70 (currently on .9 and 20 PEEP as determined by balloon study). Lungs clear anteriorly, suctioned for minimal amount of secretions. See flow sheet for multiple abgs done during the day.\n\nCV: Patient continues to deteriorate, with increasing pressor requirement during the day. WBC jumped from 16 to 47 by this pm. Currently on Neo/Pit/Levo (see flow sheet for details). Titrated for MAP>60. Patient does respond well to fluid boluses when pressure trends down. Maxed out on neo, can go up on levo\nif needed. Pit at 2.4,will not change. Aline and cuff corrolate, going by a line pressures. Received total of 6 u prbc since admission and multiple fluid boluses, cvp around 16-20, bedside cardiac echo done by ICU fellow which showed full ventricles at the time. Pt to angio this am and no source of bleed found. Angio site CDI. Current K+ 3.4, repleted with 60meq of K+ during shift.\n\nGI: Abdominal continues to be soft and distended. No BS detected. NGT in place and conts on LCS with BRB out. Hematocrit stable. Pt to angio this am and no source of noted. No , flexiseal in place. G/J Tube remains to gravity with moderate output. R bil. tube out and MD's aware. To remain tegadermed in current place.\n\nGU: Urine output diminished despite bolus of albumin. Approx 10-20 cc/hr. Creatine stable.\n\nIntegumentary: Pt with pitting edema throughout. Doppler required to obtain PP. Coccyx red, turning and reposioning as tolerated.\n\nSocial: Wife and patient's children aware of gravity of situation. Pt's children needed to hear prognosis from Nsg and MD's. SW involved to assist with coordination of visits and to support wife emotionally. Wife and 2 sons met with attending/chief resident. Continue with full code status and aggressive treatment.\n\nPlan: Continue to moniter and support hemodynamically. Continue to follow all labs closely. Continue to moniter I&O's. Continue to moniter respiratory status. Support and educate family. Continue to treat pt aggressively per family's wishes.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-25 00:00:00.000",
"description": "Report",
"row_id": 1644264,
"text": "N - Patient is sedated on fentanyl 100mcg/hr and propofol 30mcg/kg/min as ordered. Initially he did not respond to an stimuli but throughout the night he has been semi responsive and followed the simple command to wiggle his toes, no other commands followed. He has a strong gag reflex and will move upper extremities weakly with painful stimuli. All aspects of his care have been explained to him prior to performing them. There are no physical indicators of pain noted.\n\nCV - Patient has had hemodynamic instability throughout the shift. He remains on neo/levo/vasopressin gtt for pressure support and has received multiple LR boluses per order. He has remained afebrile. Radial pulses are palpable and pedal pulses are weakly palpable though her is ++ edematous throughout his periphery (legs, arms, scrotum, face, sclera). HR is NSR without ectopy in the 60s-70s. BPs range in the low 100s (SBP) with MAPs greater than 60mmHg for the most part. At 0400 patient turned slightly and noted to drop pressure to the 60s SBP, increased pressors to max and patient's BP increased to WNL, titrated down with good effect and LR bolus given.\n\nR - Patient continues to require mechanical ventilation this shift, multiple ABGs drawn and FiO2 weaned accordingly. Esophageal balloon remains in place as ordered. Lung sounds are coarse throughout with diminished bases. ETT suctioned for white, thin and frothy sputum in small amounts PRN, good cough/gag noted. Patient on AC of 26, PEEP of 20. PCXR this am completed, continue to monitor.\n\nGI - Patient's abdomen is softly distended and large. Bowel sounds were absent and most frequent assessment revealed slight faint distant sounds in the left lower quadrant. Left GJ tube draining in amounts documented. J draining bilious, G draining bloody thick, dressing changed. Midabdominal wound dressing changed, steristrips removed with dressing change, open area was cleaned with NS and packed with sterile technique and wet to dry dressing applied. Within wound edges are granulated, base mostly red and there is a small necrotic area in the middle the size of a pencil eraser. To the right of the open wound is a very small open area with yellow drainage noted, cleaned and dressed, continue to monitor. Right flank has pigtail draining bilious drainage, dressing reinforced and skin cleaned. Drainage device next to the pigtail draining bloody drainage in amounts documented. No BM this shift, flexiseal remains intact.\n\nGU - Patient has foley catheter to gravity draining small amounts of yellow urine that has sedimentation noted to increase throughout the night, flushed with 10mL NS with 10mL return, no further amount urine noted. BUN/Creatinine noted to be trending up. IVF of LR at 200mL/hr.\n\nSKIN - Patient's coccyx has red area that blanches, turned and placed allevyn dressing on area. Unable to frequently turn patient due to hemodynamic instability and inability to tolerate turns. ? specialty bed. Neck has ecchy\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-10 00:00:00.000",
"description": "Report",
"row_id": 1644334,
"text": "please see carevue for details of care\n\npt , non-verbal trach, able to mouth words to express needs. Moves all extremities, generalized weakness noted. Denies pain. Afebrile, HR 60s-70s, SR, no ectopy. BP 120s-130s/60s. Generalized edema noted, on lasix gtt @ 3 cc/hr, urine output 60-100 cc/hr. Goal -1800 cc/day, currently even fluid balance, lasix gtt increased to 4 cc/hr. + DP/PT pulses. Lungs coarse upper lobes, diminished at bases. #8 trach collar with vent weaned from 15 pressure support/10 PEEP to 8 pressure support/5 PEEP. ABGs WNL. Suctioned for small amount of thick white secretions. R pigtail capped. L pigtail to suction, draining serous fluid. RR 20-30. O2 sat> 98%. Abdomen soft, distended, +BS. pt remains NPO. Replete with fiber infusing via J tube at 70 cc/hr. G tube to gravity, draining bilious fluid. Flexiseal draining brown liquid stool. Foley catheter draining clear yellow urine. Reddened skin noted on trunk and back. RUQ gauze dressing changed wet-dry dressing. Wife at bedside, updated re: plan of care.\n\nPlan: continue to monitor respiratory status, monitor hemodynamic status, monitor fluid status, titrate lasix gtt as ordered, monitor pain level.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-10 00:00:00.000",
"description": "Report",
"row_id": 1644335,
"text": "Resp Care\nPt remains trached on PSV vent settings weaned throughout the shift down to 8/5 with vts 350-400 and rr 20-30. BLBS slightly wheezey, suctioned for small amt thick tan and mdis given per order. PLan to reamins on current vent settings overnight as tolerated ? attempt TM tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-11 00:00:00.000",
"description": "Report",
"row_id": 1644336,
"text": "Resp care,\nPt. remains on IPS overnoc. Suctioned small amount white sputum. ABG acceptable. RSBI 87 this am, plan trach collar trial today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-11 00:00:00.000",
"description": "Report",
"row_id": 1644337,
"text": "NPN (NOC);\n\nRESP: PT REMAINS . CURRENT VENT SETTINGS: PS 8, PEEP 5, FI02 40%. RR HIGH 20'S, VT'S 300'S TO 400'S. LATEST ABG: 94/36/7.48/28/3. BS'S CLEAR BUT DIMINISHED AT BASES. SX'D MANY TIMES FOR SM TO MOD AMTS OF THICK WHITE SECRETIONS. CT APPEARS PLUGGED. PRIMARY AND SICU TEAMS AWARE. CXR DONE IN AM. I&O - 1600 AT MN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-11 00:00:00.000",
"description": "Report",
"row_id": 1644338,
"text": "please see carevue for details of care\n\npt , non-verbal secondary to trach, able to mouth words to communicate needs. Moves all extremities, generalized weakness noted. Denies pain. Afebrile, HR 60s-80s, SR, no ectopy. BP 90s-130s/50s-60s, on lasix gtt, titrated to achieve neg 2L fluid balance. Generalized edema noted, +DP/PT pulses. Lungs CTA upper lobes, decreased at bases. #8 trach collar in place with CPAP & PS ventilation @ 40% FiO2, 5 pressure support, tidal volumes 400, PEEP 5, ABG WNL. RR >35 @ 16:00, PS increased to 10 with decrease in RR to <25. Suctioned x 2 thick white secretions. + cough. Abdomen soft, distended, +BS. pt remains NPO, replete with fiber tube feeds infusing via J tube at 70 cc/hr. G tube to gravity with small amount of bilious fluid noted. Flexiseal draining loose brown stool. Foley catheter draining approx 90-200cc light yellow urine/hr. Skin reddened on back and truck. RUQ wound changed with wet-dry dressing. Wife @ bedside updated re: pt status and plan of care.\n\nPlan: continue to monitor respiratory status, monitor hemodynamic status, monitor fluid status, titrate lasix as ordered, replete lytes as ordered, maintain pt safety, monitor invasive lines s/s infection.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-27 00:00:00.000",
"description": "Report",
"row_id": 1644276,
"text": "Resp Care:Pt remains intubated via #8 ETT secured 23cm at lip. BS rel clear bilat. Sx'd for mod amt thick tan sputum. No vent changes made thus far. Plan: cont vent support. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-28 00:00:00.000",
"description": "Report",
"row_id": 1644277,
"text": "Respiratory note:\nPt remained on pressure control ventilation. No vent changes made overnight. Sx for small tan secretions.Last ABG 7.44/33/153/23/0\nWill continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-22 00:00:00.000",
"description": "Report",
"row_id": 1644257,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: and oriented x3, MAE, Denies pain,pleasant and co op with care.helping in turning even tough weak.\n\nCV: NSR, HR in 70's with rare PVC's, SBP 100-120, IVF LR at 70ml/hr, ++PP, ++edema LE,HCT stable ~24.7 this am,K and Mag replaced.denies CP or discomfort.\n\nResp: Remains on NC at 4L, LS clear and diminished at bases, O2 sat 93- 96%, Good cough, pt uses yaunker to sxn.\n\nGI: Abd soft, + bS, BM x1 . sm amt maleena.tolerated clears, nausea early shift, zofran x1 with good effect.G J and pigtail clamped, DSD for pitail site changed ? foul smell, Dr. informed.\n\nGU: Voiding yellow clear urine adq amt.\n\nEndo: sug q6h, wnl.\n\nId: Afebrile, no anbx.\n\nAct: Turned from side to side,coccyx red care given,skin intact.\n\nSocial: visited by left, left ICU at 2300, Updtaed with her.\n\nPlan: Cont monitoring, pulm hygiene, tubes and drain care, ambulate as tolerates, serial hct.? transfer to floor if remains stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-22 00:00:00.000",
"description": "Report",
"row_id": 1644258,
"text": "N - Pt is awake and oriented x 3, moving all extremities and denies pain. PERRL.\n\nCV - HR is 70s NSR with PVCs noted on occasion, K and Mg replaced on prior shift. BP stable with MAP greater than 65mmHg. Afebrile. Pulses palpable in radial and pedal locations. ++edema noted in periphery.\n\nR - Patient is on 4L NC O2 with crackles in right upper lobe with diminished bases. He denies shortness of breath and has no cough noted/reported. Sats have been greater than 95%.\n\nGI - Abdomen is softly distended with bowel sounds noted. He has had no BM this shift. Diet advanced to clear liquids and tolerated well. Left GJ tube clamped. Right abdominal wound has steristrips intact and quarter sized open wound packed wet to dry sterile dressing this shift, wound pink with granulated tissue noted, serous drainage in small amounts. Right flank has dressing changed with pigtail clamped. Old insertion site for pigtail oozing green bilious drainage, skin cleaned and new dressing applied.\n\nGU - Voiding in handheld urinal without event.\n\nENDO - glucose WNL, no insulin coverage needed.\n\nSKIN - coccyx has reddened area that is clean and blanches, AV moisture barrier applied once skin cleaned, otherwise skin intact.\n\nLABS - 1 unit PRBCs given with subsequent increase in hct, stable, patient planned to transfer to 9 when bed made available.\n\nPLAN - transfer to floor and eventual transfer to rehab. Continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-09 00:00:00.000",
"description": "Report",
"row_id": 1644328,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt easily arousable to voice when asleep. . Follows simple commands inconsistently (opened mouth, squeezed RN's hands, and moved toes). +gag/cough/corneal reflex. Pt shakes/nods head to questions at times. Moves all extremities in bed, but does not assist in turning and repositioning. Dilaudid 0.5mg IV given x1 during bedbath d/t pt grimacing; +effect. Pt comfortable and able to sleep after Dilaudid given. Tmax 100.8. HR 60s-80s (NSR). ABP 100s-140s/40-60s. CVP 7-10. Pt with generalized edema (pitting). Venodyne boots on BLE. Multipodus boots off/on. Hct: 25.7. Per Dr. , goal was to keep pt even yesterday. 24hr net I&O balance was +6cc. Lasix gtt currently at 4mg/hr. Calcium, potassium, and magnesium repleted. Lungs clear after suctioning. Pt with less secretions this shift compared to night before. Suctioned for thick/thin white secretions. Pt tachypneic (RR 30s); Dr. aware. Respiratory therapist increased PS to 18. Current vent setting: CPAP 40%, PEEP 5, PS 18. RR decreased to 20s after vent change. See CareVue for ABG result. Pt going to OR today for tracheostomy; pt and pt's wife aware. pigtail chest tube to 20cm suction; straw-colored drainage. Negative fluctuation, leak, crepitus. CVL/A-line/G-J tube/chest tube/biliary drain/ RUQ dsg changed. Right biliary tube capped. Abdomen softly distended with hypoactive bowel sound. TF at goal rate via J-tube; will be stopped at 0600 per Dr. d/t pt will be trached today. G-tube to gravity bag with yellow-green output. Flexi-seal intact. Loose brown stool; guaiac positive. FS q6hr; treated with regular insulin sliding scale. Foley intact with clear yellow urine; see CareVue for hourly urine output. No pressure sores noted. Pt on KinAir mattress. Pink rash on body unchanged. RUQ abd wet to dry dsg changed; wound bed pink with yellow tissue. wife visited until around 9:30 PM. Dr. (vascular team) discussed the causes, prognosis, and treatment of right IJ clot with pt's wife. RN updated pt's wife on pt's condition and on plan of care.\n Plan: Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. OR today for trach. TF will be stopped at 0600 as ordered by Dr. . Dilaudid prn for pain. Pan culture if temp >101.5. Continue Lasix gtt. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-09 00:00:00.000",
"description": "Report",
"row_id": 1644329,
"text": "RESP CARE NOTE\nPT RECIEVED ON PSV 10/40%/+5. DURING THE NIGHT PT BECAME TACHYPNEIC RR INTO 30'S.PS INCREASED TO 18 AND @ 0400 DECREASED TO 15 RR26. MDI'S GIVEN AS ORDERED THICK/THIN WHITE. RSBI 90. PT IS SCHEDULED FOR A TRACH TODAY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-28 00:00:00.000",
"description": "Report",
"row_id": 1644278,
"text": "Please See Carevue for Specifics.\n\nPt remains sedated on Propofol and Fentanyl gtt's. Pt does not arouse to voice nor nailbed pressure. PERL. SB-NSR, 40-60. MAP >65 maintained throughout shift with Levophed gtt varing between 0.20mcg/kg/min to 0.26mcg/kg/min. Vasopressin gtt remains at 1.2units/hr. CVP: , CO: , CI: 2.5-3.0, SVR decreasing throughout shift. Pt afebrile, and was placed on Bair hugger when Temp was 96.1. Anasarca, Pt 30+ Liters from base weight. Lungs remain clear, slightly diminished at bases. Remains on AC peep 16, rate 16, FiO2 .40, ABG WNL. NGT drainage changed from old bloody drainage to foul brown drainage, SICU resident made aware. G-tube to gravity with scant amounts of old bloody drainage. J-tube to gravity with bilious drainage. RUQ pigtail grain is half out and half in, SICU team and surgical teams aware. Pigtail site with moderate amounts of bilious drainage, collection bag placed around site for skin protection. ?IR for pigtail replacement. Abd is round and firm, -BSx4. No stool this shift. Foley with cloudy amber urine. RUQ open wound without drainage, +granulating tissue, repacked with one 2x2 wet->dry dressing. Multiple small pin hole areas throughout body weeping sero fluid. Scrotal edema and weeping copious amounts of sero fluid and requiring frequent DSD changes. Wife called twice during the evening and was updated on pt condition.\n\nPOC: Continue to closely monitor hemodynamics, HCT checks every eight hours. ?replete platelets. Continue to closely monitor skin integrity. ?CVVHD in near future. Wean vent and pressor as tolerates. COntinue to offer emotional support to pt and pt family throughout hospital stay. Social Worker follwing pt family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-28 00:00:00.000",
"description": "Report",
"row_id": 1644279,
"text": "Resp Care: Pt remains intubated via #8 ETT secured 23cm at lip. BS clear bilat. sx'd for small to mod amts thick yellow and copious p.o., and purulent drainage from L nare. RN aware. Slow PEEP wean today. ABG WNL. Plan: cont slow wean as tol. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-28 00:00:00.000",
"description": "Report",
"row_id": 1644280,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Ppf gtt off. Fentanyl gtt @ 50mcg/hr. Pt grimaces with activity and with turning/repositioning at times, but appears comfortable once settled. Pt does not open eyes. PERRLA. No spontaneous movement noted. Pt moves toes on BLE when nailbed pressure applied. No movement noted on BUE. Impaired gag/cough/corneal reflex. Tmax 99.3. HR 50s-60s (sinus brady/NSR; no ectopy noted). Per Dr. , vasopressin gtt off. Levophed gtt titrated to keep MAP >65. See CareVue for ABP, CO, CVP; CI >2. Pt with generalized anasarca. DP/PT pulses dopplerable. Venodyne boots on BLE. Labs sent this afternoon; potassium repleted. Per Dr. , cefepime started for +E.coli in sputum. Lungs clear. Vent setting: AC 40%, Vt 550 x 16, PEEP 12. Pt suctioned for thick white/yellow/tan secretions. See CareVue for ABG results. Abdomen softly distended; bowel sound absent. NPO. G and J tubes to gravity bag. G-tube with small amount brown output. J-tube with greeen output. NGT to low continuous suction with brown output. Flexi-seal in place; no stool this shift. FS q6hr; no insulin coverage needed. Allevyn on coccyx intact. Wet to dry dsg on RUQ abdomen changed; wound bed pink with yellow tissue. Pigtail drain to gravity bag (no drainage). Green liquid oozing from around pigtail drain (wound pouch around pigtail drain intact). Skin is very weepy (large amount serous drainage). Pads under arms changed frequently. Right arm with several wound pouches to collect serous drainage. Introducer d/c'd by Dr. . Skin tear noted on right side of neck (small amount serosang drainage); Adaptic and DSD placed. Bed rotation on. wife called several times during the shift and visited at 1900; updated by RN on pt's condition and on plan of care. wife also spoke to Dr. over the phone regarding plan of care.\n Plan: Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. Titrate levophed gtt to keep MAP >65. Fentanyl gtt for comfort. Monitor output from all tubes and wounds; change dsg as ordered. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-29 00:00:00.000",
"description": "Report",
"row_id": 1644281,
"text": "Respiratory note:\nNo significant changes in pt condition, remained on PRVC/AC . Sx for small thick yellow secretions. Pt has good oxygenation revealed ABG's, PEEP wean to 12. ?plan, pt is heavily sedated. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-15 00:00:00.000",
"description": "Report",
"row_id": 1644354,
"text": "Respiratory Care\nRemains on cpap/psv with no remarkable changes overnight. Tidal volumes in 350 range with resp rate up at times into 30s, generally mid 20s. ABGs within normal limits. RSBI =111.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-09 00:00:00.000",
"description": "Report",
"row_id": 1644330,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nPt awake and following commands, dozing off throughout the day. CPAP 15 /10% all morning with improved abg's. Perc trach #8 done by MD Hausser at bedside and pt currently on ac 40% and sedated on propofol. Pt received fentanyl, veceronium, and propofol for the procedure. Pt wife is now at bedside and has been updated. Lasix gtt continues for goal - 1 liter today. Even fluid balance yesterday. K 3.3 and repleted with 60meq kcl. (3.8 prior to 3rd dose of 20meq). Lungs are clear. Abdomen softly distended. Tube feedings on hold all day for trach d/t unknown time for procedure. Gtube to gravity with jelly-like greenish/tan output. Pigtail CT to dry suction with straw colored/serosang out. Continues with loose brown stool. Peripheral cultures and central line cultures sent per ID. Tmax 100.4. Plan: continue diuresis as tolerated. EMotional support. Leave trach ties in place MD . CXR done. Vanco/flaygyl discontinued. Cont zosyn. Please see carevue for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-09 00:00:00.000",
"description": "Report",
"row_id": 1644331,
"text": "resp care - Pt was trached today at the bedside with #8 Portex DIC. Pt was put on A/C 500/20 during procedure with an FiO2 of 1.0. Coarse BS cleared slightly on suctioning of small amounts of thin, white secretions. MDIs were given as ordered. Plan is to wean vent settings as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-10 00:00:00.000",
"description": "Report",
"row_id": 1644332,
"text": "Resp Care,\nPt. changed to IPS 15/10 overnoc. Tol. well, VT 400's RR 20. RSBI this am 109. Suctioned little sputum, MDI's as ordered. ABG acceptable, continue to wean IPS/peep as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-10 00:00:00.000",
"description": "Report",
"row_id": 1644333,
"text": "NPN (NOC):\n\nPT WAS RESTED OVERNOC ON PS 15 AND 10 PEEP. THIS WAS CHANGED TO 10 PS AND 5 PEEP ~ 6AM. RR INCREASED TO LOW 30'S AND VT'S DECREASED TO 200'S TO 300'S. ABG: 119/32/7.48/25/1. DECISION MADE ON ROUNDS TO RETURN TO 15 PS AND 10 PEEP. RR HAS SINCE RETURNED TO 20 AND VT'S 400'S TO 500'S. PLAN IS TO CONTINUE W/ LASIX DRIP W/ GOAL OF 1800 NEGATIVE TODAY (IS 400 NEGATIVE SO FAR). KCL REPLETED AT 2AM. K = 3.1 SO SECOND ROUND OF K REPLETION BEGUN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-15 00:00:00.000",
"description": "Report",
"row_id": 1644355,
"text": "STATUS\nD: /ORIENTED X1(PERSON)ANXIOUS AT TIMES..FOLLOWS COMMANDS..LASIX GTT REMAINS ON\nA: LASIX GTT INCREASED TO 3MGM..C/O ABD PAIN ON & OFF\u0013(? GAS PAINS) MED WITH DILAUDID .5MGM WITH SOME RELIEF..HOYERED OOB TO CHAIR TOL FAIRLY WELL..KINAIR BED CHANGED TO SICU BED TO HELP IMPROVE PULMONARY STATUS VENT: IPS DOWN TO 8 NO OTHER CHANGES..SUCTIONED FOR MOD AMT THICK/THIN WHITE SECREATIONS..TRACH CARE DONE..CENTRAL LINE SITE & A-LINE SITE REDDENED HO AWARE LINES TO REMAIN IN FOR NOW PER HO & WILL CONSULT FOR PICC LINE IN AM..ALL DSG'S D&I..SM BLISTER NOTED ON LF SIDE(UPPER).. AQUACEL & TEGRADERM APPLIED..MOD AMT LOOSE GOLDEN/BROWN STOOL FLEXISEAL IN PLACE..\nR: STABLE\nP: TRANSFER TO REHAB MONDAY..NEED SOCIAL SERVICE TO SEE PT & SPEAK WITH FAMILY RE TRANSFER ETC..LASIX GTT TO HAVE PATIENT FLUID OUTPUT NEG 1L X24H..WEAN VENT AS TOL & MONITOR SAT'S Q1H..FREQ TURNING & KEEP HOB >30 TO HELP IMPROVE PULMONARY STATUS..CONTINUE WITH PATIENT/FAMILY SUPPORT & TRY TO DECREASE NEED FOR ANXIETY MEDICATION\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-15 00:00:00.000",
"description": "Report",
"row_id": 1644356,
"text": "Patient remains on PSV with acceptable ABG.MDI's given with vent chek.Weaned down to ps 8. Suctioned for thick amount of clear secretion.Plan to send patient to rehab on monday if afebrile,\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-16 00:00:00.000",
"description": "Report",
"row_id": 1644357,
"text": "Resp care,\nPt. remains on IPS overnoc. VT 300's RR high 20's. Suctioned small amount white sputum. RSBI 75 this am, continue to wean as toleratd.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-16 00:00:00.000",
"description": "Report",
"row_id": 1644358,
"text": "condition updated\nS/P GI BLEED\nLess anxious and appears more focused c/o abd discomfort related to flatus continues with liquid stool.\nresp status improved although still has periods of increased rate when attempting to talk or move.\nlasix gtt @2 mg achieved -1liter.\nPOC:\ncontinue to increase activity\nmed sparingly\nplan rehab for monday\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-16 00:00:00.000",
"description": "Report",
"row_id": 1644359,
"text": "rsp care - Pt is and on PSV. Several attempts were made to wean PS. Pt is able to tolerate lower PS when medically calmed, however, when aggitated, pt needs higher PS in order to maintain Vts over 300ml and a rate below 30. Coarse BS cleared on suction of small amounts of thin, white secretions. Plan is for transfer to rehab on Monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-20 00:00:00.000",
"description": "Report",
"row_id": 1644253,
"text": "RESPIRATORY CARE: PT INTUBATED TODAY FOR AN ENDOSCOPIC PROCEDURE. EXTUBATED AFTER PROCEDURE FINISHED AND PROPOFOL TURNED OFF. WEARING O2 AT 6 LPM AND SPO2 92 - 96 %/ BREATHING COMFORTABLY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-26 00:00:00.000",
"description": "Report",
"row_id": 1644272,
"text": "Resp Care\n\nPt remains intubated and currently vented on full support with no changes made to parameter settings this shift. BS course sxing for small amts of thin white secretions. Last ABG WNL with good oxygenation noted on present settings. Espohageal balloon remains in place with transpulmonary end exp pressures -2cmh20 on 20 PEEP. ETT rotated and resecured at 23cm at the lip. Will cont with vent support and make changes accordingly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-20 00:00:00.000",
"description": "Report",
"row_id": 1644254,
"text": "ADMIT NOTE\n76 Y.O. TRANSFERRED TO SICU FROM FLOOR FOR REPORTS OF BRB FROM RECTUM AND HYPOTENSION REQUIRING FLUID BOLUS. PRIOR TO THIS EPISODE, PT HAD A EGD AND HAD HAD MELENA STOOL OVERNIGHT. OVERNIGHT ON FLOOR PT WAS TRANSFUSED W/ 2 UNITS PRBC.\nUPON ARRIVAL TO UNIT PT A/OX3, DENYING SOB OR PAIN. SBP 109 POST 1.2L FLUID BOLUS ON FLOOR. SHORTLY AFTER ARRIVAL PT'S SBP FALLING INTO THE 80'S - GIVEN 500CC NS BOLUS W/ EFFECT. GI CONSULTED DECISION TO DO REPEAT EGD. PRIOR TO EGD PT ELECTIVELY INTUBATED - STARTED ON PPF DRIP. PT BECOMING HYPOTENSIVE REQUIRING NEO DRIP. SBP VERY LABILE DURING CASE - NEO TITRATED ACCORDINGLY. SHORTLY POST PROCEDURE PT W/O INCIDENT. NEO WEANED OFF. PPF STOPPED BEFORE EXTUBATION. NO FURTHER PROBLEMS W/ HYPOTENSION. THIS PM PT TAKEN TO ANGIO - RESULTS PENDING.\nPT HAS PIGTAIL DRAIN WHICH IS CAPPED, AN OLD JTUBE SITE (THE DRAIN WAS IN THE GB FOSSA) COVERED BY AN OSTOMY APPLIANCE AND A G/J TUBE WHICH WAS TO GRAVITY. DRK RED, SEROUS DRAINAGE OUT GTUBE, BROWN/GREEN BILIOUS DRAINAGE OUT JTUBE.\nCONT TO MONITOR FOR S/S OF INCREASED BLEEDING. PAIN MANAGEMENT. MONITOR FOR S/S OF INFECTION. PT AND FAMILY TEACHING AND SUPPORT. CONT CURRENT ICU CARE AND ASSESSMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-21 00:00:00.000",
"description": "Report",
"row_id": 1644255,
"text": "Nursing Progress Note\nNeuro: and oriented x3. MAE. very weak but attempting to roll by self. Denies pain.\n\nCV: afebrile, HR 70's NSR with occasional PVC. Started on neo for SBP <90, presently at 0.6mcg/kg/min with SBP>110. R Pedal and dorsal pulses strong following IR.\n\nRESP: lungs clear to diminished at bases. O2 at 4l via n/c.\n\nGI: NPO ABD soft with +BS. GT draining mod amount dark red drg. JT draining bilious drg.\n\nGU: voiding in small amount tonight.\n\nPLAN: Cont monitor for bleeding. Attempt to wean Neo\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-21 00:00:00.000",
"description": "Report",
"row_id": 1644256,
"text": "CONDITION UPDATE\n AFEBRILE. A/OX 3. DENIES SOB OR PAIN. SATS ACCEPTABLE ON 4L O2 VIA NP. PT DOES TO HIGH 80'S ON R.A. LUNGS CLEAR W/ FINE CRACKLES NOTED AT BASES. ABD OBESE,SOFT. G/J TUBE CLAMPED W/O INCIDENT. MOD AMT OF OLD BLOODY DRAINAGE NOTED AROUND PIGTAIL SITE. VOIDING W/O DIFFICUTLY. MULT LOOSE MAROON STOOLS THIS SHIFT. HCT STABLE (SEE FLOWSHEETS FOR DETAILS).\nMONITOR FOR S/S OF INCREASED BLEEDING. PULMONARY TOILET. PT AND FAMILY TEACHING. CONT CURRENT ICU CARE AND ASSESSMENTS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-08 00:00:00.000",
"description": "Report",
"row_id": 1644326,
"text": "resp care - Pt remains intubated and on PSV. BS were coarse t/o. Pt was suctioned for varying amounts of thin/frothy white secretions. MDIs given as ordered. ABG shows slight resp alkalosis. Plan is for trach and peg tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-27 00:00:00.000",
"description": "Report",
"row_id": 1644273,
"text": "Please See Carevue for Specifics.\n\nPt is sedated on 40mcg/kg/min of Propofol and 140mcg/hr of fentanyl. Pt does not respond to nailbed pressure. PERL 2mm brisk. SB, rare PVC's noted. CVP 13-18, SVR 800-1200, CCO . CI . Levophed slowly being weaned down, current dose is it 0.22mcg/kg/min. Lungs are clear, slightly diminished at bases, suctioned infrequently for thick white/pale yellow secretions. Peep weaned from 20 to 16 and rate decreased from 22 to 16, see ABG's. Abd is distended and slightly firm, BS are absent. NGT and Gtube to gravity with minimum abouts of old bloodly drainage. J-tube with bilious drainage. RUQ pigtail without drainage except for around pigtail site. Pigtail site with small amounts of bilious drainage, ? if pigtail has migrated from original placement. RUQ wound site is pink, +granulation, wound repacked with one 2x2 wet->dry dressing. Foley with cloudy amber urine. Skin with multiple pin hole weaping areas with sero fluid. Aline site is draining copious amounts of sero/sang fluid.\n\nPOC: COntinue to closely monitor hemodynamics, wean vent as tolerates, wean pressor to sustain a MAP >65. Continue to offer emotioanl support to pt and pt family throughout hospital stay. SW is following pt case.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-27 00:00:00.000",
"description": "Report",
"row_id": 1644274,
"text": "Respiratory note:\nPt remained on full ventilatory support. Ronchi BS, sx as necessary for small amt of thick white secretions. ABG revealed resp alka. RR was decreased from 22 to 16, peep to 16. Last ABG 7.44/32/129/22/0. No RSBI, due to the level of Peep. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-27 00:00:00.000",
"description": "Report",
"row_id": 1644275,
"text": "Nursing Note 7a-7P:\nNursing Assessment:\n\nPt remains heavily sedated on prop/fent gtts. No vent weaning done today per sicu MDs; remains on 16 peep with rate 16 fio2 40% with good abg's. HR Sinus brady 40-50. Vasopressin and levophed weaning. UO 20-30 amber and cloudy. CO Index 2 and CVV . Minimizing all fluid intact. sugars 140-180 and treated with regular insulin. ABdomen still firm and distended with absent bowel sounds. NGT to LCWS with scant amts drk red out. G/J tubes to gravity. Jwith small amt bilious/ G tube with scant amt drk red . Multiple drainage bags applied to oozing skin-yellow liquid drg. Pigtail drain way out and ?IR on monday to replace drain. Drain is to remain in it's current position for now despite it's lack of drainage from tube MD . Bilious output from around insertion site and drainage bag placed to collect and measure. Largely edematous scrotum with frequent pad changes d/t oozing fluid and citric aid cream applied under and around in reddened areas. Softsorb dressing applied. Pt continues on triadyne bed. Atropine at bedsides. Late afternoon labs to be drawn. HCT 24. K repleted. Cont with pressor weaning as tolerated. Family updated and at bedside. Please see carevue for all further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-13 00:00:00.000",
"description": "Report",
"row_id": 1644347,
"text": "ADDENDUM.\n\nSpoke with PT, they are unable to see pt today, he is top of list for tommorow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-13 00:00:00.000",
"description": "Report",
"row_id": 1644348,
"text": "Resp CAre\nPt remains on V IPS weaned to 10 today with Vts 350-450 rr 25-30. BLBS diminished suctioned for thick white secretions, mdis given per order. Plan to continue on current vent settings overnight as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-04 00:00:00.000",
"description": "Report",
"row_id": 1644309,
"text": "Resp Care\n\nPt remaining on PSV 12/+5, 40%. Sx for small to mod amts of thk wht secr. BS , better aeration on left side since left chest taped. ABG WNL, RSBI 100\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-04 00:00:00.000",
"description": "Report",
"row_id": 1644310,
"text": "CONDITION UPDATE:\nD/A: T MAX 99.8\n\nNEURO: MIDAZOLAM OFF, WAKES SPONTANEOUSLY AT TIMES APPEARS SCARED AND VITALS REFLECT THAT. PT MOUTHING WORDS, NODDING, FOLLOWING COMMANDS, MAE'S. PAIN WITH TURNING, NO PAIN AT REST ON FENTANYL GTT.\n\nCV: HR 70'S-80'S NSR WITH PVC'S. LOPRESSOR Q 4 HOURS. FLUID BALANCE MN-1600 - ~900 CC'S. LASIX GTT CONTINUES. HCT 26.3 (25.2). CVP ~12. GENERALIZED EDEMA THROUGHOUT.\n\nRESP: LS CLEAR. VENT WEANED TO CPAP + PS, 50%, 5 PEEP, 8 PS WITH ABG: 7.45, 42, 102, 30, 4. LEFT PLEURAL DRAIN WITH SERO-SANG DRG.\n\nGI: G TUBE TO GRAVITY, J TUBE FOR FEEDING. CAPPED DRAIN ON RIGHT WITH DRAINAGE AT NEARBY PUNCTURE SITE. TUBE FEEDS AT GOAL. SMALL AMOUNT LIQUID STOOL VIA FLEXISEAL SENT FOR CDIFF.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSX: WIFE .\n\nR: LOW GRADE TEMP, VENT WEAN IN PROGRESS, SEDATION WEANING.\n\nP: CONTINUE VENT WEAN AS TOLERATED. ? EXTUBATE -VS- TRACH.\nPAIN MED\nFREQUENT TURNING AND PULMONARY TOILET.\nLASIX GTT FOR GENTLE DIURESIS.\nPT AND FAMILY SUPPORT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-01 00:00:00.000",
"description": "Report",
"row_id": 1644296,
"text": "Please See Careuve for Specifics.\n\nPt remains comfortable on Fentanyl gtt. Fentanyl gtt dise increased throughout night due to pt gagging on ETT. Pt requiring Fentanyl boluses with position changing and abd dressing change. Pt arousable to name, opens eyes. Pt does not follow commands, will spont purposefully move upper ext. NSR-ST. ST and increased SBP to 190's with position change and vent suctioning. Lopressor dose increased to 10mg every four hours. CVP remains elevated in the 20's, generalized edema, scrotal edema improving. Lungs are clear to coarse, suctioned for scant amounts of thin white secretions, see respir note. Abd is firm, distended, and absent BSX4. NGT to LWCS with bilious drainage, G-tube to gravity with bilious drainage. Pigtail drain site draining copious amounts of bilious drainage, pigtail tube without drainage. Replete with Fiber vis J-tube currently at 65cc/hr. Small amounts of loose guaiac positive stool via flexi-seal. Foley with yellow sedimaent urine, clots noted towards the morning.\n\nPOC: Wean vent as tolerates, lasix gtt versus lasix boluses when Na+ and Cl- levels normalize. Continue to closely monitor hemodynamics. ?trach toward beginning of next week. Continue to closely monitor skin integrity. SW following pt family. Continue to offer emotional support to pt and pt family throughout hospital stay.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-01 00:00:00.000",
"description": "Report",
"row_id": 1644297,
"text": "resp care\nremains intub/vented in psv mode. required incr ps this shift. found on ctscan to have ett in right main stem..pulled back 4 cm. increased secretions since. per cxr left lung still not expanded. refer to flow sheet for info.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-01 00:00:00.000",
"description": "Report",
"row_id": 1644298,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt on fentanyl and midazolam gtt. Fentanyl gtt decreased to 50mcg/hr after midazolam gtt started. Pt grimaces with turning and repositioning, but appears comfortable once settled. Pt opens eyes to painful stimulus. PERRLA. Withdraws all extremities to nailbed pressure; does not follow commands. +gag/cough/corneal reflex. Afebrile. Tmax 98.7. HR 60s-90s (NSR; no ectopy noted). ABP 90s-180s/40s-80s. Metoprolol 10mg IV q4hr ordered. CVP 12-18. Pt with generalized edema (pitting pedal and BUE edema). Scrotal edema improving (Critic-Aid clear applied and scrotum elevated). Venodyne boots and multipodus boots on. DP/PT pulses palpable. Lungs clear. Suctioned for thick/thin white secretions. PS increased to 12; see CareVue for ABG results (Dr. aware). Chest CT done; showed that ETT tip is in the right bronchus and worsening bilateral moderate to severe pleural effusion with adjacent atelectasis. Per Dr. , ETT pulled back 3cm. Repeat CXR done. Abdomen softly distended with hypoactive bowel sound. TF at goal rate via J-tube. TPN d/c'd per Dr. . G-tube to gravity bag with bilious output. NGT d/c'd this morning per Dr. . Flexi-seal intact with liquid melena stool; guaiac positive. FS q6hr; treated per regular insulin sliding scale. Urine with oatmeal-like sediment (SICU team aware); foley irrigated x1. Urine sent for UA, culture, and cytologic exam. Foley catheter changed (16 French) per Dr. after culture sent. Coccyx pink (skin intact). Aloe Vesta applied to coccyx and buttocks. Abdominal wet to dry dsg changed; wound bed is pink with yellow tissue. No drainage noted in pigtail drain, but large amount of bilious drainage noted from around pigtail insertion site (collection bag intact). Pt on KinAir mattress. wife and daughter visited. RN and Dr. discussed CT scan result and plan of care with pt's wife and daughter.\n : Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. Wean vent setting as tolerated. ?trach if unable to wean vent. Fentanyl and midazolam gtt. Continue TF at goal rate via J-tube. Monitor wounds and output from drains. Follow up result of urine culture and cytologic exam. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-02 00:00:00.000",
"description": "Report",
"row_id": 1644299,
"text": "Please See Carevue for Specifics.\n\nPt remains lightly sedated on a fentanyl and versed gtt. Pt will occasionally opens eyes to name, Does not follow commands, purposeful spont movement with upper ext. NSR-ST, no ectopy, no electrolytel repletion need this shift. SBP 120-170's, received 10mg IV lopressor every four hours. CVP remains elevated in the mid teens to 20's. Generalized edema, scrotal edema improving. Na+ and Cl- levels remains slightly elevated for lasix gtt. Lungs are coarse, suctioned for small amounts of thin/thick white secretions. Abd is firm and distended, hypoactive BSX4. J-tube spontaneously clogged this morning. Multiple attempts to flush without successfully unclogging. Currently J-tube is instilled with . SICU resident aware, no further intervention at this time. Flexi seal with soft/loose brown guaiac positive stool. HCT Stable. Foley with sediment yellow urine. Skin is impaired but intact.\n\nPOC: Wean vent as tolerates, continue to closely monitor hemodynamics. ?replete bile from pigtail to j-tube when j-tube is unclogged. continue to closely monitor skin integrity. Family meeting to discuss trach toward the beginning of next week. Continue to offer emotional support to pt and pt family throughout hospital stay. SW following pt case.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-02 00:00:00.000",
"description": "Report",
"row_id": 1644300,
"text": "Resp Care\n\nPt remained on PSV 12/+5 Peep, FiO2 is 40% overnight. Pt has been weaned over few days from 20 Peep and esophageal balloon was removed.He was sx several times for small to moderate amts of thk whte secretions. SpO2 has been mid to high 90 tonight. BS are course but clear. RSBI this morning is 96.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-03 00:00:00.000",
"description": "Report",
"row_id": 1644305,
"text": "RESPIRATORY CARE: PT REMAINS W/ AN 8.0 ORAL ETT IN PLACE AND ON PS 12 /5 .40 AS PER CV. APPEARS COMFORTABLE W/ VT 400-500 CC AND RR 20-24 BPM. SX FOR WHITE SPUTUM. ABG C/W A MILD MIXED PRIMARY METABOLIC - RESPIRATORY ALKALOSIS AND SLIGHTLY IMPROVED OXYGENATION. PIGTAIL CATHETER PLACED BY SICU TEAM TO DRAIN LARGE LEFT PLEURAL EFFUSION > 1 LITER THUS FAR. WILL C/W PS 12 AS TOLERATED AND POSSIBLY BEGIN TAPER IN AM OR AS LEFT LUNG REEXPANDS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-04 00:00:00.000",
"description": "Report",
"row_id": 1644306,
"text": "Correction. Disregard above note. It is for a different patient. Error\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-04 00:00:00.000",
"description": "Report",
"row_id": 1644307,
"text": "Resp Care\n\nPt had some wheezes and rhonchi overnight, bs mostly course. Dyspneic episode x 1 with RR in mid 30's. Orderfor bronchodilator changed to atrovent Q4 and albuterol Q 2 prn. Pt on factent with cool aerosol most of the night, to help soften secretions so that she can clear more easily. Pt also gvn some lasix which seems to have helped. ABG show adequte oxygenation and compensated respiratory acidosis.\n7.38,57,83\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-04 00:00:00.000",
"description": "Report",
"row_id": 1644308,
"text": "Nursing Progress Note\nNeuro: Pt remains sedated on fentanyl and versed. Pt opens eyes occasionally and will follow directions. Pupils 2-3mm brisk. Appears uncomfortable during repositioning.\n\nCV: Low grade temp 100.6, HR 70-80's NSR with occasional PVC's. ABP very labile SBP 90-170's. presently 110's/50's, CVP 8-10. extremities warm anasarca with oozing arms. Lasix gtt pt draining 100+ clear yellow urine q hr\n\nRESP: NO vent changes overnight. ABG acceptable this am.\n\nGI: tol tube feed at goal. Flexi seal intact and draining large amount of clear urine\n\nGU: foley draining clear yellow urine.\n\nEndo: sugar wnl\n\nPlan: cont to monitor SBP and need for continued sedation, frequent lyte check due to ,\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-31 00:00:00.000",
"description": "Report",
"row_id": 1644290,
"text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nPt is lightly sedated on fent gtt. Opens eyes to voice and inconsistently following commands. Lightly squeezes hands and slightly wiggles toes. Tmax 99. Lungs are clear and no vent changes overnight. ABG's good and RISBI 87 per RT. Suctioned infrequently for thick white/clear secretions. Abdomen is softly distended with absent bowel sounds. Tube feeds Replete with fiber started at 10cc/hr via jtube. Not to be advanced. TPN continues. Gtube to gravity with brown output and NGT to LCWS also with brown drg. Pigtail drain remains displaced and draining bilious around site into drainage bag but not through pigtail drain. Multiple skin tears and reddened areas of skin from previous oozing of serous fluid. Citric-aid barrier cream applied. UO adequate via foley. HR NSR 70-80s. Remains off levophed. Emotional support provided. Pts wife updated over the phone. Plan: Wean to extubate. Frequent turning and skin care. W-D dressing to abdominal wound. ?tighten insulin sliding scale/increase insulin in tpn? Please refer to carevue for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-31 00:00:00.000",
"description": "Report",
"row_id": 1644291,
"text": "Respiratory Care\nPt device: pt remains orally intubated on CPAP+PS 8/5, pt tol well with NARN. No changes made to vent t/o the noc. RSBI this AM 57.\n\nChest: BBS diminished in the bases.\n\nGas Exchange: ABG this AM shows a normal acid-base balance. Pt is afebrile and TBB is positive.\n\nPlan: Monitor and support, wean to extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-31 00:00:00.000",
"description": "Report",
"row_id": 1644292,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt was easily arousable to voice and followed simple commands when fentanyl gtt @ 25mcg/hr. Fentanyl gtt increased to 50mcg/hr (Dr. aware) d/t pt tachycardic, hypertensive, tachypneic, anxious/agitated during turning, repositioning, activity. When fentanyl gtt @ 50mcg/hr, pt became more lethargic this afternoon, but still arousable to voice. PERRLA. Pt squeezed RN's hands and moved toes to command inconsistently. +gag/cough/corneal reflex. Afebrile. HR 70s-100s (NSR/sinus tach; rare PVCs noted this morning). Pt hypertensive (SBP 160-170s) and tachycardic (HR 100s) during activity. Metoprolol 5mg IV q6hr ordered. ABP 110s-170s/50s-70s. CVP 12-22. Pt with generalized anasarca. Venodyne boots on BLE. Old left femoral A-line site oozing moderate amount serous drainage; covered with gauze. Right angio site clean, dry, intact. DP/PT pulses weakly palpable. Type and screen sent as ordered. Sodium will be checked at 1600. Cefepime d/c'd. Lungs coarse; clear after suctioning. Pt suctioned for white secretions (thin/thick). CPAP 40%, PEEP 5, PS 5. ABG WNL. Abdomen softly distended with hypoactive bowel sound. TPN with lipids infusing. Replete with fiber currently infusing at 25cc/hr via J-tube. NGT to low continuous suction with brown drainage. G-tube to gravity bag with brown drainage. Flexi-seal intact; no stool noted. FS q6hr; treated with regular insulin sliding scale. Foley intact with yellow/amber urine; +sediments. UO >/= 30cc/hr. Pt on KinAir mattress. Coccyx pink; skin intact (Aloe Vesta applied). No drainage noted in pigtail drain. Large amount of yellow/brown drainage noted from around pigtail drain insertion site; drainage bag intact. Wet to dry dsg on abdomen changed x1; wound bed is pink with yellow tissue. +scrotal edema; elevated. Critic-Aid clear with antifungal applied to scrotum. wife visited; updated by RN and Dr. on pt's condition and on plan of care.\n Plan: Monitor VS, I's and O's, labs. Follow up sodium level. Monitor neuro and respiratory status. Wean vent setting as tolerated. Plan for trach if unable to wean off vent. Fentanyl gtt for comfort. Monitor output from all drains and wounds. Slowly increase TF to goal rate of 80cc/hr (see order in POE). Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-31 00:00:00.000",
"description": "Report",
"row_id": 1644293,
"text": "Respiratory Care Note\nPt received on PSV 8/5 and weaned to at start of shift. Pt tolerating well with VT 390-410 and RR 17-25. ABG on is within normal limits. ETT repositioned and retaped without incident. Plan to continue on current settings as tolerated at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-31 00:00:00.000",
"description": "Report",
"row_id": 1644294,
"text": "Addendum to NPN:\nThis afternoon, drainage noted in pigtail drain (yellow-brown in color). Low urine output in foley catheter bag; Dr. aware and assessed pt at bedside. Foley catheter irrigated x3; no resistance. Per Dr. , albumin ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-01 00:00:00.000",
"description": "Report",
"row_id": 1644295,
"text": "Respiratory Care:\n\nPatient intubated on mechanical support. Pt. weaned to PSV 5, Peep 5, Fio2 40% yesterday. Tolerated well most of the shift. Pt. tiring and spont vols decreasing from 400's to 300 with RR ^ 40's. Sx'd for moderate amount of thin white secretions. BS coarse bilaterally. No change in RR or vols. Repeat ABG 7.32, 49, 78, 26. PSV ^ 10cm to rest patient. Spont vols ^ 400-490. RR decreasing to mid 20's. RSBI ^ to 66. Fluid positive. No further changes made.\nPlan: Continue with PSV as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-19 00:00:00.000",
"description": "Report",
"row_id": 1644371,
"text": "Resp Care: Pt continues #8 portex and on ventilatory support, tol 10 hours on trach collar, placed back on cpap 5/5 for overnoc rest maintaining spo2 99-100%; bs rhonchorous, sxn thick white secretions, rx with mdi albuterol/atrovent, rsbi 64, will cont slow vent wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-30 00:00:00.000",
"description": "Report",
"row_id": 1644286,
"text": "focus hemodynmics\ndata: neuro: on fentanyl gtt at 50mcg. responds to painful stimuli. depressing fingernails. attempts to open eyes when name being called loudly. pupils # and reacts briskly.\n\nresp: remains intubated and suctioned for thick white sputum. abg 7.41-35-104-23. vap mouth care done as per protocol. on 40% -500-15-8 no rsbi today. bed rotating.\n\ncardiac: sinus brady tonite 47-59. occ heart rate in the 60's. bp 90's120's. on levophed gtt and titrated. co 6.7-8.6 ci 3.3-5.8 svr 585-791 pcco line intact. k 3.8 and repleted with 20meq/ kcl. magnesium 1.7 and repleted lwith 2gms magnesium sulfate. hct 31.9 sodium 148 and pt received 1 liter of d5w. venodynes on legs.\n\ngu : foley patent and draining yellow urine.\n\ngi abd soft. tpn infusing. g and j tube to gravity. j tube drained 400cc ofgolden brown drainage. g tube drained 50cc brown drainage. 2 pigtail drains not draining. flexiseal intact with no stool tonite.\n\nskin: edematous extremities. arms oozing fluid and pt has skin tears on neck and torso. neck area ecchymotic due to line insertion. scrotum edematous and elevated on sling. alleyn applied to coccyx decubitius\n\nsocial: wife spokesperson and no calls tonite.\n\nresponse: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-30 00:00:00.000",
"description": "Report",
"row_id": 1644287,
"text": "N - Patient has remained sedated on a fentanyl gtt, titrated down to 25mcg/hr. Over the course of the day patient has become more and more awake and now opens his eyes to verbal stimuli. He does not move his extremities on bed besides withdrawing to painful stimuli. He opens his eyes and will focus on RN face with stimulation. He provides nurse /nodding to simple questions. RN oriented patient and asked if he was in pain in which he slightly shook his head to deny pain. He does not provide hand grasps at this time. PERRL at 3mm bilaterally/briskly.\n\nCV - Patient has been on small dose of levophed gtt to maintain a MAP greater than 60-65mmHg, at this time gtt is off and monitoring BP. HR initially was in the low 50s SB and now is in the 60s NSR without ectopy throughout the day. Radial pulses are palpable and initially pedal/post tibial pulses were obtained via doppler, now both are weakly palpable though present. Peripheral edema present throughout patient, ++ pitting in both upper/lower extremities. Coloring is slightly pale and skin at times moist from weeping extremities. He has been afebrile with Tmax of 99.0 orally.\n\nR - Patient has been on CPAP most of the day today and tolerating well. RR have been with sats 96% or greater on FiO2 os 40%. Lung sounds are clear bilaterally. ETT suctioned for small amounts of clear thin secretions. PRN mouthcare returns clear, thin secretions with suctioning. ABGs as documented. Current vent settings CPAP with PS 8 PEEP 5cm. HOB elevated greater than 30 degrees as ordered.\n\nGI - Abdomen remains softly distended with absent bowel sounds. He has flexiseal system intact with no drainage noted. Right lateral flank site is draining bilious drainage, right flank pigtain draining bilious drainage. LUQ GT tube to gravity drainage with green/bilious/brown draining in each collection device. Right abdominal dressing changed last shift, dressing remains CDI. TPN running as ordered. Plan to start tubefeedings of replete with fiber at 2400 at rate of 10mL/hr via J tube without plans to advance.\n\nGU - Patient has foley draining sedimented yellow urine in amounts documented, greater/equal to 30mL/hr as documented. Penis and scrotum are edematous and weeping, scrotum elevated and placed on absorbable dressing with serous drainage in small amounts noted, skin excoriated on scotum, criticaid ointment applied to area.\n\nSKIN - Patient has right neck ecchymosis and skin tear wtih adaptic dressing applied with scant serous drainage noted (area from prior cordis placement). Right femoral angio site CDI. Left femoral artline site has dressing CDI. Scotum and abdominal wound as documented above. Patient has allevyn on coccyx due to redness, no breakdown noted. Patient placed on kinair mattress from a rotation pulmonary bed this shift, patient tolerated well. Right medial great toe area has redness noted, blanches, continue to monitor.\n\nIV - Left subclavian TLC has dressing intact, \n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-30 00:00:00.000",
"description": "Report",
"row_id": 1644288,
"text": "(Continued)\nen patent and good return, CVP as documented. machine discontinued this shift. Left femoral artline discontinued and new radial artline placed in left radial artery, patient tolerated well.\n\nLABS - Patient potassium replaced this shift. Monitor labs at 1900 as ordered. Sodium noted to be elevated, continue to monitor, prior orders last night for 1L D5W.\n\nENDO - Patient covered with RSSI per order for elevated glucose.\n\nP/S - Wife, , called multiple times this shift, updated on patient plan of care and continued but improved critical condition. Patient and family updated on his plan of care.\n\nPLAN - continue CPAP trial, pain control, monitor labs, replace electrolytes, antibiotics, keep skin clean and dry, kinair to prevent skin breakdown, monitor VS closely with vasoactive meds to maintain adequate BP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-30 00:00:00.000",
"description": "Report",
"row_id": 1644289,
"text": "Respiratory Care Note\nPt received on AC and placed on PSV 12/5 at start of shift. Pt tolerating well with VT 390-420 and RR 10-17. BS are clear bilaterally. PS weaned slowly throughout shift to 8. ABG within normal limits. Esophageal balloon discontinued. Plan to continue on PSV as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-17 00:00:00.000",
"description": "Report",
"row_id": 1644364,
"text": "add: wbc 17.3 team aware, urine and c-diff cultures sent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-17 00:00:00.000",
"description": "Report",
"row_id": 1644365,
"text": "resp care - Pt is and on PSV. PS was raised to 8 for pt comfort. TM trials were successfully attempted. RR was in the 20s, and SpO2 remained >95%. Scant amounts of thin, white secretions were suctioned. MDIs given as ordered. Plan is to continue TM trials as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-18 00:00:00.000",
"description": "Report",
"row_id": 1644366,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support all night with no parameter changes made. No orning abg resukts at this time.\n\nRSBI = 95 on 0-PEEP and 5 cm PSV.\n\nPlan is to continue trach collar trials as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-18 00:00:00.000",
"description": "Report",
"row_id": 1644367,
"text": "condition update\nd: pt and follows commands. moves all extremities. pt comfortable on cpap and pressure support. pt suctioned for thick white sputum. tolerating tube feeds at goal. abd soft with bowel sounds. pt incontinent for thick pastey stool. perineum reddened and painful. antifungal cream and aloevesta lotion applied.\na: monitor labs. attempt trache collar again today.\nr: pt slept in short naps. rash painful and reddened. pt suctioned for thick white sputum. no anxiety or pain and no ativan or pain meds needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-18 00:00:00.000",
"description": "Report",
"row_id": 1644368,
"text": "resp care - Pt is with #8 Portex DIC trach and is currently on 50% TM. Coarse BS clear after suctioning of small amounts of thin, white secretions. Pt also has strong, productive cough and is able to clear own airway. RR range from 25-30. MDIs given as ordered. Plan is to transfer pt to rehab tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-18 00:00:00.000",
"description": "Report",
"row_id": 1644369,
"text": "Neuro: , pt follows commands, pt mouthing words.\n\npain: pt denies any c/o pain\n\npulm: pt put on trach collar at ~12noon and has tolerating trach collar thus far. pt is coughing and raising small amt of whitish secretions.\n\ncards: pt in sr occasional pvc's noted. aline at times dampened, following cuff pressures along with aline pressures. lasix gtt remains at 1mg/hr\n\ngi: pt tolerating tube feedings at goal, pt incontinent x2 of moderate amt of stool, buttucks is reddened applied dueoderm barrier cream\n\ngu: foley catheter patent drainage.\n\nf/e: sugars covered by sliding scale\n\nsocial: pt wife into visit,and updated by physican\n\nactivity:pt oob to chair via for ~5hours\n\nplan: continue to monitor, ? transfer to rehab in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-19 00:00:00.000",
"description": "Report",
"row_id": 1644370,
"text": "condition update\nD: pt denies any pain. one episode of anxiety stating he wanted to go home and get out of bed to go to the bathroom. pt getting frustated trying to mouth words and wants trache out. pt medicated with .5mg of ativan with good response. pt slept well after ativan.\ncardiac: nsr rate in the 60's. sbp 110-140's/60's. aline is positional and not accurate.\nresp: pt tolerated 10hrs on trache collar and placed back on vent at 2200 to rest on cpap for the night.\ngi: pt tolerating tube feeds at goal and abd is soft. pt with 2 loose bm's.\ngu: foley patent and draining clear yellow urine.\nskin: perineum improved since yesterday. less reddened and painful. continue with fungal cream and aloevesta lotion.\na: ? transfer to rehab in the am. continue with trache trials. continue with skin care.\nr: pt ready to transfer to rehab tomorrow. skin rash improving with aloevesta lotion.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-03 00:00:00.000",
"description": "Report",
"row_id": 1644303,
"text": "Somewhat problem night after pt developed AW leak which was identified as high positioned ETT. A chest X-Ray was taken and confirmed this. ETT was noted to have slipped out to 18 cm. It was now advanced to 20 cm and retaped. After which there was no leak and Vte resumed to typical levels of 450-500 ml on PSV settings. Pt sx several times for mod amts of thk wht secretins. In A.M peep was decreased in stages to 5 Cm. ~ 30 minutes later SpO2 had decreased so fio2 was increased from 40% to 50%. AN agb is to be done @ new setting\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-02 00:00:00.000",
"description": "Report",
"row_id": 1644301,
"text": "SICU Nursing Note: see flowsheet for details\nEvents: Head CT (prelim -); to IR for new biliary drain and new G/J tube after j tube unable to be successfully unclogged.\n\nPt remains intubated, sedated on fent/versed, both increased secondary to pt. apparent anxiety/discomfort intermittently. Currently sedated but occassionally opens eyes to voice, arouses to stimuli, not following commands, PERRL. Remains on PSV with Bilateral pleural effusions - lasix 5 mg IVP then gtt at 1 mg started with good effect - per , TBB should be goal of about -2L today, currently patient about -1600 cc. Has generalized anasarca. K+ repleted, KPhos administered and IV KCL administered. Tolerating lopressor doses though missed a couple this afternoon when off of floor and SBP 90s-low 100s. Sinus rhythm 50s-80s PVCs occasionally, BP labile depending on level of awareness between 90s-170s systolic. Jtube clogged since night shift - Bicarb, papain used to no effect - tube replaced at IR, pt tolerated procedure well. Biliary tube was cracked - also replaced at IR and capped (per order) no leaking noted from dressing site. G/J tube is not sutured in secondary to skin breakdown around insertion site. Head CT prelim. neg; Head ct obtained to r/o infarct after chest CT from yesterday showed possible areas of infarct in spleen and liver. Mild fungal rash in inguinal folds; coccyx intact; flexiseal in place, thick liquid, dark brown, guiac positive stool. Wife in to visit and adequately updated as to status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-03 00:00:00.000",
"description": "Report",
"row_id": 1644304,
"text": "CONDITION UPDATE:\nD/A: T MAX 100.6, PLEURAL EFFUSION TAPPED.\n\nNEURO: WAKES TO VOICE AND AT TIMES WITHOUT STIMULATION. PERL. AT TIMES FOLLOWS COMMANDS TO SQUEEZE HAND, AND AT OTHER TIMES DOES NOT. MOVES ALL EXTREMITIES, RIGHT MORE THAN LEFT. ON FENTANYL AND MIDAZOLAM GTTS FOR PAIN CONTROL AND SEDATION TO TOLERATE ETT.\n\nCV: HR 70'S-80'S NSR WITH PVC'S. ELECTROLYTES TREATED. ABP ~ 140'S/60'S WITH LOPRESSOR Q 4 HOURS. FLUID BALANCE MN-1700 - 1300 CC'S DUE TO 1200 CC OUT VIA PIGTAIL CATHETER PLACED IN LEFT PLEURAL EFFUSION. + GENERALIZED EDEMA. ALBUMIN TID TO ASSIST WITH PULLING FLUID BACK IN, AND LASIX GTT @ 1.5 MG/HR FOR GENTLE DIURESIS.\n\nRESP: LS COARSE, CLEAR WITH SUCTIONING. NO VENT CHANGES MADE THIS SHIFT. PT ON CPAP + PS, 50%, 5 PEEP, 12 PS WITH ABG: 7.46, 38, 89, 28, 2. CHEST X-RAY DONE POST PIGTAIL PLACEMENT AND EFFUSION REDUCED, ETT IN ACCEPTABLE POSITION.\n\nGI: G TUBE TO GRAVITY, J TUBE WITH TUBE FEEDS NOW RUNNING @ 70 CC'S/HR. LIQUID BROWN STOOL VIA FLEXISEAL. ABDOMEN REMAINS DISTENDED. SMALL OPEN AREA WITH W-D DSG CHANGED. PCT DRAIN ON RIGHT SIDE CAPPED, INTACT, NO DRAINAGE.\n\nGU: FOLEY-BSD WITH CLEAR URINE. FLUCONAZOLE STARTED FOR YEAST IN URINE AND YEAST IN SKIN FOLDS.\n\nSX: WIFE AND DAUGHTER VISITED.\n\nR: LOW GRADE TEMP, PIGTAIL DRAIN PLACED IN PLEURAL EFFUSION, FLUCONAZOLE STARTED FOR YEAST IN 2 PLACES S/P GIB POST PANCREATITIS.\n\nP: VENT WEAN AS TOLERATED.\nGENTLE DIURESIS WITH LASIX GTT AND ALBUMIN.\nTF AT GOAL.\nFREQUENT REPOSITIONING AND SUCTIONING.\nPAIN CONTROL.\nPT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-05 00:00:00.000",
"description": "Report",
"row_id": 1644311,
"text": "Neuro: Pt continues on fentanyl gtt. PEARLA Opens eyes to voice, able to nod appropriately. Follows directions. Pt denies pain.\n\nCV: Low grade temp 100.0, HR 70-100's NSR- Sinus tach with occasional PVC. ABP labile 130/50's-180/90's. HCT drop to 24 from 26 sicu team informed. Cont on lasix with adequate diuresis. lytes repleated.\n\nRESP: lungs clear through out. No vent changes overnoc. Occasional suctioning of thin white secretions. L pigtail draining minimal sero sang drg.\n\nGI: Tol tube feed at goal. GT to gravity small amount of bilious drg. Flexiseal intact with liquid brown stool.\n\nGU: foley patent with clear yellow urine.\n\nENDO: sugar slightly elevated. requiring coverage\n\nPLAN: ? wean to attempt extubation today. Continue with diuresis. Emotional support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-05 00:00:00.000",
"description": "Report",
"row_id": 1644312,
"text": "Pt has better aeration to left lung after chest tube inserted to drain pl effusion.Pt gvn alb/atr MDI Q 4-6 hrs.Sx for small amt of thinish white secretons. RSBI today is WNL. Pt to be evaluated for extubation on rounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-05 00:00:00.000",
"description": "Report",
"row_id": 1644313,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt easily arousable when name is called. ; briskly reactive. Follows simple commands (squeezed RN's hands and moved toes to command). Grimaces during suctioning, turning, repositioning; appears comfortable once settled. Fentanyl gtt @ 100mcg/hr. Midazolam 1mg IV given x1 for agitation with +effect. Tmax 99.5. HR 60s-90s (NSR with rare PVCs). ABP 90s-150s/40s-70s. SBP increases to 160-180s when agitated. Metoprolol 5mg IV q4hr ordered; dose at 1600 held d/t SBP 90s. CVP 9-14. Pt with generalized edema; pitting edema on BUE and BLE. DP/PT pulses palpable. Venodyne boots on BLE. Multipodus boots on/off. Lungs coarse; clear after suctioning. Pt tolerated CPAP 40%, PEEP 5, PS 5. ABG showed compensated metabolic alkalosis. PS increased back to 8 this afternoon. Plan to extubate tomorrow. Pt with +cough reflex; impaired gag. Pt suctioned for thin, white secretions. Right posterior pigtail drain chest tube placed at bedside by Dr. and Dr. . Morphine 4mg IV given for chest tube placement. Left pigtail drain chest tube intact. Bilateral chest tubes to 20cm dry suction per Dr. ; serosanguinous output. Dr. aware of negative fluctuation on both chest tubes; negative crepitus. Furosemide gtt increased to 5mg/hr per Dr. . Goal is for pt to be 2L negative today (not including chest tube output per Dr. . Acetazolamide x3 doses ordered. Abdomen softly distended with hypoactive bowel sound. TF at goal rate via J-tube. G-tube to gravity bag with dark yellow drainage. Flexi-seal intact; liquid brown stool (guaiac positive). FS q6hr; treated per regular insulin sliding scale. Foley intact; clear yellow urine. No pressure sore noted. Coccyx pink, but skin intact (Aloe Vesta applied). Pt on KinAir mattress. Scrotal edema much improved from last week. RUQ abdominal wet to dry dsg changed; wound bed pink with yellow tissue (no drainage). G-J tube dsg changed x1. Right pigtail drain (in biliary system per Dr. ) capped; small amount of bilious drainage noted from around pigtail drain (dsg changed x1). wife visited; updated by RN and Dr. on pt's condition and on plan of care.\n Plan: Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. Wean vent setting; extubate tomorrow. Fentanyl gtt for comfort. Continue Lasix gtt; goal is for pt to be 2L negative today (not including chest tube output per Dr. . Monitor output from drains and wound. TF at goal rate. Monitor output from chest tubes. Bilateral chest tubes to 20cm suction. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-05 00:00:00.000",
"description": "Report",
"row_id": 1644314,
"text": "RESPIRATORY CARE: PT REMAINS INTUBATED W/ AN 8.0 ORAL ETT IN PLACE.\nRSBI ABOUT 55/ MIP - 30 TODAY. CHANGED FROM PS 8 TO PS 5/5 AND\nFIO2 DECREASED TO .40. STILL BEING SUCTIONED FOR A FAIR AMT\n OF SECRETIONS. COUGH IS FAIR TO GOOD W/ GOOD GAG REFLEX. PS INCREASED BACK TO 8 AFTER SOME AGGITATION. PLAN IS TO POSSIBLY GIVE PT A TRIAL OF EXTUBATION IN THE AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-06 00:00:00.000",
"description": "Report",
"row_id": 1644315,
"text": "SICU NPN\nHypertensive\n\nHR 80-110s, NSR/ST with few PVCs. SBPs 120-180s. Lopressor intially held. Restarted at MN for hypotensive periods. PRN Hyralazine given. On CPAP 8/5. Periodically tachypenia, mildly anxious.\n\n\nSBPs < 160. HR unchanged. On Fentanyl infusion at 100mcg/hr. Denies pain. Pt non-verbally communicates anxiety. Pt calming to positive reinforcement. Tachypenia resolving with postive reinforcement. .\n\nWean to extubate. Keep SBP < 160, Pulmonary toilet as tolerated.\nPRN Versed/Ativan if needed post extubation. If tolerates OOB to chair.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-06 00:00:00.000",
"description": "Report",
"row_id": 1644316,
"text": "Rsp Care\n\nPt on PSV 8 most of the night, weaned to PSV 5/+5 this morning. RSBI = 45. Atrovent gvn Q 4 - 6 hrs.Pt sx for small to mod amts of somewhat thick clear to white sputum. Plan is to atteempt extubation today. ABG reflecting mild to moderate metabolic alkalosis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-06 00:00:00.000",
"description": "Report",
"row_id": 1644317,
"text": "NPN\nPlease see carevue for further details\nArousable to voice. follows simple command. moves all extremities. fentanyl gtt for pain management with good effect. Pan cultured early this morning. Temp down to 99 for the rest of the day. IV Vanco and zosyn started today.\nNSR/ST 80-100s SBP 90-120s. Pboots on. Heparin SQ. Hct stable. lytes stable. L CVL discontinued and tip sent for culture. R CVL placed at bedside today. CVP 8-10. LR bolus for hypotension and low u/o midmorning.\n+ BS x4 abd firm, distended. team aware. Abd CT this morning. Flexiseal intact with large amounts of loose stool.\nBLSCTA even unlabored. CPAP 5/5, ABGs wnl. sats 94-98. R and L pigtail to wall suction with mod amounts of output. R pigtail with large amounts of serosang drainage. team aware.\nLow u/o during most of the day. Foley advanced per SICU HO and radiology with increased u/o after advancing. team aware.\nPLAN: Continue to closely monitor respiratory status, hemodynamics, and temp. Provide comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-29 00:00:00.000",
"description": "Report",
"row_id": 1644282,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-REMAINS SEDATED ON FENT GTT. OPENS EYES TO PAIN. PERRL. DOES NOT MOVE EXTREMTIES OR FOLLOW COMMANDS.\n\nCV-REMAINS IN SINUS RATE 50'S. CON'T ON LEVO TO KEEP MAP >65. SKIN WARM. + ANASARCA WITH MULTI AREAS OF WEEPING SKIN. +PP VIA DOPPLER. HCT STABLE. LYTES REPLETED.\n\nRESP-NO VENT CHANGES MADE OVER NOC. LS CLEAR. O2 SAT 97%. SXN FOR SM AMT THICK YELLOW SPUTUM. MOUTH CARE DONE.\n\nGI-ABD DISTENDED. NO BS. G-TUBE TO GRAVITY WITH SM AMT BROWN DRG, NGT TO SXN WITH BROWN DRG. J-TUBE TO GRAVITY WITH GREEN BILIOUS DRG. T-TUBE WITH GREEN BILIOUS DRG. DSG CHANGED. ON TPN.\n\nGU-VOIDING VIA FOLEY LG AMTS DILUTE URINE. TEAM AWARE. URINE LYTES SENT. +SCROTAL EDEMA.\n\nENDO-SSRI. NO COVERAGE NEEDED.\n\nID-AFEB. ON ABX.\n\nSKIN-ON TRIADYNE BED. ROTATION ON ALL NOC. CON'T WITH MULTI SKIN ISSUES.\n\nP-CON'T WITH CURRETN PLAN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-29 00:00:00.000",
"description": "Report",
"row_id": 1644283,
"text": "Respiratory Care Note\nPt received on AC as noted. PEEP and rate weaned as noted. BS essentially clear bilaterally. ABG on vent changes is 7.46/34/112/25/0. Ptp ranges this shift are -6.5 to -10.6 and Pes 16.3-25.6. Plan to continue on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-29 00:00:00.000",
"description": "Report",
"row_id": 1644284,
"text": "Nursing Note 7a-11p:\nNursing Assessment:\n\nPt is sedated on fentanyl at 50mcq/hr and slowly waking up. Propofol off since yesterday. Pt opens eyes to stimuli but not tracking or following commands. Moves arms to deep stimuli and when coughing. Wrist restraints with fem aline and ETT. wife at bedside and updated by MD . PiCCO2 monitoring as documented in carevue. CO/indexes increasing. Large urine outputs all night and all morning 400cc/hr and now decreasing towards 100-200cc/hr. Urine lytes and chemistry sent. Potassium repletions. NA increasing quickly from hyponatremia and free water iv started and increased as na continues to rise. Levophed slowly weaning. HR 50s sinus brady without ectopy. Lungs clear throughout and peep decreased to 8/ rate 15 fi02 40%. Minimal suctioning. Abdomen softly distended. HCT stable at 30-31. NGT with brown output/ gtube and jtube also with brown output J>G. Pigtail without drainage and MD team will not attempt to replace drain (migrated out) at this time. Draining scant bile around insertion site. Skin less weepy/edematous today. Abdominal w-d ns dressing changed. Plan: cont weaning levophed as tolerated. CO monitoring. Attempt CPAP tommorrow. Weaning sedation. Heparin sq restarted. TPN. Skin care/wound care. Emotional support to pt's wife. Please see carevue for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-30 00:00:00.000",
"description": "Report",
"row_id": 1644285,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Minimal changes made overnight. BS's diminished, sxing pale yellow secretions. Mouth broken down, ETT taped off mouth edge, in hopes of promoting healing. See flowhsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-03 00:00:00.000",
"description": "Report",
"row_id": 1644302,
"text": "NPN\nPlease see carevue for specifics:\n\n overnight with TMax 100.8 orally at 0400. HR 60-70's NSR with PVC's, sbp 110-160's, RR 20-30, 02 sat 95-99%. Pt sedated on fentanyl and versed drips that were not titrated overnight; pt will open eyes to verbal/physical stimulation and at times follow commands by squeezing hands and opening eyes and will grimmace to painful stimulation. LS clear to coarse in upper lobes, and left side lower lobe diminished sounds, and right lower lobe clear; at 2400 ventillator alarming and pateint appeared to have a massive cuff leak. ETT placement confirmed by CXR and tube pushed in to 20 at the lip; leak went away and patient began pulling larger TV. Pt on CPAP .40 decreased to this am; morning ABG at baseline for patient. Pt being suctioned for large amounts of thick white frothy secretions. Abd firmyl distended with hypoactive BS x4; feeding through J-tube and g-tube draining small amounts of bilious drainage- bile being re-fed q2-4 hours. Pt had small response to lactulose administered on day shift; pt was administered miralax x1 at 2200 with no response overnight; flexiseal was removed and checked for hard stool, none was present and small amounts of loose stool was present. Flexiseal reinserted. Foley draining moderate amounts of CYU- lasix drip increased to 1.5mg/hr to help patient reach goal of -2L at mn (-2.2 at MN); CVP 9-12 overnight. AM labs drawn and sent and awaiting results. Wife present for the evening adn aware of the current plan of care. COntinue to monitor labs, vs, i/o's, assess BM status, and frequent suctioning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-16 00:00:00.000",
"description": "Report",
"row_id": 1644360,
"text": "Neuro: pt open his eyes when you call his name, pt does follow commands. pt does to yes and no questions. pt agigated at times, providing reassurance, and \u0013 recieved 1mg of ativan with effect.\u0013\n\npain: pt c/o pain, pt recieved .5mg of diluadid with good effect.\n\npulm: pt on cpap with ps 5. lung sounds diminished at bases. suctioned for small to moderate whitish secretions.\n\ncards: pt in sr, with an occasional pvc's noted. following cuff pressure along with aline pressure, aline waveform dampened at times.\nlasix gtt at 1.5mg per hour goal is to have pt 1 liter negative\n\ngi: pt on tube feedings at goal. noted yellow/tannish drainage around g-tube site, dr. into assess site, drianage sent for culture. flexiseal intact draining yellowish/golden stool. pt oob to chair via via 2\n\ngu: foley intact draining straw-colored urine\n\nf/e: sugars covered by sliding scale.\n\nid: periphal iv's placed, central line to be d/c'd and tip to be sent for culture.\n\nsocial: pt wife called and updated.\n\nplan: continue to monitor, medicate for pain an needed. d/c central line and sent tip for culture\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-17 00:00:00.000",
"description": "Report",
"row_id": 1644361,
"text": "condition updated\nS/P GI Bleed with resp complications.\nFor complete objective data please refer to carevue flowsheet\nPt and more reactive; MAE OOB to chair for 3hrs to watch the fireworks. transfer to chair but pt very weak and required hoyered back. Slept in longer naps than previous and has not needed ativan.\nLasix gtt decreased to 1mg since 1liter neg in 24hrs. wt down\nTolerates CPAP 5/5 and secretions have lessened. No other issues.\nspoke w/wife x2 and given updates.\nPOC:\nminimize sedation\nincrease activity level\nkeep wife informed\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-17 00:00:00.000",
"description": "Report",
"row_id": 1644362,
"text": "Resp Care,\nPt. remains on IPSAf f5/5 overnoc. VT 300's RR high 20's. Little sputum. RSBI 94 this am, ABG acceptable. Possible trach collar trial today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-06-17 00:00:00.000",
"description": "Report",
"row_id": 1644363,
"text": "Nuero: open eyes when you call her name, pt follows commands, pt mouths word at times difficult understanding patient. pt c/o anxiety pt recieved ativan po with some effect.\n\nPulm: pt on cpap with ps 8, suctioning pt for scant amt of whitish secretions, pt put on trach collar by resp therapy which he only tolerated for a short times.\n\n\ncards: pt c/o chest pain at 0745 ekg done, dr. assessed ekg, pt recieved .5mg of iv diluadid with relief of chest pain. ck's and iso sent. aline waveform dampened, follow cuff pressures. pt continues on lopressor. pt continues on lasix gtt at 1mg/hr.\n\ngi: abd soft, distended, positive bowelsounds. pt with small amt of thick stool, flexiseal d/c'd. c-diff culture sent.\n\ngu: pt c/o of \" burning when peeing\", foley catheter irrigated, pt continued to c/o of burning, dr. called and into assess patient, pt has bladder scan done which showed 500ml of urine in bladder, urology into assess patient, foley catheter changed by urology and pt put out 500cc of urine, pt denies any further c/o.\n\nf/e sugar 147 pt recieved 2 units of regular insulin per sliding scale\n\nsocial: pt wife into visit, and updated by physician\n\nplan: continue to monitor, check ck's and iso at 1700 and at 0200, monitor resp status, attempt to wean vent if pt tolerates.\n"
},
{
"category": "Echo",
"chartdate": "2124-05-25 00:00:00.000",
"description": "Report",
"row_id": 86000,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function\nWeight (lb): 240\nBP (mm Hg): 140/57\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 11:07\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. RV function depressed.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Focal calcifications in ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. No TS. Mild [1+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Small pericardial effusion. Effusion is loculated. Brief RA\ndiastolic collapse.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews. Suboptimal image quality - poor subcostal views. Suboptimal image\nquality - body habitus. Suboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF 70%) The right\nventricular free wall is hypertrophied. The right ventricular cavity is\ndilated with depressed free wall contractility. The ascending aorta is mildly\ndilated. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Trivial\nmitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is a small sized pericardial effusion. The effusion\nappears loculated subtending the right atrial free wall. There is brief right\natrial diastolic invagination but cardiac tamponade is not present.\n\nCompared with the findings of the prior study (images reviewed) of , the findings are similar, but the technically suboptimal nature of both\nstudies precludes definitive comparison.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2124-06-17 00:00:00.000",
"description": "Report",
"row_id": 216158,
"text": "Sinus rhythm\nLeft axis deviation - possible left anterior fascicular block\nInferior T wave changes are nonspecific\nSince previous tracing of , heart rate faster, amplitude more prominent\nClinical correlation is suggested\n\n"
},
{
"category": "ECG",
"chartdate": "2124-05-26 00:00:00.000",
"description": "Report",
"row_id": 216159,
"text": "Artifact is present. Sinus rhythm at a rate of 55. The P-R interval is\nnormal at 160 milliseconds. There is a non-specific intraventricular\nconduction delay with a short QRS duration of 120 milliseconds. The QRS axis\nis indeterminate. The Q-T interval is 500 milliseconds which is prolonged.\nLow voltage. Non-specific ST-T wave changes. Compared to the previous tracing\nsinus rhythm has replaced atrial fibrillation and the Q-T interval is\nprolonged.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2124-05-25 00:00:00.000",
"description": "Report",
"row_id": 216363,
"text": "Artifact is present. Atrial fibrillation with a rapid ventricular response.\nVentricular ectopy. Indeterminate axis. Non-specific intraventricular\nconduction delay. There is a late transition which is probably normal. Low\nvoltage. Non-specific ST-T wave changes. Compared to the previous tracing\natrial fibrillation and indeterminate axis are new.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2124-05-24 00:00:00.000",
"description": "Report",
"row_id": 216364,
"text": "Sinus rhythm. Non-specific intraventricular conduction delay. Non-specific\ndiffuse T wave flattening. Low QRS voltage in the limb leads. Compared to the\nprevious tracing of QRS voltage is decreased. T wave flattening is more\npronunced.\n\n"
}
] |
14,883 | 115,790 | Pt transferred from outside hospital and brought directly to EP laboratory where he underwent biventricular pacemaker placement without complication. Pt tolerated procedure well and then brought to CCU for close monitoring. Pt did well in CCU without symptoms, mentating well, answering questions appropriately. Pt then transferred to 3 but remained on CCU team. About 5 AM , pt found to have SBP in 50s and CCU team called emergently. Pt found to be hypoxic with O2 sats in 70s, not mentating appropriately, and emergently intubated. Pt brought back to CCU and started on dopamine for BP support. Pt's hypotension continued despite increasing dopamine and adding levophed & dobutamine, with MAPs in the 30s. son was called & came to bedside. Per family wishes, no further aggressive measures were undertaken. Pt went into ventricular fibrillation at 1:30 PM and passed away within minutes. son declined post-mortem. | There is evidence of some blunting of the left costophrenic diaphragm, which seems to have progressed from yesterday, and likely represents a small left-sided effusion. As before, there is an esophageal stent in-situ. NG tube appears in good position at the distal end of the esophageal stent. A right-sided internal jugular line is identified in good position. Granulomatous changes are noted in right mid lung zone. An esophageal stent is in situ. An esophageal stent is in situ. Bilateral pedal edema noted, peripheral pulses weakly palpable. New left-sided subclavian line is identified in good position. Pt occasionally has native beats that look sinus with bbb and prolonged pr interval. Pt had been being txc for aspiration px and is on aspiration precautions requiring thickened liquids. In addition, on the lateral view, there is progressive opacification posteriorly from superior-to-inferior consistent with a layering effusion, posteriorly and inferiorly. There is evidence of bibasal emphysema. Demand ventricular pacingSince previous tracing of , paced rhythm seen The patient has been intubated, and the ET tube now lies 4.2 cm from the tip of the carina. INDICATION: Patient has new left subclavian line. Degenerative changes are noted in the spine. Supraventricular tachycardia - ? Received alert/oriented yr old male to ccu s/p DDD pacemaker insertion. with ngt and r ij line. NPNCCUS/P BIVENTRICULAR PLACEMENTS DENIES PAINO CV HR 100-1110'S..V PACED WITH RARE INTRINSIC BEATS...SBP 90-100'S/50-60'S...LEFT ARM IN SLING ..PACER DSG INTACT ..WITHOUT DRAINAGERESP ON 3L NP RR 28..BECOMES TACHYPNEIC WITH MINIMAL EXERTION..ALTHOUGH DENIES SOB....LUNG SOUNDS DIMINISHED AT BASES WITH INSP CXS ..USING INHALERS WITH ASSISTGI/GU URINE OUTPUT 50 CCQ1AFEBRILE ..CONTINUES ON LEVO/VANCO/FLAGYL..CDIFF PRECAUTIONS MAINTAINEDTURNED Q3 HOURS ..PT REFUSING PAIN MEDPT REPORTS POOR APPETITE..BUT DENIES DYSPHAGIA..HOB > 45 DEGREES FOR ASP PRECAUTIONS..LOOSE PROD COUGH AFTER SMALL SIPS OF THICKEN SHAKEA RESP DISTRESS WITH MINIMAL EXERTION LIKELY FROM END STAGE COPD/CHF/ASPIRATIONP CONTINUES ON LASIX/STEROIDSABXS FOR CDIFF/POST PACEMAKER PLACEMENT SOCIAL WORK TEAM WORKING TOWARD SHORT TERM HOSP LEVEL PLACEMENTA He wears bilateral hearing aides which fall out frequently. CHEST, PA and lateral views: The patient has a intracardiac device in-situ with right atrial and right ventricular leads, and a 3rd biventricular pacer lead in-situ. GI: Abd soft, concave, bs hypoactive. COMPARISON: Compared to previous examination from . There appears to be a separate biventricular pacing wire in-situ. sinusLeft axis deviationLeft bundle branch blockNo previous tracing A small left-sided pleural effusion is seen. At ~1315 he went from from paced rhythm with capture to minmimal capture and by 1320 he was in fine VF. REASON FOR THIS EXAMINATION: please evaluate ngt and central line placement FINAL REPORT STUDY: Chest radiograph. Skin: surfaces grossly intact, bottom of feet slightly mottled. Rt clear to auscultation. GU: Uo picking up to >45cc/hr clear yellow after gentle hydration. Allowing for a degree of rotation these appear in good position. Patient has a dual chamber pacemaker in situ with a third biventricular pacing wire. The lungs otherwise appear grossly normal. Pt was asystolic by 1325. Allowing for differences in technique, the lungs appear grossly clear and not significantly changed from radiograph taken previous day. To evaluate for line placement. Pt pronounce dead and son was with him at the time. Arrangements will be made. There may be some collapse/consolidation at this site. 9:06 PM CHEST (PORTABLE AP) Clip # Reason: r/o pneumothorax: px in cath recovery area Admitting Diagnosis: CONGESTIVE HEART FAILURE\BIVENTRICULAR PACEMAKER UPGRADE MEDICAL CONDITION: year old man s/p PM via lt subclavian v REASON FOR THIS EXAMINATION: r/o pneumothorax: px in cath recovery area FINAL REPORT PORTABLE AP CHEST: The patient has a dual chamber pacemaker in situ, with apparent good placement of the leads, although a lateral has not been obtained. CV: Monitor pattern shows vpacing at a rate that varries from 125-101. The heart is normal in size. These all appear to be in satisfactory positioning. They are currently in a labeled cup at the bedside. The lungs are otherwise clear. CCU NSG NOTE: PT DEATHPt deteriorated on 3 overnight, was started on dopamine and intubated and transfered to CCU ~7:30am. P: Contiue full support as above, notify team of any change in hemodynamics, pulmonary funciton or other distress. COMPARISON: Study is compared to the radiograph of . Pt had been on pressor support at outside hospital for hypotension due to diuresis. 11:24 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate ngt and central line placement Admitting Diagnosis: CONGESTIVE HEART FAILURE\BIVENTRICULAR PACEMAKER UPGRADE MEDICAL CONDITION: year old man s/p PM via lt subclavian v now s/p intubation. He is hard of hearing, R>L. Blood gases showed increasing acidosis and lactate up to 11. 9:35 AM CHEST (PA & LAT) Clip # Reason: lead position Admitting Diagnosis: CONGESTIVE HEART FAILURE\BIVENTRICULAR PACEMAKER UPGRADE MEDICAL CONDITION: year old man s/p BiV PM via lt subclavian v REASON FOR THIS EXAMINATION: lead position FINAL REPORT INDICATION: Status-post pacemaker insertion. | 8 | [
{
"category": "Radiology",
"chartdate": "2120-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836737,
"text": " 11:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate ngt and central line placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\BIVENTRICULAR PACEMAKER UPGRADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p PM via lt subclavian v now s/p intubation. with ngt and r\n ij line.\n REASON FOR THIS EXAMINATION:\n please evaluate ngt and central line placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest radiograph.\n\n COMPARISON: Study is compared to the radiograph of .\n\n INDICATION: Patient has new left subclavian line. To evaluate for line\n placement.\n\n The patient has been intubated, and the ET tube now lies 4.2 cm from the tip\n of the carina. An esophageal stent is in situ. NG tube appears in good\n position at the distal end of the esophageal stent. New left-sided subclavian\n line is identified in good position. A right-sided internal jugular line is\n identified in good position. Patient has a dual chamber pacemaker in situ\n with a third biventricular pacing wire. Allowing for a degree of rotation\n these appear in good position.\n\n There is evidence of bibasal emphysema. A small left-sided pleural effusion\n is seen. Allowing for differences in technique, the lungs appear grossly\n clear and not significantly changed from radiograph taken previous day.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836594,
"text": " 9:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumothorax: px in cath recovery area\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\BIVENTRICULAR PACEMAKER UPGRADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p PM via lt subclavian v\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax: px in cath recovery area\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE AP CHEST: The patient has a dual chamber pacemaker in situ, with\n apparent good placement of the leads, although a lateral has not been\n obtained. There appears to be a separate biventricular pacing wire in-situ.\n An esophageal stent is in situ. No pneumothorax is present. The heart is\n normal in size. The medial aspect of the left lower lobe is not clearly\n defined. There may be some collapse/consolidation at this site.\n\n Granulomatous changes are noted in right mid lung zone. The lungs are\n otherwise clear. Degenerative changes are noted in the spine.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-09-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 836630,
"text": " 9:35 AM\n CHEST (PA & LAT) Clip # \n Reason: lead position\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\BIVENTRICULAR PACEMAKER UPGRADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man s/p BiV PM via lt subclavian v\n REASON FOR THIS EXAMINATION:\n lead position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status-post pacemaker insertion.\n\n COMPARISON: Compared to previous examination from .\n\n CHEST, PA and lateral views: The patient has a intracardiac device in-situ\n with right atrial and right ventricular leads, and a 3rd biventricular pacer\n lead in-situ. These all appear to be in satisfactory positioning. There is\n evidence of some blunting of the left costophrenic diaphragm, which seems to\n have progressed from yesterday, and likely represents a small left-sided\n effusion. In addition, on the lateral view, there is progressive\n opacification posteriorly from superior-to-inferior consistent with a layering\n effusion, posteriorly and inferiorly. The lungs otherwise appear grossly\n normal. As before, there is an esophageal stent in-situ. No stent or wire\n fracture is seen.\n\n\n\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2120-09-28 00:00:00.000",
"description": "Report",
"row_id": 183689,
"text": "Demand ventricular pacing\nSince previous tracing of , paced rhythm seen\n\n"
},
{
"category": "ECG",
"chartdate": "2120-09-27 00:00:00.000",
"description": "Report",
"row_id": 183690,
"text": "Supraventricular tachycardia - ? sinus\nLeft axis deviation\nLeft bundle branch block\nNo previous tracing\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-09-27 00:00:00.000",
"description": "Report",
"row_id": 1456076,
"text": "Received alert/oriented yr old male to ccu s/p DDD pacemaker insertion. He is hard of hearing, R>L. He wears bilateral hearing aides which fall out frequently. They are currently in a labeled cup at the bedside. CV: Monitor pattern shows vpacing at a rate that varries from 125-101. Pt occasionally has native beats that look sinus with bbb and prolonged pr interval. Sbp baseline per hx 70-90. Pt had been on pressor support at outside hospital for hypotension due to diuresis. Pulm: Has productive cough of thick dark brown sputum. Left lung sounds decreased all fields. Rt clear to auscultation. Pt had been being txc for aspiration px and is on aspiration precautions requiring thickened liquids. He is able to take his pills with water with no difficulty. GU: Uo picking up to >45cc/hr clear yellow after gentle hydration. GI: Abd soft, concave, bs hypoactive. Pt filled out kosher meal plan with assist. Skin: surfaces grossly intact, bottom of feet slightly mottled. Bilateral pedal edema noted, peripheral pulses weakly palpable. Soc: Has very involved family, who have called in and visited this evening. P: Contiue full support as above, notify team of any change in hemodynamics, pulmonary funciton or other distress.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-09-28 00:00:00.000",
"description": "Report",
"row_id": 1456077,
"text": "NPN\nCCU\nS/P BIVENTRICULAR PLACEMENT\nS DENIES PAIN\nO CV HR 100-1110'S..V PACED WITH RARE INTRINSIC BEATS...SBP 90-100'S/50-60'S...LEFT ARM IN SLING ..PACER DSG INTACT ..WITHOUT DRAINAGE\nRESP ON 3L NP RR 28..BECOMES TACHYPNEIC WITH MINIMAL EXERTION..ALTHOUGH DENIES SOB....LUNG SOUNDS DIMINISHED AT BASES WITH INSP CXS ..USING INHALERS WITH ASSIST\nGI/GU URINE OUTPUT 50 CCQ1\nAFEBRILE ..CONTINUES ON LEVO/VANCO/FLAGYL..CDIFF PRECAUTIONS MAINTAINED\nTURNED Q3 HOURS ..PT REFUSING PAIN MED\nPT REPORTS POOR APPETITE..BUT DENIES DYSPHAGIA..HOB > 45 DEGREES FOR ASP PRECAUTIONS..LOOSE PROD COUGH AFTER SMALL SIPS OF THICKEN SHAKE\nA RESP DISTRESS WITH MINIMAL EXERTION LIKELY FROM END STAGE COPD/CHF/ASPIRATION\nP CONTINUES ON LASIX/STEROIDS\nABXS FOR CDIFF/POST PACEMAKER PLACEMENT\n SOCIAL WORK TEAM WORKING TOWARD SHORT TERM HOSP LEVEL PLACEMENT\n\nA\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-09-29 00:00:00.000",
"description": "Report",
"row_id": 1456078,
"text": "CCU NSG NOTE: PT DEATH\nPt deteriorated on 3 overnight, was started on dopamine and intubated and transfered to CCU ~7:30am. He received a-line and triple lumen, had dopamine increased from 5 to 12 mic/kilo, received a 2nd 500cc NS bolus and had levofed up to 2 mic/kilo and dobutamine at 5 mic/kilo added with continued poor blood pressure. Blood gases showed increasing acidosis and lactate up to 11. His son as the health care proxy, advised continuing pressures without adding further treatment. At ~1315 he went from from paced rhythm with capture to minmimal capture and by 1320 he was in fine VF. Pt was asystolic by 1325. Pt pronounce dead and son was with him at the time. Son appreciative of care, being supported by wife. Arrangements will be made.\n"
}
] |
68,651 | 122,672 | MEDICAL COURSE: Ms. is a 77yoF with h/o remote MI in , HTN, HLD, hypothyroidism, gout, who presented with worsening chest pain, found to have 3 vessel disease on cath, admitted for management prior to CABG. . # CORONARIES: Cath on showed prox OM 80% not a great candidate for stenting. mid 70% LAD, mid 30% diag lesion. 2 vessel disease, rec. CABG. Plavix was held starting on . She initially was doing well, chest pain free. However on she started developing chest pain after going to the bathroom, EKG unchanged. On she developed chest pain at rest, EKG with ST depressions in lateral leads. This pain was responsive immediately to nitro 0.4mg SL x1, and a heparin gtt was started. She went for CABG on #### . # Acidosis: Pt persistently has low bicarb, ~16-18. ABG on showed 7.26/39/76/18. This represents a mixed metabolic acidosis and respiratory acidosis. Differential for non-AG metabolic acidosis is GI losses of HCO3- (possible, given 18" colon resected for villous adenoma, when this issue arose, and has chronic watery diarrhea as a result), renal tubular acidosis (potential), early renal failure (less likely as GFR is in 30's). Urine anion gap is +17, which suggests a failure of kidneys to excrete NH4+, as opposed to bicarb losses. Suggests type I or IV RTA. Persistent hyperkalemia suggests type IV, as type I usually has hypokalemia. Also FeHCO3- is <5%, which also supports type IV RTA. Renin/aldosterone levels were sent which showed #####. She was started on sodium bicarb 325mg PO BID, which improved her serum bicarb. Prior to surgery, she was infused 1L D5W with 150meq NaHCO3. If truly type 4 RTA, may benefit from fludrocortisone in the future. . # Acute on chronic kidney injury: baseline creatinine 1.4, briefly up to 1.7 during admission. Possible CIN from cath . Gentle hydration was given, and ACEi (benazapril) was held. resolved. . # PUMP: no evidence of CHF. Dry weight 145lbs on admission. . # HTN: held carvedilol, amlodipine, and benazapril during admission for mild hypotension and bradycardia. On discharge ####### . # HLD: continued crestor 40mg daily. . # GOUT: continued allopurinol 100mg PO daily ================================ TRANSITIONAL ISSUES # incidentalomas on CT chest: 1) Multiple hypodense kidney lesions, statistically likely cysts, but not fully characterized on this non-contrast study. Recommend ultrasound examination on an outpatient basis. 2) Bilateral adrenal adenomas. To be further worked-up in outpatient setting. # | There isno pericardial effusion.IMPRESSION: Normal regional and global left ventricular systolic function.Mildly dilated right ventricle with borderline free wall function. Mild (1+) MR.TRICUSPID VALVE: Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Non-specific inferior ST-T wave changes.Compared to the previous tracing of ST-T wave changes in lead V6 haveresolved towards normal. The right ventricular cavity is mildly dilated withborderline normal free wall function. Borderline normal RV systolicfunction.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Poor R wave progression, probably a normal variant butcannot exclude prior anteroseptal myocardial infarction. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. Status post median sternotomy for CABG with stable postoperative contours. Trivial mitral regurgitationis seen. )Height: (in) 61Weight (lb): 145BSA (m2): 1.65 m2BP (mm Hg): 98/48HR (bpm): 48Status: InpatientDate/Time: at 16:25Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Evidence ofprior inferior myocardial infarction persists. Doppler parameters are indeterminate for left ventriculardiastolic function. Resolved central pulmonary vascular congestion. Intraventricular conduction delay.Possible old inferior myocardial infarction.TRACING #1 Nosignificant valvular abnormality seen. No resting LVOT gradient.RIGHT VENTRICLE: Mildly dilated RV cavity. Normal PA systolic pressure.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium and right atrium are normal in cavity size. Prior inferior wall myocardial infarction. No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. PATIENT/TEST INFORMATION:Indication: CABGStatus: InpatientDate/Time: at 11:02Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending aorta diameter. Slightly delayedanterior R wave progression may indicate prior anteroseptal myocardialinfarction. Sinus arrhythmia. No aortic regurgitation is seen.The mitral valve leaflets are moderately thickened. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Diffuse low voltage aswell as diffuse ST-T wave flattening, as recorded on . LEFT: B-mode images show mild bifurcation and moderate distal common carotid plaque. Compared to tracing #1, computed QRS duration is even shorter,and RSR' morphology in lead V1 is obscured by baseline artifact. Mild tomoderate [+] TR. The aortic valve leaflets (3) are mildlythickened but aortic stenosis is not present. Mild (1+) mitralregurgitation is seen.There is no pericardial effusion.Post-CPB:The patient is AV-Paced, on no inotropes.Preserved biventricular systolic fxn.Aorta intact. The findings are again consistent with bilateral pleural effusions and compressive atelectasis. Central pulmonary vascular congestion has resolved. Doppler parameters are indeterminate for LVdiastolic function. Bilateral carotid duplex was performed. IMPRESSION: AP chest compared to preoperative chest radiograph, : Lung volumes are low attributable to moderately severe bibasilar atelectasis. FRONTAL CHEST RADIOGRAPH: Mediastinal drains and left thoracostomy tube have been removed. No TEE related complications.Conclusions:Pre-CPB:No spontaneous echo contrast is seen in the left atrial appendage.Overall left ventricular systolic function is normal (LVEF>55%).Right ventricular chamber size and free wall motion are normal.There are complex (>4mm) atheroma in the descending thoracic aorta.The aortic valve leaflets (3) are moderately thickened but aortic stenosis isnot present. Evidence of prior inferior myocardial infarction isunchanged.TRACING #1 Poor anterior R waveprogression suggests prior anterolateral myocardial infarction. Inferior wall myocardial infarction of indeterminate age.Inferolateral ST-T wave changes suggestive of myocardial ischemia. Q waves inleads III and aVF consistent with prior inferior myocardial infarction. Ischemic appearing inferior ST-T wave changes persist.However, there is now ST segment depression in lead I and biphasic to invertedT waves in leads V4-V6 consistent with further evidence of inferolateralischemic process. Rule out myocardial infarction. Inferior myocardialinfarction of indeterminate age. Intraventricular conduction delay. Possible old inferiormyocardial infarction. Intraventricularconduction delay. Sinus bradycardia. Sinus bradycardia. Sinus bradycardia. Sinus bradycardia. Delayed R wave progression. Rule out infarction. Anterior R wave progression is differentwith RSR' pattern throughout, suggesting incorrect electrode placement ratherthan interval myocardial infarction or ongoing ischemia. Sinus bradycardia with slowing of the rate as compared with previous tracingof . Incomplete right bundle-branch block. Diffuse non-specificST-T wave changes in leads V4-V6. Bilateral adrenal adenomas. Compared to the previous tracing of the inferiorischemic appearing ST-T wave changes are less prominent. T wave inversion in leads II, III and aVF withdownsloping ST segment consistent with active inferior ischemic process.Clinical correlation is suggested.TRACING #1 Lowprecordial QRS voltage. There is moderate atherosclerotic calcification of the thoracic aorta, centered at the ascending portion (2:19), with sparing along the arch. Inferolateral ischemic appearing ST-T wave changes withsome improvement in the ischemic ST-T wave abnormalities recorded inleads V4-V6. Sinus bradycardia with prolonged A-V conduction. Sinus rhythm. Sinus rhythm. Sinus rhythm. Clinical correlation issuggested.TRACING #3 A-V sequential pacing is no longer seen. The airways are patent to the subsegmental levels. Compared to the previous tracing of QRS voltage has decreased.TRACING #1 Multiple hypodense kidney lesions, statistically likely cysts, but not fully characterized on this non-contrast study. Clinicalcorrelation is suggested. No contraindications for IV contrast FINAL REPORT INDICATION: Two-vessel disease, plan for CABG, but recent desaturations. Computed QRS durationis slightly shorter. 4:33 PM CT CHEST W/O CONTRAST Clip # Reason: Please evaluate lungs for abnormalities. REASON FOR THIS EXAMINATION: Please evaluate lungs for abnormalities. Followup and clinical correlation aresuggested.TRACING #4 Relatively low QRS voltage throughout. Atherosclerotic calcifications are seen throughout the coronary vessels (2:29). Compared to the previous tracing of , the rateis faster and no longer bradycardic. There are 14-mm and 20-mm left and right adrenal adenomas, respectively (2:57,51). Followup and clinicalcorrelation are suggested.TRACING #3 Otherwise,no diagnostic interim change.TRACING #2 A-V sequential pacing. Comparison chest radiograph available from . Compared to tracing #1 rightbundle-branch block is new. Multiple subcentimeter hepatic lesions (2:56, 47) are statistically likely biliary hamartomas or simple cysts, but remain too small for further characterization. | 23 | [
{
"category": "Echo",
"chartdate": "2103-04-10 00:00:00.000",
"description": "Report",
"row_id": 93079,
"text": "PATIENT/TEST INFORMATION:\nIndication: CABG\nStatus: Inpatient\nDate/Time: at 11:02\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: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma in the\ndescending thoracic aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Moderately 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. No TEE related complications.\n\nConclusions:\nPre-CPB:\nNo spontaneous echo contrast is seen in the left atrial appendage.\nOverall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal.\nThere are complex (>4mm) atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) are moderately thickened but aortic stenosis is\nnot present. No aortic regurgitation is seen.\nThe mitral valve leaflets are moderately thickened. Mild (1+) mitral\nregurgitation is seen.\nThere is no pericardial effusion.\n\nPost-CPB:\nThe patient is AV-Paced, on no inotropes.\nPreserved biventricular systolic fxn.\nAorta intact. Trace MR, no AI.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2103-04-04 00:00:00.000",
"description": "Report",
"row_id": 93080,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pre-operative for CABG (h/o remote MI in , HTN,HLD, hypothroidism, gout, worsening chest pain, 3 vessel disease on cath.)\nHeight: (in) 61\nWeight (lb): 145\nBSA (m2): 1.65 m2\nBP (mm Hg): 98/48\nHR (bpm): 48\nStatus: Inpatient\nDate/Time: at 16:25\nTest: 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%). Doppler parameters are indeterminate for LV\ndiastolic function. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic\nfunction.\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. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild to\nmoderate [+] TR. Normal PA systolic pressure.\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%). Doppler parameters are indeterminate for left ventricular\ndiastolic function. The right ventricular cavity is mildly dilated with\nborderline normal free wall function. The diameters of aorta at the sinus,\nascending and arch levels are normal. 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. Trivial mitral regurgitation\nis seen. The estimated pulmonary artery systolic pressure is normal. There is\nno pericardial effusion.\n\nIMPRESSION: Normal regional and global left ventricular systolic function.\nMildly dilated right ventricle with borderline free wall function. No\nsignificant valvular abnormality seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-04 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1230082,
"text": " 2:30 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: pre-op for CABG\n Admitting Diagnosis: CHEST PAIN; CARDIAC ISCHEMIA\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Ms. is a 77yoF with h/o remote MI in , HTN, HLD, hypothyroidism,\n gout, who presented with worsening chest pain, found to have 3 vessel disease\n on cath, admitted for plavix washout prior to CABG.\n REASON FOR THIS EXAMINATION:\n pre-op for CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old female with remote history of MI and all other\n atherosclerotic risk factors. Schedule for CABG.\n\n Bilateral carotid duplex was performed.\n\n FINDINGS:\n\n RIGHT: B-mode images show mild, heterogeneous plaque. The common carotid\n artery waveform is within normal limits and has a peak velocity of 134 cm/sec.\n The ICA velocities are 132/36. The ECA velocity is 202. The ICA/CCA ratio is\n 0.9. By velocity criteria, this correlates with a near 40% stenosis.\n\n LEFT: B-mode images show mild bifurcation and moderate distal common carotid\n plaque. The common carotid artery waveform is within normal limits and has a\n peak velocity of 130 cm/sec. The ICA velocities are 116/32. The ECA velocity\n is 185. The ICA/CCA ratio is 0.8. By velocity criteria, this correlates with\n a near 40% stenosis.\n\n Both vertebral arteries have antegrade, monophasic flow.\n\n IMPRESSION: Mild-to-moderate heterogeneous plaque with bilateral near 40% ICA\n stenosis. Antegrade vertebral flow.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-04 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1230079,
"text": " 2:22 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CHEST PAIN; CARDIAC ISCHEMIA\\LEFT HEART CATHETERIZATION\n Admitting Diagnosis: CHEST PAIN; CARDIAC ISCHEMIA\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Ms. is a 77yoF with h/o remote MI in , HTN, HLD, hypothyroidism,\n gout, who presented with worsening chest pain, found to have 3 vessel disease\n on cath, admitted for plavix washout prior to CABG.\n REASON FOR THIS EXAMINATION:\n pre-op for CABG\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiac ischemia, preoperative.\n\n FINDINGS: No previous images. Cardiac silhouette is within normal limits and\n there is no evidence of vascular congestion, pleural effusion, or acute focal\n pneumonia. Opacification in the supraclavicular region on the right medially\n could be an artifact or represent some area of calcification.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1231030,
"text": " 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evidence of volume overload?\n Admitting Diagnosis: CHEST PAIN; CARDIAC ISCHEMIA\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with hypoxia.\n REASON FOR THIS EXAMINATION:\n Evidence of volume overload?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia, to assess for volume overload.\n\n FINDINGS: In comparison with the study of , there is slight increase in\n opacification at the left base. The findings are again consistent with\n bilateral pleural effusions and compressive atelectasis. There is probably a\n substantial volume loss in the left lower lobe.\n\n No evidence of pulmonary vascular congestion. Central catheter remains in\n place with its tip probably in the right atrium.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1230917,
"text": " 9:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CHEST PAIN; CARDIAC ISCHEMIA\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p cabg and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post CABG and chest tube removal.\n\n Comparison radiographs available from and .\n\n FRONTAL CHEST RADIOGRAPH:\n Mediastinal drains and left thoracostomy tube have been removed. There is no\n pneumothorax. Multiple intact sternal wires, mediastinal clips, a right IJ\n terminating at the low SVC are unchanged in position. The patient is\n extubated and the orogastric tube removed. The cardiac and mediastinal\n contours are unchanged. Central pulmonary vascular congestion has resolved.\n The lung volumes are decreased as compared to the prior examination, with\n worsening bibasilar opacities concerning for bilateral lower lobe collapse.\n\n IMPRESSION:\n 1. New bilateral lower lobe collapse.\n 2. Removal of left thoracostomy tube. No pneumothorax.\n 3. Resolved central pulmonary vascular congestion.\n\n The findings were determined at 11:45 AM, then discussed by Dr. with\n , NP, of the thoracic surgery service, via telephone at 12:52\n PM, on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-15 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1231398,
"text": " 1:38 PM\n CHEST (PA & LAT) Clip # \n Reason: eval effusion\n Admitting Diagnosis: CHEST PAIN; CARDIAC ISCHEMIA\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with s/p cabg pod 4\n REASON FOR THIS EXAMINATION:\n eval effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST FILM, AT 1350\n\n CLINICAL INDICATION: Postop day 4 status post CABG, evaluate effusion.\n\n Comparison to previous study of , 751.\n\n PA and lateral views of the chest dated , 1350 are submitted.\n\n IMPRESSION:\n 1. Status post median sternotomy for CABG with stable postoperative contours.\n There are bilateral layering pleural effusions with associated airspace\n disease, most likely representing compressive atelectasis, although pneumonia\n cannot be excluded. No evidence of pulmonary edema. No pneumothorax.\n Degenerative changes in the mid thoracic spine but no acute bony abnormality\n appreciated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-10 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1230835,
"text": " 3:26 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placmeent, r/o\n Admitting Diagnosis: CHEST PAIN; CARDIAC ISCHEMIA\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with CAD s/p CABG x 3. Please at with\n abnormalities\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placmeent, r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:16 P.M., \n\n HISTORY: Check line placements and rule out pneumothorax following heart\n surgery.\n\n IMPRESSION: AP chest compared to preoperative chest radiograph, :\n\n Lung volumes are low attributable to moderately severe bibasilar atelectasis.\n Lungs are otherwise clear. Cardiomediastinal silhouette is not all dilated.\n ET tube, midline drains, nasogastric tube, and a right internal jugular line\n are in standard placements respectively. No pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-17 00:00:00.000",
"description": "Report",
"row_id": 247119,
"text": "Sinus rhythm. Prior inferior wall myocardial infarction. Diffuse low voltage as\nwell as diffuse ST-T wave flattening, as recorded on . There is\ncontinued delayed R wave transition. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-16 00:00:00.000",
"description": "Report",
"row_id": 247120,
"text": "Sinus bradycardia. Poor R wave progression, probably a normal variant but\ncannot exclude prior anteroseptal myocardial infarction. Possible prior\ninferior wall myocardial infarction. Non-specific inferior ST-T wave changes.\nCompared to the previous tracing of ST-T wave changes in lead V6 have\nresolved towards normal. Other findings are similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-14 00:00:00.000",
"description": "Report",
"row_id": 247121,
"text": "Sinus rhythm. Compared to tracing #1, computed QRS duration is even shorter,\nand RSR' morphology in lead V1 is obscured by baseline artifact. Evidence of\nprior inferior myocardial infarction persists. Anterior R wave progression\nis improved, again suggesting improper electrode placement on the prior\nelectrocardiograms. Precordial QRS voltage remains low. Slightly delayed\nanterior R wave progression may indicate prior anteroseptal myocardial\ninfarction. Clinical correlation is suggested. Non-specific repolarization\nabnormalities in the inferolateral leads may be residual from the\nintraventricular conduction delay, although an inferolateral ischemic process\ncannot be excluded. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-04 00:00:00.000",
"description": "Report",
"row_id": 247366,
"text": "Sinus bradycardia. Sinus arrhythmia. Intraventricular conduction delay.\nPossible old inferior myocardial infarction.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-03 00:00:00.000",
"description": "Report",
"row_id": 247367,
"text": "Sinus bradycardia. Inferior wall myocardial infarction of indeterminate age.\nInferolateral ST-T wave changes suggestive of myocardial ischemia. Clinical\ncorrelation is suggested. No previous tracing available for comparison.\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-08 00:00:00.000",
"description": "Report",
"row_id": 247363,
"text": "Sinus rhythm. Compared to the previous tracing of the inferior\nischemic appearing ST-T wave changes are less prominent. Otherwise,\nno diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-08 00:00:00.000",
"description": "Report",
"row_id": 247364,
"text": "Sinus bradycardia. T wave inversion in leads II, III and aVF with\ndownsloping ST segment consistent with active inferior ischemic process.\nClinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-13 00:00:00.000",
"description": "Report",
"row_id": 247122,
"text": "Sinus rhythm. Incomplete right bundle-branch block. Poor anterior R wave\nprogression suggests prior anterolateral myocardial infarction. Q waves in\nleads III and aVF consistent with prior inferior myocardial infarction. Low\nprecordial QRS voltage. Compared to the previous tracing of , the rate\nis faster and no longer bradycardic. Anterior R wave progression is different\nwith RSR' pattern throughout, suggesting incorrect electrode placement rather\nthan interval myocardial infarction or ongoing ischemia. Computed QRS duration\nis slightly shorter. Evidence of prior inferior myocardial infarction is\nunchanged.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-12 00:00:00.000",
"description": "Report",
"row_id": 247123,
"text": "Sinus bradycardia. Right bundle-branch block. Compared to tracing #1 right\nbundle-branch block is new. Otherwise, no significant change compared to\ntracing #2. A-V sequential pacing is no longer seen. Clinical correlation is\nsuggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-11 00:00:00.000",
"description": "Report",
"row_id": 247124,
"text": "A-V sequential pacing. Compared to the previous tracing pacing is new.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-10 00:00:00.000",
"description": "Report",
"row_id": 247125,
"text": "Sinus bradycardia with prolonged A-V conduction. Inferior myocardial\ninfarction of indeterminate age. Delayed R wave progression. Intraventricular\nconduction delay. Relatively low QRS voltage throughout. Diffuse non-specific\nST-T wave changes in leads V4-V6. Compared to the previous tracing of \nQRS voltage has decreased.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-09 00:00:00.000",
"description": "Report",
"row_id": 247126,
"text": "Sinus bradycardia with slowing of the rate as compared with previous tracing\nof . Inferolateral ischemic appearing ST-T wave changes with\nsome improvement in the ischemic ST-T wave abnormalities recorded in\nleads V4-V6. Rule out infarction. Followup and clinical correlation are\nsuggested.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-09 00:00:00.000",
"description": "Report",
"row_id": 247127,
"text": "Sinus rhythm. Ischemic appearing inferior ST-T wave changes persist.\nHowever, there is now ST segment depression in lead I and biphasic to inverted\nT waves in leads V4-V6 consistent with further evidence of inferolateral\nischemic process. Rule out myocardial infarction. Followup and clinical\ncorrelation are suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-07 00:00:00.000",
"description": "Report",
"row_id": 247365,
"text": "Sinus bradycardia. Intraventricular conduction delay. Possible old inferior\nmyocardial infarction. Compared to the previous tracing of no new\nchanges are noted.\nTRACING #2\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-06 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1230392,
"text": " 4:33 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evaluate lungs for abnormalities.\n Admitting Diagnosis: CHEST PAIN; CARDIAC ISCHEMIA\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with 2 vessel disease. Planned for CABG but pO2 75 on ABG\n with 99% O2 sats.\n REASON FOR THIS EXAMINATION:\n Please evaluate lungs for abnormalities.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Two-vessel disease, plan for CABG, but recent desaturations.\n\n Comparison chest radiograph available from .\n\n TECHNIQUE: MDCT-acquired 5-mm axial images of the chest were obtained without\n the use of IV contrast. Coronal and sagittal reformations were performed at\n 5-mm slice thickness.\n\n FINDINGS:\n There is no mediastinal or axillary lymphadenopathy. The heart size is normal\n and there is no pericardial effusion. Atherosclerotic calcifications are seen\n throughout the coronary vessels (2:29). There are also extensive\n calcifications across the aortic valve (2:34). There is moderate\n atherosclerotic calcification of the thoracic aorta, centered at the ascending\n portion (2:19), with sparing along the arch.\n\n The airways are patent to the subsegmental levels. No consolidation,\n pneumothorax, or pleural effusion is present. There are no pulmonary nodules\n or masses.\n\n Multiple hypodense lesions are seen throughout both kidneys, which demonstrate\n cortical scarring (2:57). There are 14-mm and 20-mm left and right adrenal\n adenomas, respectively (2:57,51). Multiple subcentimeter hepatic lesions\n (2:56, 47) are statistically likely biliary hamartomas or simple cysts, but\n remain too small for further characterization.\n\n There are no bone lesions suspicious for malignancy or infection. No acute\n fracture is present.\n\n IMPRESSION:\n 1. No acute pulmonary process to explain recent hypoxia on this non-contrast\n study.\n 2. Multiple hypodense kidney lesions, statistically likely cysts, but not\n fully characterized on this non-contrast study. Recommend followup ultrasound\n examination on an outpatient basis.\n 3. Bilateral adrenal adenomas.\n 4. Aortic valve calcifications warrants further evaluation/correlation with\n echocardiogram.\n (Over)\n\n 4:33 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evaluate lungs for abnormalities.\n Admitting Diagnosis: CHEST PAIN; CARDIAC ISCHEMIA\\LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
}
] |
72,354 | 168,065 | 69F with stage IV adenoca of the lung with h/o PEs, therapeutically anticoagulated on lovenox at home, presents with shortness of breath, new acute PEs found on CT. With this heavy clot burden, as well as a filling defect in the SVC decision was made to not place IVC filter and not to anticoagulate her any longer. Given likely tumoral invasion into SVC, decision was made to send her to hospice over the weekend. However, patient expired from cardiopulmonary collapse at 5:36AM on Saturday, . | Right pleural effusion with adjacent compressive atelectasis. IMPRESSION: Persisting right hemidiaphragmatic elevation with associated atelectasis and small pleural effusion. Sinus tachycardia with baseline artifact. Worsening right pleural effusion with adjacent compressive atelectasis compared to . There is opacification of the right lower lung lobe concerning for right lower lobe pulmonary infarct. Filling defects are noted in multiple segmental and subsegmental right lower lobe pulmonary vessels. A filling defect is noted in the adjacent involved superior vena cava in apparent continuity with the tumoral invasion. The aortic contour is mildly tortuous with calcified atherosclerotic disease of the aortic knob. Lower thoracic spine fixation is again noted. Right lower lobe infarct. Right sided heart strain. Hepatic metastases. Sinus tachycardia. Left anteriorfascicular block. At the right costophrenic angle, a meniscus is also noted suggestive of pleural effusion. Tumor attenuates right upper vessels and airways. In association with this hemidiaphragmatic elevation, there is right basilar atelectasis. PE in multiple segemental and subsegmental right lower lobe vessels. Findings consistent with right heart strain are noted. Right hilar/suprahilar opacity consistent with known pulmonary mass. Possibly developing peripheral left upper lobe infarct. The lung volumes are low and the right hemidiaphragm again is noted to be elevated. Additionally, there is opacification within the peripheral left upper lobe which is concerning for developing peripheral left upper lobe infarct. IMPRESSION: Diffuse ground-glass attenuation in both lungs with a wedge-shaped configuration of the left upper lobe, in the setting of acute pulmonary embolism, pulmonary edema, and left upper lobe pulmonary infarct are likely. Multilevel degenerative changes are noted within the thoracic spine. There is associated adjacent compressive atelectasis. COMPARISON: Reference CT chest . OSSEOUS STRUCTURES: Left lower rib fracture is noted (3, 60) of indeterminate chronicity. Overall appearance is consistent with acute pulmonary embolism with significant clot burden. Mediastinal adenopathy, right pleural effusion and spinal fixation are stable findings. PE in left segmental vessels. FINAL REPORT INDICATION: Pulmonary embolism. There is also a new obscuration of the left medial hemidiaphragm suggesting left lower lobe pathology. Acute bilateral pulmonary embolism with significant clot burden, developing bilateral pulmonary infarcts, and right heart strain. Background of metastatic adenocarcinoma to lower thoracic vertebrae and liver. Right hilar/suprahilar opacity is consistent with patient's know pulmonary mass. Elevation of the right hemidiaphragm, splaying of the carina, right hilar adenopathy and a right pleural effusion are stable since . CT OF THE CHEST: Right interlobar artery is completely occluded with thrombus. There is apparent depression of the mid sternal body (400, 35) with smooth margins, which does not appear acute. A small left pleural effusion is also new. Left lower rib fracture, indeterminate chronicity. Respiratory motion limits complete evaluation. FINDINGS: The previously described rod and screw posterior spinal fusion hardware projects over the lower thoracic spine with intervertebral disc spaces noted as well. Left lower rib fracture of indeterminate chronicity. Within this limitation, there are innumerable scattered hypodensities within the liver consistent with hepatic metastases. TECHNIQUE: Contiguous MDCT axial images were obtained through the chest with and without the administration of IV contrast. Filling defect in SVC is likely also tumoral invasion versus clot 3. Tumor invasion of the mediastinum. Tumor invasion of the mediastinum. Left axis deviation. Leftward precordial R wave transition point. There is a right-sided pleural effusion which is increased in size compared to the prior CT of . Filling defects are also noted within the left lower lobe pulmonary vessels. There is a right paramediastinal mass with apparent invasion of the mediastinum. Tumor invasion of the SVC. Non-diagnosticrepolarization abnormalities. FINDINGS: Comparison to serial radiographs dating back to and a recent CTA chest dated . 5:18 AM CHEST (PORTABLE AP) Clip # Reason: new PE or interval change? Overall appear acute. Assess for interval change. New ground-glass attenuation in a wedge-like distribution in the left upper lobe and more homogenous ground-glass attenuation in the right upper lobe are new since . COMPARISON: . IMPRESSION: 1. STUDY: Upright AP portable chest radiograph. Minimal thickening of the left adrenal gland is noted, but is incompletely evaluated within this study. Axillary lymph nodes do not meet CT size criteria for pathologic enlargement. Low QRS voltage in the limb leads. (Over) 3:08 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: please assess for PE, compare to prior Contrast: OPTIRAY Amt: FINAL REPORT (Cont) The study is not optimized for subdiaphragmatic evaluation. Multiplanar reformats were generated and reviewed. The left lung is clear. Otherwise, no diagnostic change.TRACING #1 4. 5. 3:08 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: please assess for PE, compare to prior Contrast: OPTIRAY Amt: MEDICAL CONDITION: 69 year old woman with acute onset SOB, history of PE, lung ca REASON FOR THIS EXAMINATION: please assess for PE, compare to prior No contraindications for IV contrast WET READ: 6:29 PM Right interlobar artery is completely occluded with clot. The osseous structures are intact. The heart size is unchanged compared to prior exam. The patient has a known history of lung cancer. | 5 | [
{
"category": "Radiology",
"chartdate": "2131-08-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149603,
"text": " 2:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with dyspnea\n REASON FOR THIS EXAMINATION:\n Eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 69-year-old female with dyspnea.\n\n STUDY: Upright AP portable chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: The previously described rod and screw posterior spinal fusion\n hardware projects over the lower thoracic spine with intervertebral disc\n spaces noted as well. The lung volumes are low and the right hemidiaphragm\n again is noted to be elevated. In association with this hemidiaphragmatic\n elevation, there is right basilar atelectasis. At the right costophrenic\n angle, a meniscus is also noted suggestive of pleural effusion. The heart\n size is unchanged compared to prior exam. The aortic contour is mildly\n tortuous with calcified atherosclerotic disease of the aortic knob. Right\n hilar/suprahilar opacity is consistent with patient's know pulmonary mass.\n The left lung is clear. There is no pneumothorax. The osseous structures are\n intact.\n\n IMPRESSION: Persisting right hemidiaphragmatic elevation with associated\n atelectasis and small pleural effusion. Right hilar/suprahilar opacity\n consistent with known pulmonary mass.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1149702,
"text": " 5:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: new PE or interval change?\n Admitting Diagnosis: PULMONARY EMBOLIS;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 yo woman c diagnosed PE on CT yesterday\n REASON FOR THIS EXAMINATION:\n new PE or interval change?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pulmonary embolism. Assess for interval change. Background of\n metastatic adenocarcinoma to lower thoracic vertebrae and liver.\n\n FINDINGS: Comparison to serial radiographs dating back to and a recent\n CTA chest dated . Elevation of the right hemidiaphragm, splaying of\n the carina, right hilar adenopathy and a right pleural effusion are stable\n since . Lower thoracic spine fixation is again noted. New\n ground-glass attenuation in a wedge-like distribution in the left upper lobe\n and more homogenous ground-glass attenuation in the right upper lobe are new\n since . A small left pleural effusion is also new. There is also a\n new obscuration of the left medial hemidiaphragm suggesting left lower lobe\n pathology.\n\n IMPRESSION: Diffuse ground-glass attenuation in both lungs with a\n wedge-shaped configuration of the left upper lobe, in the setting of acute\n pulmonary embolism, pulmonary edema, and left upper lobe pulmonary infarct are\n likely.\n Mediastinal adenopathy, right pleural effusion and spinal fixation are stable\n findings.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-08-16 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1149606,
"text": " 3:08 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please assess for PE, compare to prior\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with acute onset SOB, history of PE, lung ca\n REASON FOR THIS EXAMINATION:\n please assess for PE, compare to prior\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:29 PM\n Right interlobar artery is completely occluded with clot. PE in multiple\n segemental and subsegmental right lower lobe vessels. PE in left segmental\n vessels. Overall appear acute.\n Right lower lobe infarct. Possibly developing peripheral left upper lobe\n infarct.\n Tumor invasion of the SVC. Tumor invasion of the mediastinum.\n Left lower rib fracture, indeterminate chronicity.\n Right pleural effusion with adjacent compressive atelectasis.\n Right sided heart strain.\n Findings d/w Dr. at 6:12pm on .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old woman with acute onset shortness of breath and\n history of PE.\n\n COMPARISON: Reference CT chest .\n\n TECHNIQUE: Contiguous MDCT axial images were obtained through the chest with\n and without the administration of IV contrast. Multiplanar reformats were\n generated and reviewed.\n\n CT OF THE CHEST: Right interlobar artery is completely occluded with\n thrombus. Filling defects are noted in multiple segmental and subsegmental\n right lower lobe pulmonary vessels. Filling defects are also noted within the\n left lower lobe pulmonary vessels. Overall appearance is consistent with\n acute pulmonary embolism with significant clot burden. Findings consistent\n with right heart strain are noted. There is opacification of the right lower\n lung lobe concerning for right lower lobe pulmonary infarct. Additionally,\n there is opacification within the peripheral left upper lobe which is\n concerning for developing peripheral left upper lobe infarct.\n\n The patient has a known history of lung cancer. There is a right\n paramediastinal mass with apparent invasion of the mediastinum. Tumor\n attenuates right upper vessels and airways. A filling defect is noted in the\n adjacent involved superior vena cava in apparent continuity with the tumoral\n invasion. Axillary lymph nodes do not meet CT size criteria for pathologic\n enlargement.\n\n There is a right-sided pleural effusion which is increased in size compared to\n the prior CT of . There is associated adjacent compressive\n atelectasis. No evidence of pericardial effusion.\n (Over)\n\n 3:08 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please assess for PE, compare to prior\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The study is not optimized for subdiaphragmatic evaluation. Within this\n limitation, there are innumerable scattered hypodensities within the liver\n consistent with hepatic metastases. Minimal thickening of the left adrenal\n gland is noted, but is incompletely evaluated within this study.\n\n OSSEOUS STRUCTURES: Left lower rib fracture is noted (3, 60) of indeterminate\n chronicity. Multilevel degenerative changes are noted within the thoracic\n spine. There is apparent depression of the mid sternal body (400, 35) with\n smooth margins, which does not appear acute. Respiratory motion limits\n complete evaluation.\n\n IMPRESSION:\n 1. Acute bilateral pulmonary embolism with significant clot burden,\n developing bilateral pulmonary infarcts, and right heart strain.\n 2. Tumor invasion of the mediastinum. Filling defect in SVC is likely also\n tumoral invasion versus clot\n 3. Left lower rib fracture of indeterminate chronicity.\n 4. Worsening right pleural effusion with adjacent compressive atelectasis\n compared to .\n 5. Hepatic metastases.\n\n Findings discussed with Dr. at 6:12 p.m. on .\n\n"
},
{
"category": "ECG",
"chartdate": "2131-08-17 00:00:00.000",
"description": "Report",
"row_id": 229989,
"text": "Sinus tachycardia. Low QRS voltage in the limb leads. Compared to the\nprevious tracing there is no diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2131-08-16 00:00:00.000",
"description": "Report",
"row_id": 229990,
"text": "Sinus tachycardia with baseline artifact. Left axis deviation. Left anterior\nfascicular block. Leftward precordial R wave transition point. Non-diagnostic\nrepolarization abnormalities. Compared to the previous tracing of \nheart rate is increased. Otherwise, no diagnostic change.\nTRACING #1\n\n"
}
] |
9,324 | 101,687 | The patient was admitted to the Coronary Care Unit for management of hypotension, for which the short differential included active blood loss which was effectively ruled out by the CT study and a vagal response necessitating inotropic support. Over the course of the first evening in the Coronary Care Unit the patient became progressively anxious and reported difficulty urinating, and eventually was given 1 mg of Ativan. After the dose of Ativan, the patient's dopamine requirement decreased from 9 mcg/kg per minute to 2 mcg/kg per minute over the course of an hour and a half. The following morning, dopamine was discontinued. The patient had excellent blood pressures, and the groin appeared stable. The patient's hematocrit was also stable, and subsequent creatine kinases remained flat. Electrocardiogram showed no evolving changes. The patient did suffer nonsustained ventricular tachycardia while in house. | Overall left ventricular systolic function is severely depressed.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal inferoseptal - akinetic; mid inferoseptal -akinetic; basal inferior - akinetic; mid inferior - akinetic; basalinferolateral - hypokinetic; mid inferolateral - hypokinetic; basalanterolateral - hypokinetic; mid anterolateral - hypokinetic; apex - akinetic;AORTIC VALVE: The aortic valve leaflets are mildly thickened. Hypotension; Evaluate for effusionHeight: (in) 65Weight (lb): 172BSA (m2): 1.86 m2BP (mm Hg): 90/60Status: InpatientDate/Time: at 17:04Test: Portable TTE(Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: There is severe regional left ventricular systolicdysfunction. Concern for retroperitoneal bleed vs vagal hypotension. CT ABDOMEN WITHOUT IV OR ORAL CONTRAST: There are slightly thickened intra- and interlobular septa associated with subtle ground glass opacities at the lung bases. Procedure c/b bradycardia and hypotension and transferred to CCU for overnoc observation.-Wean Dopa to off-Transfer to floor. Trace aortic regurgitation isseen. Righ femoral sight with "egg" sized hematoma. Pt originally admitted to for evaluation of increasing episodes of angina, ruled out for MI, transfered here for cath. There is an anterior spacewhich most likely represents a fat pad, though a loculated anteriorpericardial effusion cannot be excluded.Conclusions:Limited study performed. Abd soft with normoactive BS's. Evaluate for retroperitoneal bleed. REASON FOR THIS EXAMINATION: r/o retroperitoneal bleed FINAL REPORT INDICATION: Status post coronary intervention, hypotension, small groin hematoma and nausea. Hypotension requiring pressors with small groin hematoma. Compared to the previous tracing of there are nowdeeper T wave inversions in leads I and aVL suggesting possible anterolateralischemia. There is severe regional left ventricular systolicdysfunction. Probableleft anterior fascicular block. Overall left ventricular systolic function is severely depressed.Resting regional wall motion abnormalities include akinesis of the inferiorand inferoseptal segments and apex and hypokinesis of the lateral wall. Delayed R wave transition. Pt given 1 mg Ativan after which he fell asleep. TECHNIQUE: Helically acquired contiguous axial images were obtained from the lung bases through the pubic symphysis, without IV or oral contrast. Also has hematoma of R groin, Integrelin dc'd and pt sent to CT abd to r/o retroperitoneal bleed. Degenerative changes are noted along the thoracic and lumbar spine. Pulses distal palpable and extremeties cool to touch.RESP: LSCTA with O2Sat >97% on 2LNC. A tiny amount of subcutaneous emphysema is noted adjacent to the soft tissue stranding. Pt c/o nausea, having dry heaves. Upon Cath procedure pt found to have re-stenosises of stent placed in LAD and had brachytherapy performed to lesion. Contrast is noted collecting within the bladder. Trace aorticregurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. The adjacent stranding and hematoma are consistent with recent catheterization. There is extensive stranding in a small approximately 1.5 x 1.5 cm hematoma adjacent to the right femoral vessels. Pulses, DP +3, PT +1 bilaterally. Responded to Dopamine and IVF, cont to have drops in BP with attempted weaning of Dopamine. S/P multiple catheterizations with stenting of LAD and OM, ^ chol, HTN, Cluster migraines.ALL: betablockers, cause bronchospasm.CV: On arrival pt very anxious, HR 60's NSR, BP 100-110/60 on 10ug of Dopa running through R anticubital IV, site looks good. Given .625mg droperidol with good effect. Clinical correlation issuggested.TRACING #2 Given two Tylenol and pt sleeping since. Slight ooze on DSD when recieved but since has not oozed overnoc. AM labs pendingENDO: FS overnoc 104. Sats 97% on 2L, decreased to 92% when asleep.A/P: Pt transfered to CCU for close observation, management of hypotension s/p intervention in cath lab. NURSING PROGREES NOTE AND TRANSFER NOTE,PLEASE SEE CARVIEW AND NURSING PROGRESS NOTE FOR FLOOR.A 59 YEAR OLD MAN S/P BRACHYTHERAPY TO LAD.PMH:MULTIPLE MI,S,PTCA AND STENT PLACEMENT ,CLUSTER MIGRAINES,HTN,ELEVATED LIPIDS,DM TYPE 2.ALLERGIES:BETABLOCKERS-BRONCHOSPASM TOLERATES LOPRESSOR DID HAVE AT OH.QUESTION TO ACE-COUGH.NEURO:AWAKE,ALERT,ORIENTEDX3.FOLLOWS COMMANDS AND MOVES ALL EXTREMITIES WITH EQUAL STRENGHT.CV:REMAINS IN NSR WITHOUT ECTOPY.DOPA WAS DCD ,BP REMAINED STABLE.STARTED ON LOPRESSOR 12.5MG PO,WITH NO REACTION.RIGHT GROIN HAS SMALL EGG SIZE HEMATOMA,DSG INTACT WITH SMALL AMOUNT OF OLD SERROSANGUINOUS DRAINAGE.RESP:BREATH SOUNDS CLEAR.SP02 95 TO 97%ON ROOM AIR.DENIES ANY SOB.GI:ABD SOFT WITH POSITIVE BOWEL SOUNDS.TOLERATES FULL DIET.GU:URINE FOR A AND CULTURE SENT.PT COMPLAINTS OF DISCOMFORT WHEN VOIDING.URINE IS BLOODY WITH FEW SMALL CLOTS.TEAM AND HO AWARE.PAIN:DENIES ANY PAIN,CHEST PAIN,SOB,TINGLING OR NUMBNESS DOWN ARMS.PLAN:TRANSFER TO FLOOR. Mild pulmonary vascular congestion noted at the lung bases. Stable overnoc. Dopamine weaned to off at 0200. Dopa currently at 2.5ugs and SBPs 90-98's and MAPs >65. Post intervention pt had episodes hypotenstion to 80/, hr to 40-50. CCU Nursing Note 2300-0700: UA,S/P BrachytherapyS: "Will I be able to go home tommorow? Theaortic valve leaflets are mildly thickened. HR 45-80's. Periods of apnea at begining of shift but since has not had any. T&C for 2 U PRBC. Initial report negitive. CCU Nursing Adm Note:59 yr old transfered from cath lab for management of hypotension on Dopamine s/p brachytherapy to LAD stent. Left axis deviation. Did wake once during night c/o back pain. Restarted at 0300 for MAPS < 60 and SBP of 77-80's. Normal sinus rhythm. Normal sinus rhythm. No acute retroperitoneal hemorrhage. Nauseated. Prior shift given Ativan. Able to wean Dopa down to 5ug/kg as of 10PM, will cont to wean as tolerated. CT PELVIS WITHOUT ORAL OR IV CONTRAST: The rectum, sigmoid colon and prostate are unremarkable. The liver, gallbladder, pancreas, spleen, adrenal glands and visualized loops of bowel are unremarkable on this noncontrast study. The mitral valve leaflets are mildly thickened. IMPRESSION: 1. PATIENT/TEST INFORMATION:Indication: Coronary artery disease. Hct 40. R groin with 4x4cm blood on dressing. Compared to the previous tracing of there has been no diagnostic interval change.TRACING #1 LS clear. Advance diet as tolerated.HEME: HCT stable at 40 from PM shift. Occasional HR quickly increasing to mid 80's and quickly decreasing back into the 50's. | 7 | [
{
"category": "Echo",
"chartdate": "2177-02-26 00:00:00.000",
"description": "Report",
"row_id": 97090,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Hypotension; Evaluate for effusion\nHeight: (in) 65\nWeight (lb): 172\nBSA (m2): 1.86 m2\nBP (mm Hg): 90/60\nStatus: Inpatient\nDate/Time: at 17:04\nTest: Portable TTE(Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: There is severe regional left ventricular systolic\ndysfunction. Overall left ventricular systolic function is severely depressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferoseptal - akinetic; mid inferoseptal -\nakinetic; basal inferior - akinetic; mid inferior - akinetic; basal\ninferolateral - hypokinetic; mid inferolateral - hypokinetic; basal\nanterolateral - hypokinetic; mid anterolateral - hypokinetic; apex - akinetic;\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. Trace aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. No mitral\nregurgitation is seen.\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:\nLimited study performed. There is severe regional left ventricular systolic\ndysfunction. Overall left ventricular systolic function is severely depressed.\nResting regional wall motion abnormalities include akinesis of the inferior\nand inferoseptal segments and apex and hypokinesis of the lateral wall. The\naortic valve leaflets are mildly thickened. Trace aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is no pericardial\neffusion.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-02-27 00:00:00.000",
"description": "Report",
"row_id": 1385373,
"text": "CCU Nursing Note 2300-0700: UA,S/P Brachytherapy\nS: \"Will I be able to go home tommorow?\"\nO: MS: Slept majority of night since recieved pt at 2300. Prior shift given Ativan. Did wake once during night c/o back pain. Given two Tylenol and pt sleeping since. Turning and moving from side to side in bed without assist.\n\nCV: SB to NSR with no ectopy. Occasional HR quickly increasing to mid 80's and quickly decreasing back into the 50's. HR 45-80's. Dopamine weaned to off at 0200. Restarted at 0300 for MAPS < 60 and SBP of 77-80's. Dopa currently at 2.5ugs and SBPs 90-98's and MAPs >65. Pt not c/o CP, palpations, jaw pain, or arm pain. Righ femoral sight with \"egg\" sized hematoma. Stable overnoc. Slight ooze on DSD when recieved but since has not oozed overnoc. Pulses distal palpable and extremeties cool to touch.\n\nRESP: LSCTA with O2Sat >97% on 2LNC. Periods of apnea at begining of shift but since has not had any. Team aware and plans to work-up post CCU course. Breathing unlabored and even.\n\nGU/GI: Voiding in urinal without difficulty. Urine pink-red in color. Urine outputs adequate. Abd soft with normoactive BS's. Advance diet as tolerated.\n\nHEME: HCT stable at 40 from PM shift. AM labs pending\n\nENDO: FS overnoc 104. AM FS pending,\n\nSOCIAL: X-wife called during night to check on pt's condition.\n\nA/P: 59 year-old male who was admitted to from OSH for Cath procedure. Upon Cath procedure pt found to have re-stenosises of stent placed in LAD and had brachytherapy performed to lesion. Procedure c/b bradycardia and hypotension and transferred to CCU for overnoc observation.\n\n-Wean Dopa to off\n-Transfer to floor.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-02-27 00:00:00.000",
"description": "Report",
"row_id": 1385374,
"text": "NURSING PROGREES NOTE AND TRANSFER NOTE,PLEASE SEE CARVIEW AND NURSING PROGRESS NOTE FOR FLOOR.\n\nA 59 YEAR OLD MAN S/P BRACHYTHERAPY TO LAD.PMH:MULTIPLE MI,S,PTCA AND STENT PLACEMENT ,CLUSTER MIGRAINES,HTN,ELEVATED LIPIDS,DM TYPE 2.\n\nALLERGIES:BETABLOCKERS-BRONCHOSPASM TOLERATES LOPRESSOR DID HAVE AT OH.QUESTION TO ACE-COUGH.\n\nNEURO:AWAKE,ALERT,ORIENTEDX3.FOLLOWS COMMANDS AND MOVES ALL EXTREMITIES WITH EQUAL STRENGHT.\n\nCV:REMAINS IN NSR WITHOUT ECTOPY.DOPA WAS DCD ,BP REMAINED STABLE.STARTED ON LOPRESSOR 12.5MG PO,WITH NO REACTION.RIGHT GROIN HAS SMALL EGG SIZE HEMATOMA,DSG INTACT WITH SMALL AMOUNT OF OLD SERROSANGUINOUS DRAINAGE.\n\nRESP:BREATH SOUNDS CLEAR.SP02 95 TO 97%ON ROOM AIR.DENIES ANY SOB.\n\nGI:ABD SOFT WITH POSITIVE BOWEL SOUNDS.TOLERATES FULL DIET.\n\nGU:URINE FOR A AND CULTURE SENT.PT COMPLAINTS OF DISCOMFORT WHEN VOIDING.URINE IS BLOODY WITH FEW SMALL CLOTS.TEAM AND HO AWARE.\n\nPAIN:DENIES ANY PAIN,CHEST PAIN,SOB,TINGLING OR NUMBNESS DOWN ARMS.\n\nPLAN:TRANSFER TO FLOOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-02-26 00:00:00.000",
"description": "Report",
"row_id": 1385372,
"text": "CCU Nursing Adm Note:\n59 yr old transfered from cath lab for management of hypotension on Dopamine s/p brachytherapy to LAD stent. Post intervention pt had episodes hypotenstion to 80/, hr to 40-50. Responded to Dopamine and IVF, cont to have drops in BP with attempted weaning of Dopamine. Also has hematoma of R groin, Integrelin dc'd and pt sent to CT abd to r/o retroperitoneal bleed. Initial report negitive. Hct 40. T&C for 2 U PRBC. Pt originally admitted to for evaluation of increasing episodes of angina, ruled out for MI, transfered here for cath. EF 38%.\n\nPMH: CAD, s/p multiple MI's, last one in of this year. S/P multiple catheterizations with stenting of LAD and OM, ^ chol, HTN, Cluster migraines.\n\nALL: betablockers, cause bronchospasm.\n\nCV: On arrival pt very anxious, HR 60's NSR, BP 100-110/60 on 10ug of Dopa running through R anticubital IV, site looks good. R groin with 4x4cm blood on dressing. Pulses, DP +3, PT +1 bilaterally. Pt c/o nausea, having dry heaves. Given .625mg droperidol with good effect. Pt given 1 mg Ativan after which he fell asleep. Able to wean Dopa down to 5ug/kg as of 10PM, will cont to wean as tolerated. LS clear. Sats 97% on 2L, decreased to 92% when asleep.\n\nA/P: Pt transfered to CCU for close observation, management of hypotension s/p intervention in cath lab. Concern for retroperitoneal bleed vs vagal hypotension.\n"
},
{
"category": "ECG",
"chartdate": "2177-02-27 00:00:00.000",
"description": "Report",
"row_id": 285864,
"text": "Normal sinus rhythm. Compared to the previous tracing of there are now\ndeeper T wave inversions in leads I and aVL suggesting possible anterolateral\nischemia. The Q-T interval is also somewhat longer. Clinical correlation is\nsuggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2177-02-26 00:00:00.000",
"description": "Report",
"row_id": 285865,
"text": "Normal sinus rhythm. Delayed R wave transition. Left axis deviation. Probable\nleft anterior fascicular block. Compared to the previous tracing of \nthere has been no diagnostic interval change.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-02-26 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 756662,
"text": " 7:10 PM\n CT ABDOMEN W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n Reason: r/o retroperitoneal bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with coronary intervention today. Hypotension requiring\n pressors with small groin hematoma. Nauseated.\n REASON FOR THIS EXAMINATION:\n r/o retroperitoneal bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post coronary intervention, hypotension, small groin\n hematoma and nausea. Evaluate for retroperitoneal bleed.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung bases through the pubic symphysis, without IV or oral contrast.\n\n CT ABDOMEN WITHOUT IV OR ORAL CONTRAST: There are slightly thickened intra-\n and interlobular septa associated with subtle ground glass opacities at the\n lung bases. The liver, gallbladder, pancreas, spleen, adrenal glands and\n visualized loops of bowel are unremarkable on this noncontrast study. There\n is no ascites or free intraperitoneal air. Contrast excretion is noted\n symmetrically in each of the renal collecting systems.\n\n CT PELVIS WITHOUT ORAL OR IV CONTRAST: The rectum, sigmoid colon and prostate\n are unremarkable. Contrast is noted collecting within the bladder. There is\n extensive stranding in a small approximately 1.5 x 1.5 cm hematoma adjacent to\n the right femoral vessels. No acute hemorrhage is identified. There is no\n free pelvic fluid or deep pelvic lymphadenopathy. A tiny amount of\n subcutaneous emphysema is noted adjacent to the soft tissue stranding.\n\n Degenerative changes are noted along the thoracic and lumbar spine.\n\n IMPRESSION:\n 1. No acute retroperitoneal hemorrhage. The adjacent stranding and hematoma\n are consistent with recent catheterization.\n 2. Mild pulmonary vascular congestion noted at the lung bases.\n\n\n"
}
] |
79,735 | 156,817 | 53 year old female admitted to the Acute care service with abdominal pain, jaundice, nausea and vomitting. Upon admission to the emergency room, she was hypotensive, and confused requiring intravenous fluids. She was admitted to the intensive care unit for intravenous hydration and monitoring. The GI service was consulted and based on her physical examination and blood work an ERCP was recommended. She underwent an ERCP on HOD #1. She was reported to have an impacted stone in the bile duct and underwent removal of the stone with placment of a stent. Overnight, she was monitored in the intensive care unit requiring additional intravenous fluids for decreased urine output. She was also maintained on ciprofloxacin and flagyl. Her liver function tests slowly improved and the intensity of her pain diminished. She was transferred to the regular floor on HD#3. Her foley catheter was discontinued at this time and she was voiding without difficulty. During this time, she did have bouts of confusion which were thought to be related to the narcotics for analgesic management. Nutrition service evaluated the patient and made recommendations about her nutritional status. She did have a mild elevation of her INR to 2.7 during her hospitalization, but his decreased to 1.6 over the last few days. On HD #7, she had an episode of decreased oxygenation. Despite a nebulizer treatment, she did receive a dose of lasix with improvment of her oxygenation. She continued to have bouts of oxygen desaturation and was taken for a chest cat scan after placment of a PICC line for intravenous access. The cat scan was negative for a pulmonary embolism but did show bibasilar atelectasis and small bilater pleural effusions. She has maintained her oxygen saturation at 96-98% on room air at rest, but continues to desaturate to 88-95% on room air while ambulating. Her vital signs have been stable and she is afebrile. She is tolerating a regular diet and voiding without difficulty. She has ambulated in the and has been encouraged to use the incentive spirometer. She is requiring minimal analgesia for management of her abdominal pain. Her antibiotics were discontinued on HD#9. She is planning for dicharge home with VNA services to assess her cardio-pulmonary status. She has been intstructed to follow up with the Acute care service in 2 weeks for discussion about elective cholecystectomy. She will need to follow-up with ERCP 1 month for stent removal. | Bilateral atelectasis and pleural effusion are most likely present, unchanged. Biliary stent without biliary ductal dilatation. Biliary stent without biliary ductal dilatation. Biliary stent without biliary ductal dilatation. There appears to be near uniform enhancement of the pancreatic parenchyma, without evidence for regions of pancreatic necrosis. Cardiomediastinal and hilar contours are mildly enlarged but unchanged. Presence of a minimal left pleural effusion cannot be excluded. Subsegmental left lower lobe atelectasis and probable small left effusion are unchanged from prior. The uterus, and adnexa appear normal. PELVIS: Pelvic loops of bowel appear normal. The thoracic aorta is normal in caliber. Numerous mediastinal lymph nodes are present, but not enlarged with nodes measuring up to 6.5 mm. No pneumothorax. No biliary ductal dilatation is present. Prominent inferior lead Q waves are non-diagnostic. Hepatic vasculature is conventional, and patent. No pulmonary embolism. No pulmonary embolism. No pulmonary embolism. CHEST: No pulmonary embolism is present. No pancreatic necrosis, pseudocyst, or vascular compromise. No pancreatic necrosis, pseudocyst, or vascular compromise. No pancreatic necrosis, pseudocyst, or vascular compromise. The kidneys enhance and excrete contrast symmetrically without masses, or hydronephrosis. Stable left lower lobe partial atelectasis and probable small left effusion. The abdominal aorta and its branches appear normal. No significant adenopathy is present in the axilla, or hila. The adrenals, and spleen appear normal. No definite pulmonary nodules are identified. No coronary artery calcification is present. There is no change in cardiomegaly, left lower lobe consolidation and interstitial pulmonary edema. The stomach and abdominal loops of small bowel appear normal. The bladder appears normal. Extensive peripancreatic fat stranding with a small-to-moderate degree of mesenteric fluid, but no well-defined fluid collections. Extensive peripancreatic fat stranding with a small-to-moderate degree of mesenteric fluid, but no well-defined fluid collections. There is no focal consolidation or pneumothorax. No pancreatic pseudocysts are present. Modest diffuse ST-T wave changes. No evidence of pulmonary edema. Borderline size of the cardiac silhouette. Extensive peripancreatic fat stranding with a small-to-moderate degree of mesenteric and para-renal fluid, but no well-defined fluid collections. Mesenteric vessels adjacent to this inflamed pancreas appear normal without any evidence for thrombosis, or (Over) 4:25 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # Reason: Evaluate for PE, evaluate pancreatitisPlease give iv+po cont Admitting Diagnosis: CHOLECYSTITIS Contrast: OPTIRAY Amt: FINAL REPORT (Cont) pseudoaneurysm formation. The partially visualized lobes of the thyroid appear normal. FINDINGS: The lung volumes are low. Bibasilar atelectasis with small bilateral pleural effusions. Bibasilar atelectasis with small bilateral pleural effusions. Bibasilar atelectasis with small bilateral pleural effusions. A left-sided approach central catheter terminates in the lower SVC. The liver parenchyma is fatty replaced, without focal lesions. There are small bilateral pleural effusions with bibasilar dependent atelectasis. Lowprecordial lead QRS voltage. CTA CHEST, AND CT ABDOMEN AND PELVIS: MDCT imaging was performed from the thoracic inlet to the upper abdomen without IV contrast. No evidence of pneumothorax. However, there is still evidence of moderate cardiomegaly with a mild-to-moderate left pleural effusion and subsequent left retrocardiac atelectasis. There is no vascular congestion or pulmonary edema. Findings arenon-specific. COMPARISON: None. There is no free intra-abdominal air. No evidence of pneumonia or pneumothorax. No newly occurred focal parenchymal opacity suggesting pneumonia. There is a collection of fluid within the left anterior abdominal mesentery (3B:109); however, this is not yet a well-defined fluid collection. No free air, free fluid or adenopathy is present. The lung volumes are low. There is slight dilation, however, of the cystic duct with possible sludge or debris within a nondistended gallbladder. COMPARISON: No comparison available at the time of dictation. Sinus rhythm. The heart is top normal in size. Subsequently, after the uneventful intravenous administration of 130 cc of Optiray, MDCT imaging was performed from the thoracic inlet to the upper abdomen according to the CTA chest pain protocol. Nondistended gallbladder may contain sludge or stones. Nondistended gallbladder may contain sludge or stones. Nondistended gallbladder may contain sludge or stones. No previous tracingavailable for comparison. There are bilateral areas of atelectasis, left more than right, with multiple air bronchograms. IMPRESSION: 1. IMPRESSION: 1. BONE WINDOWS: No suspicious bone lesions are identified. Patient with new left PICC. COMPARISON: Chest radiograph from . Fatty liver. Fatty liver. Fatty liver. New left PICC, tip at the level of the right atrium. At the bases of the right lung, a plate-like atelectasis is seen. Sagittal, coronal and oblique reformats were performed. Oral contrast was present. PORTABLE AP CHEST RADIOGRAPH: The tip of the new left PICC projects over the expected location of the right atrium. 4. 4. 4. 2. 2. 2. 2. 3. 3. 3. 3. COMPARISON: . Portable AP chest radiograph was compared to prior study obtained . A stent extends from the ampulla into right hepatic biliary ducts. Clinical correlation is suggested. 4:25 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # Reason: Evaluate for PE, evaluate pancreatitisPlease give iv+po cont Admitting Diagnosis: CHOLECYSTITIS Contrast: OPTIRAY Amt: MEDICAL CONDITION: 53 year old woman gallstone pancreatitis with transient hypoxemia and tachycardia overnight REASON FOR THIS EXAMINATION: Evaluate for PE, evaluate pancreatitisPlease give iv+po contrast No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw TUE 5:31 PM 1. | 7 | [
{
"category": "Radiology",
"chartdate": "2134-03-16 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1185295,
"text": " 4:25 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: Evaluate for PE, evaluate pancreatitisPlease give iv+po cont\n Admitting Diagnosis: CHOLECYSTITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman gallstone pancreatitis with transient hypoxemia and\n tachycardia overnight\n REASON FOR THIS EXAMINATION:\n Evaluate for PE, evaluate pancreatitisPlease give iv+po contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw TUE 5:31 PM\n 1. No pulmonary embolism. Bibasilar atelectasis with small bilateral pleural\n effusions.\n 2. Extensive peripancreatic fat stranding with a small-to-moderate degree of\n mesenteric fluid, but no well-defined fluid collections. No pancreatic\n necrosis, pseudocyst, or vascular compromise.\n 3. Biliary stent without biliary ductal dilatation. Nondistended gallbladder\n may contain sludge or stones.\n 4. Fatty liver.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Gallstone pancreatitis and transient hypoxemia and tachycardia\n overnight, evaluate for PE and evaluate pancreatitis.\n\n CTA CHEST, AND CT ABDOMEN AND PELVIS: MDCT imaging was performed from the\n thoracic inlet to the upper abdomen without IV contrast. Subsequently, after\n the uneventful intravenous administration of 130 cc of Optiray, MDCT imaging\n was performed from the thoracic inlet to the upper abdomen according to the\n CTA chest pain protocol. Subsequently, MDCT imaging was performed from the\n upper abdomen to the pubic symphysis. Oral contrast was present. Sagittal,\n coronal and oblique reformats were performed.\n\n COMPARISON: None.\n\n CHEST: No pulmonary embolism is present. There are small bilateral pleural\n effusions with bibasilar dependent atelectasis. No definite pulmonary nodules\n are identified. The heart is top normal in size. No coronary artery\n calcification is present. A left-sided approach central catheter terminates\n in the lower SVC. Numerous mediastinal lymph nodes are present, but not\n enlarged with nodes measuring up to 6.5 mm. The thoracic aorta is normal in\n caliber. No significant adenopathy is present in the axilla, or hila. The\n partially visualized lobes of the thyroid appear normal.\n\n ABDOMEN: There is extensive peripancreatic fat stranding and left anterior\n pararenal and mesenteric fluid. There is a collection of fluid within the\n left anterior abdominal mesentery (3B:109); however, this is not yet a\n well-defined fluid collection. No pancreatic pseudocysts are present. There\n appears to be near uniform enhancement of the pancreatic parenchyma, without\n evidence for regions of pancreatic necrosis. Mesenteric vessels adjacent to\n this inflamed pancreas appear normal without any evidence for thrombosis, or\n (Over)\n\n 4:25 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: Evaluate for PE, evaluate pancreatitisPlease give iv+po cont\n Admitting Diagnosis: CHOLECYSTITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pseudoaneurysm formation. A stent extends from the ampulla into right hepatic\n biliary ducts. No biliary ductal dilatation is present. There is slight\n dilation, however, of the cystic duct with possible sludge or debris within a\n nondistended gallbladder. The liver parenchyma is fatty replaced, without\n focal lesions. Hepatic vasculature is conventional, and patent. The\n adrenals, and spleen appear normal. The kidneys enhance and excrete contrast\n symmetrically without masses, or hydronephrosis. The abdominal aorta and its\n branches appear normal. There is no free intra-abdominal air. The stomach\n and abdominal loops of small bowel appear normal.\n\n PELVIS: Pelvic loops of bowel appear normal. No free air, free fluid or\n adenopathy is present. The uterus, and adnexa appear normal. The bladder\n appears normal.\n\n BONE WINDOWS: No suspicious bone lesions are identified.\n\n IMPRESSION:\n 1. No pulmonary embolism. Bibasilar atelectasis with small bilateral pleural\n effusions.\n 2. Extensive peripancreatic fat stranding with a small-to-moderate degree of\n mesenteric and para-renal fluid, but no well-defined fluid collections. No\n pancreatic necrosis, pseudocyst, or vascular compromise.\n 3. Biliary stent without biliary ductal dilatation. Nondistended gallbladder\n may contain sludge or stones.\n 4. Fatty liver.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-15 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1185139,
"text": " 10:00 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pna, pneumonitis\n Admitting Diagnosis: CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with gallstone pancreatitis\n REASON FOR THIS EXAMINATION:\n ? pna, pneumonitis\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Gallstone pancreatitis, questionable pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the lung volumes have\n increased, potentially reflecting improved ventilation. However, there is\n still evidence of moderate cardiomegaly with a mild-to-moderate left pleural\n effusion and subsequent left retrocardiac atelectasis. At the bases of the\n right lung, a plate-like atelectasis is seen. No newly occurred focal\n parenchymal opacity suggesting pneumonia. No evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1184677,
"text": " 11:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for infiltrate, interval changes\n Admitting Diagnosis: CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with sepsis\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrate, interval changes\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Sepsis.\n\n Portable AP chest radiograph was compared to prior study obtained .\n\n There is no change in cardiomegaly, left lower lobe consolidation and\n interstitial pulmonary edema. Bilateral atelectasis and pleural effusion are\n most likely present, unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1185272,
"text": " 2:13 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: pls assess tip of 49cm LUE POWER PICC, call # w\n Admitting Diagnosis: CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with new left power picc\n REASON FOR THIS EXAMINATION:\n pls assess tip of 49cm LUE POWER PICC, call # w/ wet read thanks\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old female with history of gallstone pancreatitis. Patient\n with new left PICC.\n\n COMPARISON: Chest radiograph from .\n\n PORTABLE AP CHEST RADIOGRAPH: The tip of the new left PICC projects over the\n expected location of the right atrium. If cavoatrial junction positioning is\n desired, recommend proximal positioning by 5 cm. The lung volumes are low.\n Subsegmental left lower lobe atelectasis and probable small left effusion are\n unchanged from prior. There is no focal consolidation or pneumothorax. There\n is no vascular congestion or pulmonary edema. Cardiomediastinal and hilar\n contours are mildly enlarged but unchanged.\n\n IMPRESSION:\n 1. New left PICC, tip at the level of the right atrium. Recommend proximal\n repositioning by 5 cm if the desired location is at the cavoatrial junction.\n 2. No pneumothorax.\n 3. Stable left lower lobe partial atelectasis and probable small left\n effusion.\n\n Dr. communicated the PICC position to (IV\n Therapy) at 14:50 on by telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1184480,
"text": " 5:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lung volumes\n Admitting Diagnosis: CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with cholangitis & pancreatitis\n REASON FOR THIS EXAMINATION:\n eval lung volumes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Cholangitis, pancreatitis, evaluation of lung volumes.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: The lung volumes are low. There are bilateral areas of\n atelectasis, left more than right, with multiple air bronchograms. Presence\n of a minimal left pleural effusion cannot be excluded. No evidence of\n pulmonary edema. Borderline size of the cardiac silhouette. No evidence of\n pneumonia or pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-03-16 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1185296,
"text": ", CC6A 4:25 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: Evaluate for PE, evaluate pancreatitisPlease give iv+po cont\n Admitting Diagnosis: CHOLECYSTITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman gallstone pancreatitis with transient hypoxemia and\n tachycardia overnight\n REASON FOR THIS EXAMINATION:\n Evaluate for PE, evaluate pancreatitisPlease give iv+po contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. No pulmonary embolism. Bibasilar atelectasis with small bilateral pleural\n effusions.\n 2. Extensive peripancreatic fat stranding with a small-to-moderate degree of\n mesenteric fluid, but no well-defined fluid collections. No pancreatic\n necrosis, pseudocyst, or vascular compromise.\n 3. Biliary stent without biliary ductal dilatation. Nondistended gallbladder\n may contain sludge or stones.\n 4. Fatty liver.\n\n"
},
{
"category": "ECG",
"chartdate": "2134-03-10 00:00:00.000",
"description": "Report",
"row_id": 258434,
"text": "Sinus rhythm. Prominent inferior lead Q waves are non-diagnostic. Low\nprecordial lead QRS voltage. Modest diffuse ST-T wave changes. Findings are\nnon-specific. Clinical correlation is suggested. No previous tracing\navailable for comparison.\n\n"
}
] |
74,282 | 121,149 | This is a 45 yo male with severe epigastric abd pain since and found to have gallstone pancreatitis and dehydration for aggressive IV hydration. He was admitted to the ICU | At OSH: Tbili 2.0, LFTs: , Tbili 2.0, Lipase , WBC 15, Hct 53.8 Chief complaint: abdominal pain PMHx: PTSD, HTN, R TKR, R cataract surgery, lipids : Lithium 300', HCTZ 25', Prilosec 20', Motrin, Lisinopril 40', Ritalin 20''', Simvastatin 20' Current medications: 1000 mL LR 3. At OSH: Tbili 2.0, LFTs: , Tbili 2.0, Lipase , WBC 15, Hct 53.8 Chief complaint: abdominal pain PMHx: PTSD, HTN, R TKR, R cataract surgery, lipids : Lithium 300', HCTZ 25', Prilosec 20', Motrin, Lisinopril 40', Ritalin 20''', Simvastatin 20' Current medications: 1000 mL LR 3. Chief complaint: PMHx: Current medications: 24 Hour Events: ERCP - At 11:00 AM off SICU to ERCP 11am - ~1500 FEVER - 102.1F - 12:00 AM Allergies: No Known Drug Allergies Last dose of Antibiotics: Ampicillin/Sulbactam (Unasyn) - 01:38 AM Infusions: Insulin - Regular - 5.5 units/hour Other ICU medications: Pantoprazole (Protonix) - 08:21 AM Heparin Sodium (Prophylaxis) - 12:51 AM Other medications: Flowsheet Data as of 07:38 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since a.m. Tmax: 38.9C (102.1 T current: 38.3C (101 HR: 85 (83 - 106) bpm BP: 140/78(92) {132/78(92) - 162/95(109)} mmHg RR: 27 (17 - 31) insp/min SPO2: 93% Heart rhythm: SR (Sinus Rhythm) Total In: 4,607 mL 2,170 mL PO: Tube feeding: IV Fluid: 4,607 mL 2,170 mL Blood products: Total out: 1,370 mL 620 mL Urine: 1,370 mL 620 mL NG: Stool: Drains: Balance: 3,237 mL 1,550 mL Respiratory support O2 Delivery Device: Nasal cannula SPO2: 93% ABG: ///26/ Physical Examination General Appearance: No acute distress HEENT: PERRL Cardiovascular: (Rhythm: Regular) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA bilateral : ) Abdominal: Bowel sounds present, Distended, Tender: midly tender Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present) Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present) Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands, Moves all extremities Labs / Radiology 158 K/uL 15.7 g/dL 133 mg/dL 0.8 mg/dL 26 mEq/L 3.2 mEq/L 15 mg/dL 106 mEq/L 142 mEq/L 43.2 % 15.3 K/uL [image002.jpg] 07:47 PM 12:30 AM 01:30 AM WBC 15.6 15.3 Hct 47.4 43.2 Plt 177 158 Creatinine 0.8 0.9 0.8 Glucose 220 229 133 Other labs: ALT / AST:329/172, Alk-Phos / T bili:76/5.3, Amylase / Lipase:356/620, LDH:540 IU/L, Ca:7.3 mg/dL, Mg:2.2 mg/dL, PO4:1.4 mg/dL Assessment and Plan HYPERGLYCEMIA, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), PANCREATITIS, ACUTE, .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS), CHOLELITHIASIS Assessment and Plan: Neurologic: Pain controlled, change PCA to dilaudid prn Cardiovascular: Beta-blocker, scheduled metoprolol and prn hydralizine for tachycardia and hypertension Pulmonary: IS, OOB Gastrointestinal / Abdomen: s/p passage of CBD stone. | 18 | [
{
"category": "Nursing",
"chartdate": "2134-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548110,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n - acute abdominal pain\n Action:\n - Given 2mg dilaudid\n - pt started on dilaudid PCA pump\n Response:\n - good response from 2mg\n - cannot assess response from PCA pump at this time\n Plan:\n - continue to monitor pain\n - encourage proper use of PCA pump\n"
},
{
"category": "Physician ",
"chartdate": "2134-01-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548134,
"text": "TITLE:\n SICU\n HPI:\n 45M with hx HTN, PTSD, lipids, presenting with severe epigastric abd\n pain since 11 PM, found to have gallstone pancreatitis,\n dehydration. At OSH: Tbili 2.0, LFTs: , Tbili 2.0, Lipase\n , WBC 15, Hct 53.8\n Chief complaint:\n abdominal pain\n PMHx:\n PTSD, HTN, R TKR, R cataract surgery, lipids\n : Lithium 300', HCTZ 25', Prilosec 20', Motrin, Lisinopril 40',\n Ritalin 20''', Simvastatin 20'\n Current medications:\n 1000 mL LR 3. HYDROmorphone (Dilaudid) 4. HYDROmorphone (Dilaudid) 5.\n Heparin 6. HydrALAzine\n 7. Insulin 8. Lithium Carbonate 9. Methylphenidate 10. Pantoprazole 11.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n BLOOD CULTURED - At 12:05 AM\n URINE CULTURE - At 12:05 AM\n FEVER - 101.4\nF - 12:00 AM\n Pain control, started insulin gtt\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 7 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 06:00 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: 38.6\nC (101.4\n T current: 38\nC (100.4\n HR: 102 (89 - 103) bpm\n BP: 142/90(102) {128/78(90) - 152/96(108)} mmHg\n RR: 22 (19 - 29) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,158 mL\n 855 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,158 mL\n 855 mL\n Blood products:\n Total out:\n 445 mL\n 345 mL\n Urine:\n 445 mL\n 345 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,713 mL\n 513 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Anxious, Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Tender: diffusely, esp @\n epigastrium, Peritoneal sign, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 177 K/uL\n 17.5 g/dL\n 229 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 103 mEq/L\n 137 mEq/L\n 47.4 %\n 15.6 K/uL\n [image002.jpg]\n 07:47 PM\n 12:30 AM\n WBC\n 15.6\n Hct\n 47.4\n Plt\n 177\n Creatinine\n 0.8\n 0.9\n Glucose\n 220\n 229\n Other labs: ALT / AST:460/348, Alk-Phos / T bili:87/5.9, Amylase /\n Lipase:, LDH:522 IU/L, Ca:8.1 mg/dL, Mg:2.1 mg/dL, PO4:2.4\n mg/dL\n Imaging: OSH CT: enlarged heterogeneous pancreas w extensive\n stranding and fluid, cholelithiasis, fatty liver, b/l fat containing\n inguinal hernias.\n Microbiology: BCx, UCx: P\n ECG: OSH EKG: normal sinus\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), PANCREATITIS, ACUTE, .H/O\n ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS), CHOLELITHIASIS\n Assessment and Plan: 45M with gallstone pancreatitis\n Neurologic: dilaudid PCA for pain\n Cardiovascular: hydralazine for BP control\n Pulmonary: no issues\n Gastrointestinal / Abdomen: severe pancreatitis, keep NPO, IVF, follow\n UOP, trend LFTs//lipase, possible ERCP in AM if Tbili still\n elevated, ERCP aware.\n Nutrition: NPO/IVF\n Renal: dehydration, f/u UOP, aggressive IVF resuscitation\n Hematology: Hct hemoconcentrated, f/u Hct\n Endocrine: needs tight blood sugar control, on inuslin gtt\n Infectious Disease: no abx, WBC trending down\n Lines / Tubes / Drains: PIV x2, foley\n Wounds: none\n Imaging: possible ERCP today\n Fluids: LR @ 200\n Consults: General surgery\n Billing Diagnosis: Pancreatitis\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 06:21 PM\n 18 Gauge - 06:23 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:\n"
},
{
"category": "Nursing",
"chartdate": "2134-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548138,
"text": "TITLE:\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abdominal pain crampy \n Action:\n Pca dose increased\n Pt educated regarding pca use\n Response:\n Pt states pain still present but more under control\n Plan:\n Continue with Dilaudid pca\n Pancreatitis, acute\n Assessment:\n Abdominal pain\n npo\n Bili increasing\n Elevated blood glucose\n Temp 101\n Action:\n Insulin drip\n Blood cultures x 2\n Urine culture and ua\n Labs sent as ordered\n Ivf infusing\n Dilaudid pca\n Response:\n blood glucose decreasing\n cultures pending\n temp 100\n urine output adequate\n Plan:\n Ercp today\n Monitor labs\n IVF for hydration\n Dilaudid for pain control\n"
},
{
"category": "Nursing",
"chartdate": "2134-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548219,
"text": "Pancreatitis, acute\n Assessment:\n - Ct showed acute pancreatitis\n Action:\n - To for ERCP today\n Response:\n - did not find stones during ERCP\n - Stent was placed\n Plan:\n - continue to monitor lab values\n - continue giving fluids LR @ 200ml/hr\n - NPO, occasional ice chips okay\n Pain control (acute pain, chronic pain)\n Assessment:\n - pt complains of sever abdominal pain at rest and worse with\n activity\n Action:\n - dilaudid PCA\n - ERCP done today\n Response:\n - pt seems to be more comfortable post ERCP\n Plan:\n - continue dilaudid PCA\n - encourage pt to use PCA as needed\n Hyperglycemia\n Assessment:\n - elevated blood sugars\n Action:\n - insulin gtt\n Response:\n - blood sugars normalized by end of shift\n Plan:\n - continue q1h blood sugars\n - continue to titrate insulin gtt per blood sugar results\n"
},
{
"category": "Nursing",
"chartdate": "2134-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548220,
"text": "Pancreatitis, acute\n Assessment:\n - Ct showed acute pancreatitis\n Action:\n - To for ERCP today\n Response:\n - did not find stones during ERCP\n - Stent was placed\n - Received antibiotics during ERCP\n Plan:\n - continue to monitor lab values\n - continue giving fluids LR @ 200ml/hr\n - NPO\n - Continue w/antibx therapy\n Pain control (acute pain, chronic pain)\n Assessment:\n - pt complains of sever abdominal pain at rest and worse with\n activity\n Action:\n - dilaudid PCA\n - ERCP done today\n Response:\n - pt seems to be more comfortable post ERCP\n Plan:\n - continue dilaudid PCA\n - encourage pt to use PCA as needed\n Hyperglycemia\n Assessment:\n - elevated blood sugars\n Action:\n - insulin gtt\n Response:\n - blood sugars normalized by end of shift\n Plan:\n - continue q1h blood sugars\n - continue to titrate insulin gtt per blood sugar results\n"
},
{
"category": "Physician ",
"chartdate": "2134-01-23 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 548113,
"text": "TITLE: SICU ADMIT NOTE\n Chief Complaint: Abdominal pain/nausea/vomiting\n HPI:\n 45M with hx HTN, dyslipidemia, presents with severe epigastric\n abdominal pain since 11PM last night, gradually worsening, constant,\n exacerbated by movement, accompanied by nausea/vomiting/anorexia.\n Denies any fever/chills, reports normal bowel movement yesterday,\n passing sm amts of flatus. Never had pain like this before. CT scan\n at OSH revealed gallstone pancreatitis. By report abdominal ultrasound\n revealed CBD of 4 mm. Admitted for aggressive IVF hydration, pain\n control, blood sugar control.\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n PTSD, HTN, dyslipidemia, s/p R knee replacement, R cataract surgery.\n : Lithium 300', HCTZ 25', Prilosec 20', Motrin, Lisinopril 40',\n Ritalin 20''', Simvastatin 20'\n Distant history of tobacco, rare EtOH. PTSD from gulf war. family\n history noncontributory\n Flowsheet Data as of 06:49 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 89 (89 - 96) bpm\n RR: 29 (20 - 29) insp/min\n SpO2: 92%\n Total In:\n 67 mL\n PO:\n TF:\n IVF:\n 67 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 67 mL\n Respiratory support\n SpO2: 92%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: diffuse tenderness esp @\n epigastrium, + rebound, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: OSH CT: enlarged heterogeneous pancreas w extensive\n stranding and fluid, cholelithiasis, fatty liver, b/l fat containing\n inguinal hernias.\n Microbiology: none\n ECG: OSH ECG WNL\n Assessment and Plan\n PANCREATITIS, ACUTE\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n CHOLELITHIASIS\n Assessment And Plan: 45M with gallstone pancreatitis, dehydration, poor\n blood sugar control\n Neurologic: dilaudid PCA for pain\n Cardiovascular: hydralazine for BP control\n Pulmonary: no issues\n Gastrointestinal: severe pancreatitis, keep NPO, IVF, follow UOP, trend\n LFTs//lipase, possible ERCP in AM if Tbili still elevated, ERCP\n aware\n Renal: dehydration, f/u UOP, aggressive IVF resuscitation\n Hematology: Hct hemoconcentrated, continue to follow with hydration\n Infectious Disease: no antibiotics, WBC trending down\n Endocrine: tight blood sugar control, may need insulin GTT\n Fluids: LR @ 200, f/u UOP\n Electrolytes: repeat in AM\n Nutrition: NPO/IVF for now\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:21 PM\n 18 Gauge - 06:23 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2134-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548114,
"text": "Pt experienced severe abd pain, n/v today. Went to where they did a CT scan and diagnosed new onset pancreatitis.\n He was transferred here to , a CT scan was done and showed pancreatic\n fat stranding and negative for gallstones. Pt was given 1 Liter NS in\n ED at then was started on LR at 200ml/hr. Lipase level was elevated\n to 1409 upon arrival to ED. Plan is for a possible ERCP in the am\n ?\n Pain control (acute pain, chronic pain)\n Assessment:\n - acute abdominal pain\n Action:\n - Given 2mg dilaudid\n - pt started on dilaudid PCA pump\n Response:\n - good response from 2mg\n - cannot assess response from PCA pump at this time\n Plan:\n - continue to monitor pain\n - encourage proper use of PCA pump\n"
},
{
"category": "Nursing",
"chartdate": "2134-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548264,
"text": "Pancreatitis, acute\n Assessment:\n pain well controlled on dilaudid pca pump\n blood glucose well controlled on insulin drip\n ivf infusing at 200cc/hr\n pt npo\n abd firm distended\n temp 102\n Action:\n md notified of temp and abd assessment\n Response:\n pt resting comfortably in bed\n Plan:\n dilaudid pca for pain control\n insulin drip for glucose control\n ivf\n npo\n monitor labs\n follow culture data\n antibiotics as ordered\n oob to chair\n dvt prophylaxis\n"
},
{
"category": "Nursing",
"chartdate": "2134-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548165,
"text": "TITLE:\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abdominal pain crampy \n Action:\n Pca dose increased\n Pt educated regarding pca use\n Response:\n Pt states pain still present but more under control\n Plan:\n Continue with Dilaudid pca\n Pancreatitis, acute\n Assessment:\n Abdominal pain\n npo\n Bili increasing\n Elevated blood glucose\n Temp 101\n Action:\n Insulin drip\n Blood cultures x 2\n Urine culture and ua\n Labs sent as ordered\n Ivf infusing\n Dilaudid pca\n Response:\n blood glucose decreasing\n cultures pending\n temp 100\n urine output adequate\n Plan:\n Ercp today\n Monitor labs\n IVF for hydration\n Dilaudid for pain control\n"
},
{
"category": "Nursing",
"chartdate": "2134-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548265,
"text": "Pancreatitis, acute\n Assessment:\n pain well controlled on dilaudid pca pump\n blood glucose well controlled on insulin drip\n ivf infusing at 200cc/hr\n pt npo\n abd firm distended\n temp 102\n pt states he uses a cpap at home for sleep apnea\n Action:\n md notified of temp and abd assessment\n pt placed on cpap machine\n Response:\n pt resting comfortably in bed\n pt tolerating cpap\n Plan:\n dilaudid pca for pain control\n insulin drip for glucose control\n ivf\n npo\n monitor labs\n follow culture data\n antibiotics as ordered\n oob to chair\n dvt prophylaxis\n cpap for osa\n"
},
{
"category": "Nursing",
"chartdate": "2134-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548266,
"text": "Pancreatitis, acute\n Assessment:\n pain well controlled on dilaudid pca pump\n blood glucose well controlled on insulin drip\n ivf infusing at 200cc/hr\n pt npo\n abd firm distended\n temp 102\n pt states he uses a cpap at home for sleep apnea\n Action:\n md notified of temp and abd assessment\n pt placed on cpap machine\n Response:\n pt resting comfortably in bed\n pt tolerating bipap\n Plan:\n dilaudid pca for pain control\n insulin drip for glucose control\n ivf\n npo\n monitor labs\n follow culture data\n antibiotics as ordered\n oob to chair\n dvt prophylaxis\n bipap for osa\n"
},
{
"category": "Nursing",
"chartdate": "2134-01-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 548384,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abd pain.\n Action:\n Pt remi nded to use Dilaudid PCA 0.37mg/6min/3.7mg lockout.\n Response:\n Pt able to rate pain a zero after using PCA.\n Plan:\n Continue to monitor pain, encourage to use PCA. OOB to chair, continue\n to offer emotional support to pt and pt family throughout hospital\n stay.\n Pancreatitis, acute\n Assessment:\n Abd is obese, firm, and distended.\n Action:\n Pt OOB to chair throughout day.\n Response:\n Pt stated relief with passing gas after walking in place in room and\n getting in and out of bed.\n Plan:\n Continue to monitor abd, repeat labs in the morning. Encourage PCA\n use.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n PANCREATITIS\n Code status:\n Height:\n Admission weight:\n 250 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: ptsd, dyslipidemia, right knee replacement, right\n cataract surgery\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:142\n D:83\n Temperature:\n 97.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 27 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 4,452 mL\n 24h total out:\n 1,400 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 01:30 AM\n Potassium:\n 3.2 mEq/L\n 01:30 AM\n Chloride:\n 106 mEq/L\n 01:30 AM\n CO2:\n 26 mEq/L\n 01:30 AM\n BUN:\n 15 mg/dL\n 01:30 AM\n Creatinine:\n 0.8 mg/dL\n 01:30 AM\n Glucose:\n 133 mg/dL\n 01:30 AM\n Hematocrit:\n 43.2 %\n 01:30 AM\n Finger Stick Glucose:\n 105\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 Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Physician ",
"chartdate": "2134-01-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548153,
"text": "TITLE:\n SICU\n HPI:\n 45M with hx HTN, PTSD, lipids, presenting with severe epigastric abd\n pain since 11 PM, found to have gallstone pancreatitis,\n dehydration. At OSH: Tbili 2.0, LFTs: , Tbili 2.0, Lipase\n , WBC 15, Hct 53.8\n Chief complaint:\n abdominal pain\n PMHx:\n PTSD, HTN, R TKR, R cataract surgery, lipids\n : Lithium 300', HCTZ 25', Prilosec 20', Motrin, Lisinopril 40',\n Ritalin 20''', Simvastatin 20'\n Current medications:\n 1000 mL LR 3. HYDROmorphone (Dilaudid) 4. HYDROmorphone (Dilaudid) 5.\n Heparin 6. HydrALAzine\n 7. Insulin 8. Lithium Carbonate 9. Methylphenidate 10. Pantoprazole 11.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n BLOOD CULTURED - At 12:05 AM\n URINE CULTURE - At 12:05 AM\n FEVER - 101.4\nF - 12:00 AM\n Pain control, started insulin gtt\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 7 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 06:00 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: 38.6\nC (101.4\n T current: 38\nC (100.4\n HR: 102 (89 - 103) bpm\n BP: 142/90(102) {128/78(90) - 152/96(108)} mmHg\n RR: 22 (19 - 29) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,158 mL\n 855 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,158 mL\n 855 mL\n Blood products:\n Total out:\n 445 mL\n 345 mL\n Urine:\n 445 mL\n 345 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,713 mL\n 513 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Anxious, Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Tender: diffusely, esp @\n epigastrium, Peritoneal sign, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 177 K/uL\n 17.5 g/dL\n 229 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 103 mEq/L\n 137 mEq/L\n 47.4 %\n 15.6 K/uL\n [image002.jpg]\n 07:47 PM\n 12:30 AM\n WBC\n 15.6\n Hct\n 47.4\n Plt\n 177\n Creatinine\n 0.8\n 0.9\n Glucose\n 220\n 229\n Other labs: ALT / AST:460/348, Alk-Phos / T bili:87/5.9, Amylase /\n Lipase:, LDH:522 IU/L, Ca:8.1 mg/dL, Mg:2.1 mg/dL, PO4:2.4\n mg/dL\n Imaging: OSH CT: enlarged heterogeneous pancreas w extensive\n stranding and fluid, cholelithiasis, fatty liver, b/l fat containing\n inguinal hernias.\n Microbiology: BCx, UCx: P\n ECG: OSH EKG: normal sinus\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), PANCREATITIS, ACUTE, .H/O\n ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS), CHOLELITHIASIS\n Assessment and Plan: 45M with gallstone pancreatitis\n Neurologic: dilaudid PCA for pain (.375 q 6 min)\n Cardiovascular: hydralazine for BP control\n Pulmonary: no issues, IS, nasal cannula as needed, OOB\n Gastrointestinal / Abdomen: severe pancreatitis, keep NPO, IVF, follow\n UOP, trend LFTs//lipase, possible ERCP in AM if Tbili still\n elevated, ERCP aware.\n Nutrition: NPO/IVF\n Renal: dehydration, f/u UOP, aggressive IVF resuscitation\n Hematology: Hct hemoconcentrated, f/u Hct\n Endocrine: needs tight blood sugar control, on inuslin gtt\n Infectious Disease: no abx, WBC trending down\n Lines / Tubes / Drains: PIV x2, foley\n Wounds: none\n Imaging: possible ERCP today\n Fluids: LR @ 200\n Consults: General surgery\n Billing Diagnosis: Pancreatitis, Respiratory Insufficiency\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines: PIV\n 20 Gauge - 06:21 PM\n 18 Gauge - 06:23 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: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2134-01-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548161,
"text": "TITLE:\n SICU\n HPI:\n 45M with hx HTN, PTSD, lipids, presenting with severe epigastric abd\n pain since 11 PM, found to have gallstone pancreatitis,\n dehydration. At OSH: Tbili 2.0, LFTs: , Tbili 2.0, Lipase\n , WBC 15, Hct 53.8; CT abd from OSH without evidence of acute\n cholecystitis.\n Chief complaint:\n abdominal pain\n PMHx:\n PTSD, HTN, R TKR, R cataract surgery, lipids\n : Lithium 300', HCTZ 25', Prilosec 20', Motrin, Lisinopril 40',\n Ritalin 20''', Simvastatin 20'\n Current medications:\n 1000 mL LR 3. HYDROmorphone (Dilaudid) 4. HYDROmorphone (Dilaudid) 5.\n Heparin 6. HydrALAzine\n 7. Insulin 8. Lithium Carbonate 9. Methylphenidate 10. Pantoprazole 11.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n BLOOD CULTURED - At 12:05 AM\n URINE CULTURE - At 12:05 AM\n FEVER - 101.4\nF - 12:00 AM\n Pain control, started insulin gtt\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 7 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 06:00 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: 38.6\nC (101.4\n T current: 38\nC (100.4\n HR: 102 (89 - 103) bpm\n BP: 142/90(102) {128/78(90) - 152/96(108)} mmHg\n RR: 22 (19 - 29) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 2,158 mL\n 855 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,158 mL\n 855 mL\n Blood products:\n Total out:\n 445 mL\n 345 mL\n Urine:\n 445 mL\n 345 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,713 mL\n 513 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Anxious, Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Tender: diffusely, esp @\n epigastrium, Peritoneal sign, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 177 K/uL\n 17.5 g/dL\n 229 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 103 mEq/L\n 137 mEq/L\n 47.4 %\n 15.6 K/uL\n [image002.jpg]\n 07:47 PM\n 12:30 AM\n WBC\n 15.6\n Hct\n 47.4\n Plt\n 177\n Creatinine\n 0.8\n 0.9\n Glucose\n 220\n 229\n Other labs: ALT / AST:460/348, Alk-Phos / T bili:87/5.9, Amylase /\n Lipase:, LDH:522 IU/L, Ca:8.1 mg/dL, Mg:2.1 mg/dL, PO4:2.4\n mg/dL\n Imaging: OSH CT: enlarged heterogeneous pancreas w extensive\n stranding and fluid, cholelithiasis, fatty liver, b/l fat containing\n inguinal hernias.\n Microbiology: BCx, UCx: P\n ECG: OSH EKG: normal sinus\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), PANCREATITIS, ACUTE, .H/O\n ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS), CHOLELITHIASIS\n Assessment and Plan: 45M with gallstone pancreatitis\n Neurologic: dilaudid PCA for pain (.375 q 6 min)\n Cardiovascular: hydralazine for BP control\n Pulmonary: no issues, IS, nasal cannula as needed, OOB\n Gastrointestinal / Abdomen: severe pancreatitis, keep NPO, IVF, follow\n UOP, trend LFTs//lipase, For ERCP today with GI\n Nutrition: NPO/IVF\n Renal: volume depleted, cont aggressive IVF and f/u UOP\n Hematology: Hct hemoconcentrated, f/u Hct with volume resuscitation\n Endocrine: needs tight blood sugar control, continue on insulin gtt\n Infectious Disease: no abx, follow WBC\n Lines / Tubes / Drains: PIV x2, foley\n Wounds: none\n Imaging: probable ERCP today\n Fluids: LR @ 200\n Consults: General surgery\n Billing Diagnosis: Pancreatitis, Respiratory Insufficiency\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines: PIV\n 20 Gauge - 06:21 PM\n 18 Gauge - 06:23 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: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2134-01-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548320,
"text": "SICU\n HPI:\n HPI: 45M with hx HTN, PTSD, lipids, presenting with severe epigastric\n abd pain since 11 PM, found to have gallstone pancreatitis,\n dehydration. At OSH: Tbili 2.0, LFTs: , Tbili 2.0, Lipase\n , WBC 15, Hct 53.8\n .\n PMH: PTSD, HTN, R TKR, R cataract surgery, hyperlipidemia, OSA\n : Lithium 300', HCTZ 25', Prilosec 20', Motrin, Lisinopril 40',\n Ritalin 20''', Simvastatin 20'\n .\n EVENTS:\n : admit to ICU\n : ERCP showed periampullary edema, no stones, put in biliary\n stent, did sphincterotomy, started on Unasyn for 24 hrs; on BiPAP at\n night for h/o OSA\n .\n MICRO: none\n .\n Imaging/Diagnostics:\n OSH CT: enlarged heterogeneous pancreas w extensive stranding and\n fluid, cholelithiasis, fatty liver, b/l fat containing inguinal\n hernias.\n .\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n ERCP - At 11:00 AM\n off SICU to ERCP 11am - ~1500\n FEVER - 102.1\nF - 12:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 01:38 AM\n Infusions:\n Insulin - Regular - 5.5 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 12:51 AM\n Other medications:\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 38.3\nC (101\n HR: 85 (83 - 106) bpm\n BP: 140/78(92) {132/78(92) - 162/95(109)} mmHg\n RR: 27 (17 - 31) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,607 mL\n 2,170 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,607 mL\n 2,170 mL\n Blood products:\n Total out:\n 1,370 mL\n 620 mL\n Urine:\n 1,370 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,237 mL\n 1,550 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\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: Bowel sounds present, Distended, Tender: midly tender\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: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 158 K/uL\n 15.7 g/dL\n 133 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 3.2 mEq/L\n 15 mg/dL\n 106 mEq/L\n 142 mEq/L\n 43.2 %\n 15.3 K/uL\n [image002.jpg]\n 07:47 PM\n 12:30 AM\n 01:30 AM\n WBC\n 15.6\n 15.3\n Hct\n 47.4\n 43.2\n Plt\n 177\n 158\n Creatinine\n 0.8\n 0.9\n 0.8\n Glucose\n 220\n 229\n 133\n Other labs: ALT / AST:329/172, Alk-Phos / T bili:76/5.3, Amylase /\n Lipase:356/620, LDH:540 IU/L, Ca:7.3 mg/dL, Mg:2.2 mg/dL, PO4:1.4 mg/dL\n Assessment and Plan\n HYPERGLYCEMIA, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), PANCREATITIS,\n ACUTE, .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS),\n CHOLELITHIASIS\n Assessment and Plan:\n Neurologic: Pain controlled, change PCA to dilaudid prn\n Cardiovascular: Beta-blocker, scheduled metoprolol and prn hydralizine\n for tachycardia and hypertension\n Pulmonary: IS, OOB\n Gastrointestinal / Abdomen: s/p passage of CBD stone. improving\n lfts/bili/amylase/lipase after ERCP (no stone seen)\n Nutrition: NPO\n Renal: Foley, Adequate UO, hypokalemia, replace electrolytes\n Hematology: stable HCT\n Endocrine: Insulin drip, change to SSI\n Infectious Disease: d/c Unasyn\n Lines / Tubes / Drains: Foley, PIV\n Wounds: none\n Imaging: none\n Fluids: LR\n Consults: General surgery, GI\n Billing Diagnosis: Pancreatitis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion\n Lines:\n 20 Gauge - 06:21 PM\n 18 Gauge - 06:23 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: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2134-01-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548296,
"text": "Pt uses bipap at home. Pt is unsure of his setting but thinks it is\n -no o2. Placed on those settings with sats maintained at 94% and no\n apnea or snoring noted. Pt\ns family will bring his home unit for use\n tonight.\n"
},
{
"category": "Nursing",
"chartdate": "2134-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548301,
"text": "Pancreatitis, acute\n Assessment:\n pain well controlled on dilaudid pca pump\n blood glucose well controlled on insulin drip\n ivf infusing at 200cc/hr\n pt npo\n abd firm distended\n temp 102\n pt states he uses a cpap at home for sleep apnea\n Action:\n md notified of temp and abd assessment\n pt placed on cpap machine\n Response:\n pt resting comfortably in bed\n pt tolerating bipap\n Plan:\n dilaudid pca for pain control\n insulin drip for glucose control\n ivf\n npo\n monitor labs\n follow culture data\n antibiotics as ordered\n oob to chair\n dvt prophylaxis\n bipap for osa\n"
},
{
"category": "Nursing",
"chartdate": "2134-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548222,
"text": "Pancreatitis, acute\n Assessment:\n - Ct showed acute pancreatitis\n Action:\n - To for ERCP today\n Response:\n - did not find stones during ERCP\n - Stent was placed\n - Received antibiotics during ERCP\n Plan:\n - continue to monitor lab values\n - continue giving fluids LR @ 200ml/hr\n - NPO\n - Continue w/antibx therapy\n Pain control (acute pain, chronic pain)\n Assessment:\n - pt complains of sever abdominal pain at rest and worse with\n activity\n Action:\n - dilaudid PCA\n - ERCP done today\n Response:\n - pt seems to be more comfortable post ERCP\n Plan:\n - continue dilaudid PCA\n - encourage pt to use PCA as needed\n Hyperglycemia\n Assessment:\n - elevated blood sugars\n Action:\n - insulin gtt\n Response:\n - blood sugars normalized by end of shift\n Plan:\n - continue q1h blood sugars\n - continue to titrate insulin gtt per blood sugar results\n"
}
] |
10,717 | 136,182 | The patient was transferred to the Cardiac Care Unit status post his cardiac catheterization. He was continued on aspirin and Plavix. He was found to be in atrial fibrillation on Telemetry upon arrival to the Cardiac Care Unit. The patient was also continued on intravenous Lopressor in the Intensive Care Unit and started on a statin as well. Due to his atrial fibrillation, he was started on Procainamide under Telemetry monitoring for conversion of his rhythm. The patient converted to sinus; he was transferred to the Floor. He did well on the floor with no post- catheterization complications. | Overall left ventricular systolic function is mildlydepressed.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -hypokinetic; basal inferior - hypokinetic; mid inferior - hypokinetic;RIGHT VENTRICLE: Right ventricular chamber size is normal. LABS=AM SENT.A:HEMODY STABLE, BUT EPISODES OF MON-SUSTAINED VT.P:?INCREASE LOPRESSOR. Mild (1+) mitral regurgitation is seen. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened.Physiologic tricuspid regurgitation is seen. There is mild symmetric left ventricularhypertrophy. There is mildregional left ventricular systolic dysfunction. ST segment depressions in leads I, aVL and V1-V6.Compared to the previous tracing of there is now presence of atrialfibrillation. The ST segment elevations in the inferior leads have almostcompletely resolved as have the diffuse ST segment depressions in theanterolateral leads.TRACING #2 There is mild regional left ventricularsystolic dysfunction. There is mildglobal right ventricular free wall hypokinesis.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are mildly thickened. TODAY CONVERTED TO NSR C PROCAINAMIDE DRIP WHICH WAS DC 230 PM .HEPARIN DRIP ALSO DC 230 PM.TOLERATING LOPRESSER,CAPTOPRIL DOSES .PMHX HTN,HI CHOL.PREASENTLY SR NO ECTOPY.BP 106/67.SAT 95 4LNP,CRACKLES IN BASES .TAKING FLUIDS,STOMACH QUESY.VOIDING QS . Comparedto the previous tracing of atrial fibrillation with a rapid ventricularresponse persists. PATIENT/TEST INFORMATION:Indication: Myocardial infarction.Height: (in) 71Weight (lb): 185BSA (m2): 2.04 m2BP (mm Hg): 92/55Status: InpatientDate/Time: at 11:47Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. Atrial fibrillation with a rapid ventricular response and ventricular ectopy.Q waves in leads III and aVF consistent with inferior Q wave myocardialinfarction. The estimated pulmonary arterysystolic pressure is normal.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.Conclusions:The left atrium is mildly dilated. The mitral valve leaflets are mildlythickened. There is mild global right ventricular free wall hypokinesis.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic regurgitation. There is now presence of ventricular ectopy. Very mild ST segment elevation in leads II, III and aVF. The estimated pulmonary artery systolicpressure is normal. ST segment depressions in I, aVL and VI-V6.Posterior myocardial infarction and lateral ischemia may be present as well.No previous tracing available for comparison.TRACING #1 CK AM LABS-REPLACE AS INDICATED. The left ventricular cavity size is normal. Overall left ventricularsystolic function is mildly depressed. ABD SOFTCONDOM CATH IN PLACE ,HAS NOT VOIDEDALERT,COOPERATIVE .WIFE C PTSERIAL CKSRESTART HEPARIN NO BOLLUS ONE HR P SHEATH PULLNOTIFY HO IF HR NOT CONTROLLED C LOPRESSER. The leftventricular cavity size is normal. ST segment elevation in II, III and aVF consistent with acuteinferior myocardial infarction. Sinus rhythmInferior infarct - recentSince previous tracing, , rhythm is sinus and further evolution ofinferior myocardial infarction Sinus rhythmRecent inferior infarctSince previous tracing, , no significant change Resting regional wall motionabnormalities include basal and mid inferio septal and inferior wallhypokinesis . transfer note37 YR OLD SP IPMI SP STENT RCA . ADMIITED TO CCU PAIN FREE . REWARMING BEGAN 320 PM .R FEMORAL VENOUS SHEATH DC, L SHEATH TO BE DC SOON. BP 120 TO 92 SYSTOLIC, DID NOT REACH TARGET TEMP ,TUBING SAVED FOR RESEARCH NURSE TO CHECK .CO NAUSEA,DIAPHORESIS DURING SHEATH PULL ,EKG NO CHANGES.GIVEN ZOFRAN DISTAL PEDALS PALP.DEMEROL DRIP DC 330 PM . Sinus rhythm. ADJUST HEPARIN TO PTT. GU=COMDOM CATH. ST segment elevations inleads II, III and aVF. The tricuspid valveleaflets are mildly thickened. With lack ofR waves in lead V1, posterior myocardial infarction is unlikely.TRACING #3 CCU NSG PROGRESS NOTE.O:CV=REMAINS IN AF W RATE LOW 100'S-LOPRESSOR INCREASED TO 25MG TID. EXPERIENCED CHB IN ER.FAILED RETAVASE .VFIB ARREST P SECOND BOLLUS RETAVASE.SHOCKED C 200 JOULES .IN CATH LAB PT IN AFIB .ENTERED IN COOL MI STUDY . Atrial fibrillation with a rapid ventricular response. GD UO. WILL THEN START HEPARIN AT 500U.HAS RECEIVED IV LOPRESSER 10 MG SINCE ADMIT TO CCU FOR AF 99 TO 120 .PMHX HTN,HYPERCHOLESTREMIAAFIB, C PVCS . GIVEN 2 BOLLUSES OF RETAVASE.HAD VFIB ARREST AFTER SECOND DOSE .CONVERTED C 200 JOULES.ADMITTED TO CATH LAB C PAIN RCA PTCA /STENTED .ENROOLED IN COOL MI STUDY .PT IN AFIB IN CATH LAB,RX C IV LOPRESSER. ?CALL-OUT. NO CP ,SOB.BS CL ,SAT 99 ON 4LNPO. 37 yr old c IPMI sp RCA STENT on COOL MI trialPT TO ER W CP,DIAPHORESIS,VOMITING .GLOBAL EKG CHANGES C COMPLETE HEART BLOCK . HR 90 TO 120. ?ECHO. ALERT,COOPERATIVE.VISITING C WIFE SUPPORT PT/FAMILY AS NEEDED. CONTIN EPISODES OF NON-SUSTAINED VT W RUNS UP TO 10. There is no pericardial effusion. | 9 | [
{
"category": "Echo",
"chartdate": "2185-04-21 00:00:00.000",
"description": "Report",
"row_id": 70774,
"text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nHeight: (in) 71\nWeight (lb): 185\nBSA (m2): 2.04 m2\nBP (mm Hg): 92/55\nStatus: Inpatient\nDate/Time: at 11:47\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. There is mild regional left ventricular\nsystolic dysfunction. Overall left ventricular systolic function is mildly\ndepressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -\nhypokinetic; basal inferior - hypokinetic; mid inferior - hypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. There is mild\nglobal right ventricular free wall hypokinesis.\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 leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened.\nPhysiologic tricuspid regurgitation is seen. The estimated pulmonary artery\nsystolic pressure is normal.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. There is mild\nregional left ventricular systolic dysfunction. Overall left ventricular\nsystolic function is mildly depressed. Resting regional wall motion\nabnormalities include basal and mid inferio septal and inferior wall\nhypokinesis . There is mild global right ventricular free wall hypokinesis.\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. The tricuspid valve\nleaflets are mildly thickened. The estimated pulmonary artery systolic\npressure is normal. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2185-04-21 00:00:00.000",
"description": "Report",
"row_id": 158428,
"text": "Atrial fibrillation with a rapid ventricular response and ventricular ectopy.\nQ waves in leads III and aVF consistent with inferior Q wave myocardial\ninfarction. Very mild ST segment elevation in leads II, III and aVF. Compared\nto the previous tracing of atrial fibrillation with a rapid ventricular\nresponse persists. There is now presence of ventricular ectopy. With lack of\nR waves in lead V1, posterior myocardial infarction is unlikely.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2185-04-20 00:00:00.000",
"description": "Report",
"row_id": 158429,
"text": "Atrial fibrillation with a rapid ventricular response. ST segment elevations in\nleads II, III and aVF. ST segment depressions in leads I, aVL and V1-V6.\nCompared to the previous tracing of there is now presence of atrial\nfibrillation. The ST segment elevations in the inferior leads have almost\ncompletely resolved as have the diffuse ST segment depressions in the\nanterolateral leads.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2185-04-20 00:00:00.000",
"description": "Report",
"row_id": 158430,
"text": "Sinus rhythm. ST segment elevation in II, III and aVF consistent with acute\ninferior myocardial infarction. ST segment depressions in I, aVL and VI-V6.\nPosterior myocardial infarction and lateral ischemia may be present as well.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2185-04-23 00:00:00.000",
"description": "Report",
"row_id": 158426,
"text": "Sinus rhythm\nRecent inferior infarct\nSince previous tracing, , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2185-04-22 00:00:00.000",
"description": "Report",
"row_id": 158427,
"text": "Sinus rhythm\nInferior infarct - recent\nSince previous tracing, , rhythm is sinus and further evolution of\ninferior myocardial infarction\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2185-04-20 00:00:00.000",
"description": "Report",
"row_id": 1403840,
"text": "37 yr old c IPMI sp RCA STENT on COOL MI trial\nPT TO ER W CP,DIAPHORESIS,VOMITING .GLOBAL EKG CHANGES C COMPLETE HEART BLOCK . GIVEN 2 BOLLUSES OF RETAVASE.HAD VFIB ARREST AFTER SECOND DOSE .CONVERTED C 200 JOULES.ADMITTED TO CATH LAB C PAIN RCA PTCA /STENTED .ENROOLED IN COOL MI STUDY .PT IN AFIB IN CATH LAB,RX C IV LOPRESSER. ADMIITED TO CCU PAIN FREE . REWARMING BEGAN 320 PM .R FEMORAL VENOUS SHEATH DC, L SHEATH TO BE DC SOON. WILL THEN START HEPARIN AT 500U.HAS RECEIVED IV LOPRESSER 10 MG SINCE ADMIT TO CCU FOR AF 99 TO 120 .\n\nPMHX HTN,HYPERCHOLESTREMIA\n\nAFIB, C PVCS . HR 90 TO 120. BP 120 TO 92 SYSTOLIC, DID NOT REACH TARGET TEMP ,TUBING SAVED FOR RESEARCH NURSE TO CHECK .CO NAUSEA,DIAPHORESIS DURING SHEATH PULL ,EKG NO CHANGES.GIVEN ZOFRAN DISTAL PEDALS PALP.DEMEROL DRIP DC 330 PM . NO CP ,SOB.\n\nBS CL ,SAT 99 ON 4L\n\nNPO. ABD SOFT\n\nCONDOM CATH IN PLACE ,HAS NOT VOIDED\n\nALERT,COOPERATIVE .WIFE C PT\n\nSERIAL CKS\nRESTART HEPARIN NO BOLLUS ONE HR P SHEATH PULL\nNOTIFY HO IF HR NOT CONTROLLED C LOPRESSER.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2185-04-21 00:00:00.000",
"description": "Report",
"row_id": 1403841,
"text": "CCU NSG PROGRESS NOTE.\nO:CV=REMAINS IN AF W RATE LOW 100'S-LOPRESSOR INCREASED TO 25MG TID. CONTIN EPISODES OF NON-SUSTAINED VT W RUNS UP TO 10. HEPARIN INCREASED FROM 500 TO 650U FOR PTT.\n GU=COMDOM CATH. GD UO.\n LABS=AM SENT.\n\nA:HEMODY STABLE, BUT EPISODES OF MON-SUSTAINED VT.\n\nP:?INCREASE LOPRESSOR. ?ECHO. ADJUST HEPARIN TO PTT. CK AM LABS-REPLACE AS INDICATED. ?CALL-OUT. SUPPORT PT/FAMILY AS NEEDED.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2185-04-21 00:00:00.000",
"description": "Report",
"row_id": 1403842,
"text": "transfer note\n37 YR OLD SP IPMI SP STENT RCA . EXPERIENCED CHB IN ER.FAILED RETAVASE .VFIB ARREST P SECOND BOLLUS RETAVASE.SHOCKED C 200 JOULES .IN CATH LAB PT IN AFIB .ENTERED IN COOL MI STUDY . TODAY CONVERTED TO NSR C PROCAINAMIDE DRIP WHICH WAS DC 230 PM .HEPARIN DRIP ALSO DC 230 PM.TOLERATING LOPRESSER,CAPTOPRIL DOSES .PMHX HTN,HI CHOL.PREASENTLY SR NO ECTOPY.BP 106/67.SAT 95 4LNP,CRACKLES IN BASES .TAKING FLUIDS,STOMACH QUESY.VOIDING QS . ALERT,COOPERATIVE.VISITING C WIFE\n\n"
}
] |
52,136 | 189,354 | The pt was initially admitted to the MICU and was observed overnight for signs of ETOH withdrawl. He was also seen by Neurosugery, that felt that there was no need for immediate surgical intervention. The pt was then transfered from from MICU following admission for SDH, to fall, and EtoH withdrawl monitoring on CIWA. The pt states he remembers falling, however the next thing he knew he was in hospital. At an OSH the pt was noted to have SAH/SDH on head CT and subsequently transferred to for further evaluation. . In the ED, initial vitals: 98.3, 97, 164/80, 20, 97%RA. Head CT with nondisplaced skull fracture, several subdural and intraventricular bleed. The pt was subsequently transfered to the MICU for closer monitoring of neuro status and withdrawal. While in the MICU he received valium 5 mg IV X 7 over 36s hrs for CIWA>10, morphine 4 mg IV X1, tylenol 650 PO X 1, and 1L NS. The pt was seen neurosurgery who felt that there was no acute indication for intervention. . Upon arrival to the floor, he reports headache, neck ache, and chronic lower back pain. Denies fevers, chest pain, palpitations, N/V, abd pain, diarrhea, melena, BRBPR. No known prior seizures. . #. Withdrawal: The pt were . Mildly tremulous and and hypertensive. Transaminases elevated, TB flat. Likely to Etoh, although ddx also included hepatitis, less likely hypotensive or biliary obstruction given benign abdominal exam. The patient was given Valium PRN over the first 72hrs and showed no additional signs of withdrawl. The pt was continued on Folate, MVI and was seen by social work. The patients LFTs normalilzed. . #. SDH/Intraventricular bleed/headache: to fall. Repeat head CT showed no interval change. Central disc bulge at C4-C5 resulting in mild central canal narrowing. The patient was initiated on Keppra IV 500mg for 48hrs (Started ) and later placed on 1000mg PO BID with plans for 1 month of treatment. The pt should be scheduled for Neurosugical follow-up in 1 months time. The pt's pain medication was titrated up to Oxycotin 40mg while in house. The patient was placed on a bowel regimen. As the patients SDH resolves, his narcotics should be weened off. . The pt underwent an MRI on that revealed degenerative disease but nofracture, subluxation or ligamentous injury. . # HTN: The patient was noted to have SBP up 210 following transfer from the MICU. The patient was initially placed on Metoprolol 25mg TID, however this was decreased to 12.5mg TID. HCTZ was initiated, but later discontinued as the patients Na fell to 127. The pt was subsequently started on Captopril 50mg TID. The patient's Metoprolol was changed to Toprol 37.5mg at time of discharge. . # Hyponatremia: During the patients hospital course the pts Na fell (see labs above) from the mid 130s down to 127. Inital differential for his euvolemic hyponatremia included to HCTZ, and/or SIADH to pain or intracerebral trauma. Osm's were elevated, thus confirming a diagnosis of SIADH. The patients Na on discharge was 130. He should have a CHM 7 drawn two days after discharge to follow resolution and should continue fluid restriction to 1.5L. | There he was found to have SAH/SDH on head CT. There he was found to have SAH/SDH on head CT. HEENT: Normocephalic, atraumatic. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. Action: Tx with 1mg iv dilaudid. Action: Tx with 1mg iv dilaudid. Action: Tx with 1mg iv dilaudid. Hypertension, benign Assessment: Sbp up to 170 this am. Allergy- Wellbutrin Hypertension, benign Assessment: Sbp 130-152. Allergy- Wellbutrin Hypertension, benign Assessment: Sbp 130-152. Allergy- Wellbutrin Hypertension, benign Assessment: Sbp 130-152. Requring iv dilaudid for c/o of ha. Requring iv dilaudid for c/o of ha. Requring iv dilaudid for c/o of ha. C-spine cleared clinically and per CT from admission. C-spine cleared clinically and per CT from admission. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. Plan: Cont po valium for withdrawal symptoms. Plan: Cont po valium for withdrawal symptoms. Plan: Cont po valium for withdrawal symptoms. Plan: Cont po valium for withdrawal symptoms. Plan: Cont po valium for withdrawal symptoms. Requring po valium for withdrawal symptoms. Requring po valium for withdrawal symptoms. Requring po valium for withdrawal symptoms. Subdural hemorrhage (SDH) Assessment: Stable neuro status. Subdural hemorrhage (SDH) Assessment: Stable neuro status. Subdural hemorrhage (SDH) Assessment: Stable neuro status. Action: Tx with diluadid 1mg x3 given. Action: Tx with diluadid 1mg x3 given. Action: Tx with diluadid 1mg x3 given. Action: Tx with diluadid 1mg x3 given. In the emergency department, initial vitals: 98.3, 97, 164/80, 20, 97%RA. There he was found to have SAH/SDH on head CT. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. To MICU for Q2H neuro checks and treatment of withdrawal. Response: Plan: Subdural hemorrhage (SDH) Assessment: Stable neuro status. HEENT: Normocephalic, atraumatic. - appreciate neurosurg recs: keppra m IV BID - can decrease frequency of neuro checks as pt is >24hrs since fall - low threshold to re-scan if altered mental status - Tylenol / Percocet / Dilaudid / Lidoderm patch for pain - goal SBP 140s-150s, cont lopressor 12.5 TID #. C-spine cleared clinically and per CT from admission. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. CT @ OSH cleared C-spine but showed subdural hematoma. Action: Tx with 1mg iv dilaudid. Allergy- Wellbutrin Hypertension, benign Assessment: Sbp 130-152. - repeat head CT in AM to eval interval change - Q2-4H neuro checks - low threshold to re-scan if altered mental status - EKG in AM - percocet and tylenol for pain . Hypertension, benign Assessment: Sbp up to 170 this am. Hypertension, benign Assessment: Sbp up to 170 this am. Hypertension, benign Assessment: Sbp up to 170 this am. Requring po valium for withdrawal symptoms. In the emergency department, initial vitals: 98.3, 97, 164/80, 20, 97%RA. Plan: Cont po valium for withdrawal symptoms. Plan: Cont po valium for withdrawal symptoms. Plan: Cont po valium for withdrawal symptoms. Plan: Cont po valium for withdrawal symptoms. Requring iv dilaudid for c/o of ha. Action: Q2H neuro checks. Action: Q2H neuro checks. SAH/SDH: Thus far, has had stable neuro exam -Per neurosurgery, they recommend keppra for seizure ppx-->will start -Holding aspirin -Continue periodic neuro checks, head CT if change. | 33 | [
{
"category": "Nursing",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672502,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o this am of pain in head, neck and back.\n Action:\n Tx with Tylenol, percocet,morphine, and lido patch\n Response:\n Pain down to 6.5/10 after all these interventions. 1 mg dialudid given\n iv with 6.5/10 pain and pain down to 6/10 which patient said was\n acceptable. Tylenol given at 1730 when pain was to keep pain\n controlled.\n Plan:\n Cont to assess and tx for pain.\n Subdural hemorrhage (SDH)\n Assessment:\n Alert and oriented x3. cooperative with care. Mae. Equal strength.\n Pearl. Main c/o is of headache.\n Action:\n Repeat head ct done without and with contrast. Meds for pain given as\n above.\n Response:\n Stable cat scan.\n Plan:\n Cont neuro checks q 2 hours.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa up to as high as 17 this am.\n Action:\n Given a total of 25mg po valium this am. Seen by social services\n regarding etoh use.\n Response:\n Need to cont prn valium for for withdrawal symptoms.\n Plan:\n Cont po valium for withdrawal symptoms.\n Hypertension, benign\n Assessment:\n Sbp up to 170 this am.\n Action:\n Lopresssor 12.5mg ordered tid.\n Response:\n Sbp went up to 180 after lopressor 12.5 had been given. Dose increased\n to 25mg . Also 10mg iv hydrallazine given x2. sbp down to 138. goal\n for sbp 140-150 for head bleed. Sbp crept back up to 160 pre tid\n lopressor dose. Dose of 25mg po lopressor given. Sbp remained 160 Dr\n made aware. Captopril 6.25mg tid started.\n Plan:\n Continue Lopressor 25mg po tid and captopril 6.25mg tid.\n Social- patient with financial concerns over rent. Seen by social\n services about his etoh issues. Social services told him they were\n available to him for finacial conerns as well. He is aware they are\n available to him should he want their assistance for finacial or etoh\n issues. He does not wish their assistance at this time.\n"
},
{
"category": "Physician ",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 672591,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 08:15 AM\n \n - CT/CTA Head w/o significant change in bleeding\n - cleared C-spine, Neuro checks OK\n - needed escalating doses of Morphine and then Dilaudid for HA\n - started withdrawing from EtOH, needing Valium per CIWA\n History obtained from Patient\n Allergies:\n History obtained from PatientWellbutrin (Oral) (Bupropion Hcl)\n skin peeling;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 11:46 AM\n Morphine Sulfate - 01:47 PM\n Hydromorphone (Dilaudid) - 05:01 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 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.7\nC (96.3\n HR: 63 (63 - 95) bpm\n BP: 126/61(77) {116/41(60) - 177/6,972(113)} mmHg\n RR: 17 (11 - 22) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 2,705 mL\n 366 mL\n PO:\n 520 mL\n 290 mL\n TF:\n IVF:\n 1,185 mL\n 76 mL\n Blood products:\n Total out:\n 2,750 mL\n 450 mL\n Urine:\n 2,750 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -45 mL\n -84 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n GENERAL: Pleasant, tremulous\n HEENT: Normocephalic, atraumatic. PERRLA/EOMI. MMM. OP clear.\n Neck: supple\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs\n LUNGS: CTA bilaterally\n ABDOMEN: Soft, NT, ND.\n EXTREMITIES: No edema\n NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation\n throughout. 5/5 strength throughout.\n Labs / Radiology\n 157 K/uL\n 13.5 g/dL\n 99 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 17 mg/dL\n 102 mEq/L\n 138 mEq/L\n 38.9 %\n 7.6 K/uL\n [image002.jpg]\n 04:00 AM\n 04:07 AM\n WBC\n 6.1\n 7.6\n Hct\n 39.0\n 38.9\n Plt\n 172\n 157\n Cr\n 0.8\n 0.9\n Glucose\n 93\n 99\n Other labs: PT / PTT / INR:12.5/27.0/1.1, ALT / AST:137/163, Alk Phos /\n T Bili:198/1.2, Albumin:3.8 g/dL, LDH:264 IU/L, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CT/CTA Head - CONCLUSION: Stable appearance of extensive\n subdural hemorrhage, particularly in the subfrontal region. No definite\n vascular pathology seen aside from probable moderate narrowing of the\n cavernous portion of the left internal carotid artery secondary to\n atherosclerotic disease at this locale.\n ECG: NSR @ 60bpm, NA/NI, no acute ST-Twave changes, no prior for\n comparison.\n Assessment and Plan\n HYPERTENSION, BENIGN\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SUBDURAL HEMORRHAGE (SDH)\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n 68 y/o M hx EtOH abuse, last drink this morning, now s/p fall resulting\n in SDH and withdrawal symptoms\n #. EtOH withdrawal: his last drink at noon . Requiring 10mg Valium\n PO Q3-4hrs currently.\n - cont 5-10mg Valium PO Q3-4hrs PRN CIWA >10\n - thiamine/folate/MVI\n - social work consult\n #. SDH/Intraventricular bleed/headache: Per neurosurg, he has tracking\n of blood near MCA raising possibility that he could have bled first,\n precipitating the fall. Repeat head CT/CTA showed no interval change\n and no source for bleeding. C-spine cleared clinically and per CT from\n admission.\n - appreciate neurosurg recs\n - can decrease frequency of neuro checks as pt is >24hrs since fall\n - low threshold to re-scan if altered mental status\n - Tylenol / Percocet / Dilaudid / Lidoderm patch for pain\n - goal SBP 140s-150s, cont lopressor 12.5 TID\n #. transaminitis: likely EtOH\n - follow daily\n # ? hx MI and ?cardiac arrest: Pt states that he \"almost died\" after a\n cardiac event at OSH. Lipid panel excellent, ECG unremarkable.\n - will need to establish PCP\n holding daily ASA 81mg given ICH\n - cont low-dose BB\n # COPD:\n - cont nebs PRN\n - nicotine patch, smoking cessation\n ICU Care\n Nutrition:\n Comments: Regular (cardiac) diet\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 11:35 PM\n 22 Gauge - 03:26 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 672592,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 08:15 AM\n \n - CT/CTA Head w/o significant change in bleeding\n - cleared C-spine, Neuro checks OK\n - needed escalating doses of Morphine and then Dilaudid for HA\n - started withdrawing from EtOH, needing Valium per CIWA\n History obtained from Patient\n Allergies:\n History obtained from PatientWellbutrin (Oral) (Bupropion Hcl)\n skin peeling;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 11:46 AM\n Morphine Sulfate - 01:47 PM\n Hydromorphone (Dilaudid) - 05:01 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 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.7\nC (96.3\n HR: 63 (63 - 95) bpm\n BP: 126/61(77) {116/41(60) - 177/6,972(113)} mmHg\n RR: 17 (11 - 22) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 2,705 mL\n 366 mL\n PO:\n 520 mL\n 290 mL\n TF:\n IVF:\n 1,185 mL\n 76 mL\n Blood products:\n Total out:\n 2,750 mL\n 450 mL\n Urine:\n 2,750 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -45 mL\n -84 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n GENERAL: Pleasant, somnolent, mildly tremulous.\n HEENT: Normocephalic, atraumatic. PERRLA/EOMI. MMM. OP clear.\n Neck: supple\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs\n LUNGS: CTA bilaterally\n ABDOMEN: Soft, NT, ND.\n EXTREMITIES: No edema\n NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation\n throughout. 5/5 strength throughout.\n Labs / Radiology\n 157 K/uL\n 13.5 g/dL\n 99 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 17 mg/dL\n 102 mEq/L\n 138 mEq/L\n 38.9 %\n 7.6 K/uL\n [image002.jpg]\n 04:00 AM\n 04:07 AM\n WBC\n 6.1\n 7.6\n Hct\n 39.0\n 38.9\n Plt\n 172\n 157\n Cr\n 0.8\n 0.9\n Glucose\n 93\n 99\n Other labs: PT / PTT / INR:12.5/27.0/1.1, ALT / AST:137/163, Alk Phos /\n T Bili:198/1.2, Albumin:3.8 g/dL, LDH:264 IU/L, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CT/CTA Head - CONCLUSION: Stable appearance of extensive\n subdural hemorrhage, particularly in the subfrontal region. No definite\n vascular pathology seen aside from probable moderate narrowing of the\n cavernous portion of the left internal carotid artery secondary to\n atherosclerotic disease at this locale.\n ECG: NSR @ 60bpm, NA/NI, no acute ST-Twave changes, no prior for\n comparison.\n Assessment and Plan\n HYPERTENSION, BENIGN\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SUBDURAL HEMORRHAGE (SDH)\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n 68 y/o M hx EtOH abuse, last drink this morning, now s/p fall resulting\n in SDH and withdrawal symptoms\n #. EtOH withdrawal: his last drink at noon . Requiring 10mg Valium\n PO Q3-4hrs currently.\n - cont 5-10mg Valium PO Q3-4hrs PRN CIWA >10\n - thiamine/folate/MVI\n - social work consult\n #. SDH/Intraventricular bleed/headache: Per neurosurg, he has tracking\n of blood near MCA raising possibility that he could have bled first,\n precipitating the fall. Repeat head CT/CTA showed no interval change\n and no source for bleeding. C-spine cleared clinically and per CT from\n admission.\n - appreciate neurosurg recs\n - can decrease frequency of neuro checks as pt is >24hrs since fall\n - low threshold to re-scan if altered mental status\n - Tylenol / Percocet / Dilaudid / Lidoderm patch for pain\n - goal SBP 140s-150s, cont lopressor 12.5 TID\n #. transaminitis: likely EtOH\n - follow daily\n # ? hx MI and ?cardiac arrest: Pt states that he \"almost died\" after a\n cardiac event at OSH. Lipid panel excellent, ECG unremarkable.\n - will need to establish PCP\n holding daily ASA 81mg given ICH\n - cont low-dose BB\n # COPD:\n - cont nebs PRN\n - nicotine patch, smoking cessation\n ICU Care\n Nutrition:\n Comments: Regular (cardiac) diet\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 11:35 PM\n 22 Gauge - 03:26 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672561,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o this am of pain in head, neck and back.\n Action:\n Tx with diluadid 1mg x3 given.\n Response:\n Pain down to 5/10 after all these interventions. 1 mg dialudid given iv\n x3 and pain ranged pain and patient said was acceptable.\n Plan:\n Cont to assess and tx for pain.\n Subdural hemorrhage (SDH)\n Assessment:\n Alert and oriented x3, no neuro deficits noted throughout this shift.\n Pt. remains cooperative with care. Mae. Equal strength. Pearl. Main\n c/o is of headache.\n Action:\n Repeat head ct done yesterday. Meds for pain given as above.\n Response:\n Stable cat scan.\n Plan:\n Cont neuro checks q 2 hours.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa ranged 0-14.\n Action:\n Given a total of 30mg po valium by this morning. Seen by social\n services yesterday regarding etoh use.\n Response:\n Need to cont valium for for withdrawal symptoms.\n Plan:\n Cont po valium for withdrawal symptoms.\n *** Social- patient with financial concerns over rent. Seen by social\n services about his etoh issues. Social services told him they were\n available to him for finacial conerns as well. He is aware they are\n available to him should he want their assistance for finacial or etoh\n issues. He does not wish their assistance at this time.\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672562,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o this am of pain in head, neck and back.\n Action:\n Tx with diluadid 1mg x3 given.\n Response:\n Pain down to 5/10 after all these interventions. 1 mg dialudid given iv\n x3 and pain ranged pain and patient said was acceptable.\n Plan:\n Cont to assess and tx for pain.\n Subdural hemorrhage (SDH)\n Assessment:\n Alert and oriented x3, no neuro deficits noted throughout this shift.\n Pt. remains cooperative with care. Mae. Equal strength. Pearl. Main\n c/o is of headache.\n Action:\n Repeat head ct done yesterday. Meds for pain given as above.\n Response:\n Stable cat scan.\n Plan:\n Cont neuro checks q 2 hours.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa ranged 0-14.\n Action:\n Given a total of 30mg po valium by this morning. Seen by social\n services yesterday regarding etoh use.\n Response:\n Need to cont valium for for withdrawal symptoms.\n Plan:\n Cont po valium for withdrawal symptoms.\n *** Social- patient with financial concerns over rent. Seen by social\n services about his etoh issues. Social services told him they were\n available to him for finacial conerns as well. He is aware they are\n available to him should he want their assistance for finacial or etoh\n issues. He does not wish their assistance at this time.\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672564,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o this am of pain in head, neck and back.\n Action:\n Tx with diluadid 1mg x3 given.\n Response:\n Pain down to 5/10 after all these interventions. 1 mg dialudid given iv\n x3 and pain ranged pain and patient said was acceptable.\n Plan:\n Cont to assess and tx for pain.\n Subdural hemorrhage (SDH)\n Assessment:\n Alert and oriented x3, no neuro deficits noted throughout this shift.\n Pt. remains cooperative with care. Mae. Equal strength. Pearl. Main\n c/o is of headache.\n Action:\n Repeat head ct done yesterday. Meds for pain given as above.\n Response:\n Stable cat scan.\n Plan:\n Cont neuro checks q 2 hours.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa ranged 0-14.\n Action:\n Given a total of 30mg po valium by this morning. Seen by social\n services yesterday regarding etoh use.\n Response:\n Need to cont valium for for withdrawal symptoms.\n Plan:\n Cont po valium for withdrawal symptoms.\n *** Social- patient with financial concerns over rent. Seen by social\n services about his etoh issues. Social services told him they were\n available to him for finacial conerns as well. He is aware they are\n available to him should he want their assistance for finacial or etoh\n issues. He does not wish their assistance at this time.\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672565,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o this am of pain in head, neck and back.\n Action:\n Tx with diluadid 1mg x3 given.\n Response:\n Pain down to 5/10 after all these interventions. 1 mg dialudid given iv\n x3 and pain ranged pain and patient said was acceptable.\n Plan:\n Cont to assess and tx for pain.\n Subdural hemorrhage (SDH)\n Assessment:\n Alert and oriented x3, no neuro deficits noted throughout this shift.\n Pt. remains cooperative with care. Mae. Equal strength. Pearl. Main\n c/o is of headache.\n Action:\n Repeat head ct done yesterday. Meds for pain given as above.\n Response:\n Stable cat scan.\n Plan:\n Cont neuro checks q 2 hours.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa ranged 0-14.\n Action:\n Given a total of 30mg po valium by this morning. Seen by social\n services yesterday regarding etoh use.\n Response:\n Need to cont valium for for withdrawal symptoms.\n Plan:\n Cont po valium for withdrawal symptoms.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt. noted to have brief episodes of apnea thoughout the night. Pt. O2\n saturation fell to 87%\n Action:\n Pt. placed on O2 at 1l/min via nasal cannula.\n Response:\n Pt. sats remained >97.\n Plan:\n To monitor resp status and Oxygenation.\n *** Social- patient with financial concerns over rent. Seen by social\n services about his etoh issues. Social services told him they were\n available to him for finacial conerns as well. He is aware they are\n available to him should he want their assistance for finacial or etoh\n issues. He does not wish their assistance at this time.\n"
},
{
"category": "Physician ",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Overnight Intensivist Admission",
"row_id": 672353,
"text": "TITLE: Intensivist Admission\n Please see resident note for details, I agree with Dr. \n findings, assessment, and plan, and have seen and examined the\n patient. I would add / emphasize: 68 y/o with subdural hemorrhage\n after a fall while intoxicated (felt he slipped on something),\n transferred here from OSH for neurosurg eval. Currently c/o h/a and\n neck pain.\n All, Meds, PMHx reviewed, notable for ill-defined CAD (?arrest / coma),\n COPD, EtOH abuse, ongoing smoking.\n Exam VSS, few exp wheezes. Mildly tremulous. PERRL, EOMI, grossly\n nonfocal motor exam.\n Labs with Na 133, Hco3 21, CBC WNL.\n CT head (here) reviewed.\n A/P:\n SDH: per neurosurg; will follow with frequent neuro checks, repeat head\n CT in AM\n Neck pain: hard collar, await CT read.\n Substance abuse: Treat and monitor for EtOH withdrawal with CIWA.\n Counseled on smoking cessation.\n ?Cardiac history?: EKG, CXR, obtain OSH records if able.\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 672626,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal. Requring iv dilaudid for c/o of ha.\n Requring po valium for withdrawal symptoms.\n Allergy- Wellbutrin\n Hypertension, benign\n Assessment:\n Sbp 130-152.\n Action:\n Cont on lopressor 25mg pot id.\n Response:\n Sbp near goal range of 140-150.\n Plan:\n Cont lopressor as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient with c/o of ha that was this Am which is acceptable to\n him. Pain up to this am.\n Action:\n Tx with 1mg iv dilaudid.\n Response:\n Patient able to fall asleep after receiving dialaudid for a couple of\n hours. When questioned again pain down to 6/10. After answering\n question fell back to sleep. Also has Lidocaine on back of neck.\n Plan:\n Med for pain with iv dilaudid. Prn.\n Subdural hemorrhage (SDH)\n Assessment:\n Stable neuro status. Lethargic but oriented x3. at times does not\n remember the name of the hospital but always knows he is in the\n hospital. Equal strength in extremities. Pearl.\n Action:\n Kepra ordered per neuro surgery for prophylaxis\n Response:\n Stable neurologically.\n Plan:\n Neuro checks as ordered.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa scale ranging today.\n Action:\n Med with 5mg po valium x1 today when ciwa up to 12.\n Response:\n Ciwa down to 9 after receiving po valium.\n Plan:\n Cont to monitor ciwa and med with valium po prn.\n Obstructive sleep apnea (OSA)\n Assessment:\n No episodes of desating on 1l nc with sleep.\n Action:\n Cont on 1l nc.\n Response:\n Stable sats in the mid to upper 90\ns on 1l nc.\n Plan:\n Cont 1l nc.\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 672627,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal. Requring iv dilaudid for c/o of ha.\n Requring po valium for withdrawal symptoms.\n Allergy- Wellbutrin\n Hypertension, benign\n Assessment:\n Sbp 130-152.\n Action:\n Cont on lopressor 25mg pot id.\n Response:\n Sbp near goal range of 140-150.\n Plan:\n Cont lopressor as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient with c/o of ha that was this Am which is acceptable to\n him. Pain up to this am.\n Action:\n Tx with 1mg iv dilaudid.\n Response:\n Patient able to fall asleep after receiving dialaudid for a couple of\n hours. When questioned again pain down to 6/10. After answering\n question fell back to sleep. Also has Lidocaine on back of neck.\n Plan:\n Med for pain with iv dilaudid. Prn.\n Subdural hemorrhage (SDH)\n Assessment:\n Stable neuro status. Lethargic but oriented x3. at times does not\n remember the name of the hospital but always knows he is in the\n hospital. Equal strength in extremities. Pearl.\n Action:\n Kepra ordered per neuro surgery for prophylaxis\n Response:\n Stable neurologically.\n Plan:\n Neuro checks as ordered.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa scale ranging today.\n Action:\n Med with 5mg po valium x1 today when ciwa up to 12.\n Response:\n Ciwa down to 9 after receiving po valium.\n Plan:\n Cont to monitor ciwa and med with valium po prn.\n Obstructive sleep apnea (OSA)\n Assessment:\n No episodes of desating on 1l nc with sleep.\n Action:\n Cont on 1l nc.\n Response:\n Stable sats in the mid to upper 90\ns on 1l nc.\n Plan:\n Cont 1l nc.\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n SDH/SAH/ETOH WITHDRAWL\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 99 kg\n Daily weight:\n Allergies/Reactions:\n Wellbutrin (Oral) (Bupropion Hcl)\n skin peeling;\n Precautions: No Additional Precautions\n PMH: COPD, ETOH, Smoker\n CV-PMH: Hypertension\n Additional history: CAD and? MI: per pt, was recently hospitalized and\n in coma, s/p cataract removal surgery, glaucoma, history of alcohol\n abuse, COPD\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:70\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 8 insp/min\n Heart Rate:\n 64 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 24h total in:\n 625 mL\n 24h total out:\n 550 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:07 AM\n Potassium:\n 4.1 mEq/L\n 04:07 AM\n Chloride:\n 102 mEq/L\n 04:07 AM\n CO2:\n 28 mEq/L\n 04:07 AM\n BUN:\n 17 mg/dL\n 04:07 AM\n Creatinine:\n 0.9 mg/dL\n 04:07 AM\n Glucose:\n 99 mg/dL\n 04:07 AM\n Hematocrit:\n 38.9 %\n 04:07 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 672628,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal. Requring iv dilaudid for c/o of ha.\n Requring po valium for withdrawal symptoms.\n Allergy- Wellbutrin\n Hypertension, benign\n Assessment:\n Sbp 130-152.\n Action:\n Cont on lopressor 25mg pot id.\n Response:\n Sbp near goal range of 140-150.\n Plan:\n Cont lopressor as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient with c/o of ha that was this Am which is acceptable to\n him. Pain up to this am.\n Action:\n Tx with 1mg iv dilaudid.\n Response:\n Patient able to fall asleep after receiving dialaudid for a couple of\n hours. When questioned again pain down to 6/10. After answering\n question fell back to sleep. Also has Lidocaine on back of neck.\n Plan:\n Med for pain with iv dilaudid. Prn.\n Subdural hemorrhage (SDH)\n Assessment:\n Stable neuro status. Lethargic but oriented x3. at times does not\n remember the name of the hospital but always knows he is in the\n hospital. Equal strength in extremities. Pearl.\n Action:\n Kepra ordered per neuro surgery for prophylaxis\n Response:\n Stable neurologically.\n Plan:\n Neuro checks as ordered.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa scale ranging today.\n Action:\n Med with 5mg po valium x1 today when ciwa up to 12.\n Response:\n Ciwa down to 9 after receiving po valium.\n Plan:\n Cont to monitor ciwa and med with valium po prn.\n Obstructive sleep apnea (OSA)\n Assessment:\n No episodes of desating on 1l nc with sleep.\n Action:\n Cont on 1l nc.\n Response:\n Stable sats in the mid to upper 90\ns on 1l nc.\n Plan:\n Cont 1l nc.\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n SDH/SAH/ETOH WITHDRAWL\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 99 kg\n Daily weight:\n Allergies/Reactions:\n Wellbutrin (Oral) (Bupropion Hcl)\n skin peeling;\n Precautions: No Additional Precautions\n PMH: COPD, ETOH, Smoker\n CV-PMH: Hypertension\n Additional history: CAD and? MI: per pt, was recently hospitalized and\n in coma, s/p cataract removal surgery, glaucoma, history of alcohol\n abuse, COPD\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:70\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 8 insp/min\n Heart Rate:\n 64 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 24h total in:\n 625 mL\n 24h total out:\n 550 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:07 AM\n Potassium:\n 4.1 mEq/L\n 04:07 AM\n Chloride:\n 102 mEq/L\n 04:07 AM\n CO2:\n 28 mEq/L\n 04:07 AM\n BUN:\n 17 mg/dL\n 04:07 AM\n Creatinine:\n 0.9 mg/dL\n 04:07 AM\n Glucose:\n 99 mg/dL\n 04:07 AM\n Hematocrit:\n 38.9 %\n 04:07 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Bag of clothes sent with patient.\n Wallet / Money: wallet money and keys locked up in security per fhp.\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: micu 786\n Transferred to: cc702\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 672349,
"text": "Chief Complaint: ETOH withdrawal, SDH\n HPI:\n 68M who stated that he was in USOH until this afternoon. He was at home\n and had approximately 40 oz of beer. He was outside of his home,\n slipped (unclear if he tripped or just slipped- he notes that he walks\n with a cane at baseline and does have a history of gait unsteadiness),\n and fell striking the back of his head. He lost consciousness for an\n undetermined amount of time.\n The next thing he remembers is waking up at an OSH. There he was\n found to have SAH/SDH on head CT. He was transferred to ED\n for further evaluation.\n .\n In the emergency department, initial vitals: 98.3, 97, 164/80, 20,\n 97%RA. Head CT with nondisplaced skull fracture, several subdural and\n intraventricular bleed. He received valium 5 mg IV X 2 for CIWA>10,\n morphine 4 mg IV X1, tylenol 650 PO X 1, and 1L NS. He was seen by\n neurosurgery who felt that there was no acute indication for\n intervention at this time. He was transferred to MICU for closer\n monitoring of neuro status and withdrawal\n .\n Upon arrival to the floor, he reports worsening headache, neck ache,\n and lower back pain. He denies any chest pain, palpitations, N/V, abd\n pain, diarrhea, melena, BRBPR. He denies ever having seizures from EtOH\n withdrawal. His last drink was noon today and drinks 60 ounces daily.\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 HOME MEDS:\n ASA 81 daily\n MVI\n Past medical history:\n Family history:\n Social History:\n # CAD and? MI: per pt, was recently hospitalized and in coma\n # s/p cataract removal surgery\n # glaucoma.\n # history of alcohol abuse\n # COPD\n NC\n Occupation: in between jobs\n Drugs: none\n Tobacco: 1 pack/day X 60 years\n Alcohol: 40-60 ounces beers daily\n Other:\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, 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 Neurologic: No(t) Numbness / tingling, Headache, No(t) Seizure\n Pain: Moderate\n Pain location: headache, neck pain, back ache\n Flowsheet Data as of 12:56 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 99 (99 - 100) bpm\n BP: 167/86(105) {167/86(105) - 167/86(105)} mmHg\n RR: 17 (14 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\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 -300 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GENERAL: Pleasant, tremulous\n HEENT: Normocephalic, atraumatic. PERRLA/EOMI. MMM. OP clear.\n Neck: c-collar in place\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs\n LUNGS: scarce wheezes bilaterally\n ABDOMEN: Soft, NT, ND.\n EXTREMITIES: No edema\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate.\n CN 2-12 intact.\n Preserved sensation throughout.\n 5/5 strength throughout.\n Labs / Radiology\n 189\n 100\n 0.8\n 12\n 21\n 97\n 3.8\n 133\n 41\n 7.6\n [image002.jpg]\n Other labs: PT / PTT / INR://1.0\n Fluid analysis / Other labs: EtOH: 126\n Imaging: Head CT: Multifocal subdural with small intraventricular\n hemorrhage and extenion along the tentorium with a non-displaced left\n frontal skull fracture. no mass effect\n .\n C-spine: no acute fx. djd with fractured anterior ostephytes\n Assessment and Plan\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n 68 y/o M hx EtOH abuse, last drink this morning, now s/p fall resulting\n in SDH and mild withdrawal symptoms\n .\n #. Withdrawal: his last drink at noon. He has no hx of seizures/severe\n withdrawal\n - valium IV Q1-2H for CIWA >10\n - banana bag tonight and then MVI/thiamine in AM\n - social work consult\n - check LFTs given hx alcohol abuse\n .\n #. SDH/Intraventricular bleed/headache: sustained during fall.\n - repeat head CT in AM to eval interval change\n - Q2-4H neuro checks\n - low threshold to re-scan if altered mental status\n - EKG in AM\n - percocet and tylenol for pain\n .\n #. C-spine:\n - follow-up final read to c-spine film and then can clear clinically in\n AM\n .\n # ? hx MI and ?cardiac arrest: Pt states that he \"almost died\" after a\n cardiac event at OSH\n - check lipid panel\n - try to obtain OSH records, but most importantly, he will need to est\n PCP\n hold ASA 81 daily\n .\n # COPD\n - atrovent nebs PRN\n - smoking cessation -> nicotine patch\n .\n FEN: replete lytes prn\n .\n PPX:\n - boots for now, hold SQ heparin until d/w neurosurg\n - no need for PPI\n .\n ACCESS: PIV's\n .\n CODE STATUS: Full\n ICU Care\n Nutrition:\n Comments: regular\n Glycemic Control:\n Lines:\n 20 Gauge - 11:35 PM\n 22 Gauge - 11:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 672348,
"text": "Chief Complaint: ETOH withdrawal, SDH\n HPI:\n 68M who stated that he was in USOH until this afternoon. He was at home\n and had approximately 40 oz of beer. He was outside of his home,\n slipped (unclear if he tripped or just slipped- he notes that he walks\n with a cane at baseline and does have a history of gait unsteadiness),\n and fell striking the back of his head. He lost consciousness for an\n undetermined amount of time.\n The next thing he remembers is waking up at an OSH. There he was\n found to have SAH/SDH on head CT. He was transferred to ED\n for further evaluation.\n .\n In the emergency department, initial vitals: 98.3, 97, 164/80, 20,\n 97%RA. Head CT with nondisplaced skull fracture, several subdural and\n intraventricular bleed. He received valium 5 mg IV X 2 for CIWA>10,\n morphine 4 mg IV X1, tylenol 650 PO X 1, and 1L NS. He was seen by\n neurosurgery who felt that there was no acute indication for\n intervention at this time. He was transferred to MICU for closer\n monitoring of neuro status and withdrawal\n .\n Upon arrival to the floor, he reports worsening headache, neck ache,\n and lower back pain. He denies any chest pain, palpitations, N/V, abd\n pain, diarrhea, melena, BRBPR. He denies ever having seizures from EtOH\n withdrawal. His last drink was noon today and drinks 60 ounces daily.\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 HOME MEDS:\n ASA 81 daily\n MVI\n Past medical history:\n Family history:\n Social History:\n # CAD and? MI: per pt, was recently hospitalized and in coma\n # s/p cataract removal surgery\n # glaucoma.\n # history of alcohol abuse\n # COPD\n NC\n Occupation: in between jobs\n Drugs: none\n Tobacco: 1 pack/day X 60 years\n Alcohol: 40-60 ounces beers daily\n Other:\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, 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 Neurologic: No(t) Numbness / tingling, Headache, No(t) Seizure\n Pain: Moderate\n Pain location: headache, neck pain, back ache\n Flowsheet Data as of 12:56 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 99 (99 - 100) bpm\n BP: 167/86(105) {167/86(105) - 167/86(105)} mmHg\n RR: 17 (14 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\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 -300 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GENERAL: Pleasant, tremulous\n HEENT: Normocephalic, atraumatic. PERRLA/EOMI. MMM. OP clear.\n Neck: c-collar in place\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs\n LUNGS: scarce wheezes bilaterally\n ABDOMEN: Soft, NT, ND.\n EXTREMITIES: No edema\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate.\n CN 2-12 intact.\n Preserved sensation throughout.\n 5/5 strength throughout.\n Labs / Radiology\n 189\n 100\n 0.8\n 12\n 21\n 97\n 3.8\n 133\n 41\n 7.6\n [image002.jpg]\n Other labs: PT / PTT / INR://1.0\n Fluid analysis / Other labs: EtOH: 126\n Imaging: Head CT: Multifocal subdural with small intraventricular\n hemorrhage and extenion along the tentorium with a non-displaced left\n frontal skull fracture. no mass effect\n .\n C-spine: no acute fx. djd with fractured anterior ostephytes\n Assessment and Plan\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n 68 y/o M hx EtOH abuse, last drink this morning, now s/p fall resulting\n in SDH and withdrawal symptoms\n .\n #. Withdrawal: his last drink with this morning.\n - valium IV Q1H for CIWA >8\n - banana bag\n - social work consult\n - check LFTs given hx alcohol abuse\n .\n #. SDH/Intraventricular bleed/headache: sustained during fall.\n - repeat head CT in AM to eval interval change\n - Q4H neuro checks\n - low threshold to re-scan if altered mental status\n - EKG in AM\n - percocet and tylenol for pain\n .\n #. C-spine:\n - follow-up final read to c-spine film and then can clear clinically in\n AM\n .\n # ? hx MI and ?cardiac arrest: Pt states that he \"almost died\" after a\n cardiac event at OSH\n - check lipid panel\n - try to obtain OSH records, but most importantly, he will need to est\n PCP\n hold ASA 81 daily\n .\n # COPD\n - atrovent nebs PRN\n - smoking cessation -> nicotine patch\n .\n FEN: replete lytes prn\n .\n PPX:\n - boots for now, hold SQ heparin until d/w neurosurg\n - no need for PPI\n .\n ACCESS: PIV's\n .\n CODE STATUS: Full\n ICU Care\n Nutrition:\n Comments: regular\n Glycemic Control:\n Lines:\n 20 Gauge - 11:35 PM\n 22 Gauge - 11:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 672423,
"text": "Chief Complaint: EtOH withdrawal, SDH\n 24 Hour Events:\n NASAL SWAB - At 04:00 AM\n - complaining of headache, neck pain, back pain, received tylenol,\n perc, morphine\n - this AM had CIWA 17, got valium 5 PO, but had not required valium\n earlier in night\n - neuro exam unchanged\n Allergies:\n Wellbutrin (Oral) (Bupropion Hcl)\n skin peeling;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:24 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: 95 (94 - 100) bpm\n BP: 158/92(108) {156/71(91) - 171/92(108)} mmHg\n RR: 16 (13 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 2,150 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,000 mL\n Blood products:\n Total out:\n 0 mL\n 1,175 mL\n Urine:\n 1,175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 975 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n GENERAL: Pleasant, tremulous\n HEENT: Normocephalic, atraumatic. PERRLA/EOMI. MMM. OP clear.\n Neck: c-collar in place\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs\n LUNGS: scarce wheezes bilaterally\n ABDOMEN: Soft, NT, ND.\n EXTREMITIES: No edema\n NEURO: A&Ox3. Appropriate.\n CN 2-12 intact.\n Preserved sensation throughout.\n 5/5 strength throughout.\n Labs / Radiology\n 172 K/uL\n 13.7 g/dL\n 93 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 103 mEq/L\n 137 mEq/L\n 39.0 %\n 6.1 K/uL\n [image002.jpg]\n 04:00 AM\n WBC\n 6.1\n Hct\n 39.0\n Plt\n 172\n Cr\n 0.8\n Glucose\n 93\n Other labs: ALT / AST:67/88, Alk Phos / T Bili:160/1.3, Albumin:3.8\n g/dL, Ca++:8.5 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SUBDURAL HEMORRHAGE (SDH)\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n 68 y/o M hx EtOH abuse, last drink this morning, now s/p fall resulting\n in SDH and withdrawal symptoms\n .\n #. Withdrawal: his last drink at noon .\n - valium IV Q1H for CIWA >10\n - thiamine/folate/MVI\n - social work consult\n - mild transaminitis c/w alcohol\n .\n #. SDH/Intraventricular bleed/headache: Per neurosurg this AM, he does\n have some tracking of blood near MCA raising the possibility that he\n could have bled first, precipitating the fall.\n - repeat head CT in AM to eval interval change\n - will also obtain CTA\n - appreciate neurosurg recs\n - Q4H neuro checks\n - low threshold to re-scan if altered mental status\n - EKG in AM\n - percocet and tylenol for pain\n - goal SBP 140-150's, will start lopressor 12.5 TID\n .\n #. C-spine:\n - follow-up final read to c-spine film and then can clear clinically in\n AM\n .\n # ? hx MI and ?cardiac arrest: Pt states that he \"almost died\" after a\n cardiac event at OSH\n - check lipid panel\n - try to obtain OSH records, but most importantly, he will need to est\n PCP\n hold ASA 81 daily\n .\n # COPD\n - CXR\n - atrovent nebs PRN\n - smoking cessation -> nicotine patch\n .\n FEN: replete lytes prn\n .\n PPX:\n - boots for now, hold SQ heparin until d/w neurosurg\n - no need for PPI\n .\n ACCESS: PIV's\n .\n CODE STATUS: Presumed full\n ICU Care\n Nutrition:\n Comments: regular\n Glycemic Control:\n Lines:\n 20 Gauge - 11:35 PM\n 22 Gauge - 11:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 672428,
"text": "Chief Complaint: EtOH withdrawal, SDH\n 24 Hour Events:\n NASAL SWAB - At 04:00 AM\n - complaining of headache, neck pain, back pain, received tylenol,\n perc, morphine\n - this AM had CIWA 17, got valium 5 PO, but had not required valium\n earlier in night\n - neuro exam unchanged\n Allergies:\n Wellbutrin (Oral) (Bupropion Hcl)\n skin peeling;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:30 AM\n Other medications:\n Flowsheet Data as of 08:24 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: 95 (94 - 100) bpm\n BP: 158/92(108) {156/71(91) - 171/92(108)} mmHg\n RR: 16 (13 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 2,150 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,000 mL\n Blood products:\n Total out:\n 0 mL\n 1,175 mL\n Urine:\n 1,175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 975 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n GENERAL: Pleasant, tremulous\n HEENT: Normocephalic, atraumatic. PERRLA/EOMI. MMM. OP clear.\n Neck: c-collar in place\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs\n LUNGS: CTA bilaterally\n ABDOMEN: Soft, NT, ND.\n EXTREMITIES: No edema\n NEURO: A&Ox3. Appropriate.\n CN 2-12 intact.\n Preserved sensation throughout.\n 5/5 strength throughout.\n Labs / Radiology\n 172 K/uL\n 13.7 g/dL\n 93 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 103 mEq/L\n 137 mEq/L\n 39.0 %\n 6.1 K/uL\n [image002.jpg]\n 04:00 AM\n WBC\n 6.1\n Hct\n 39.0\n Plt\n 172\n Cr\n 0.8\n Glucose\n 93\n Other labs: ALT / AST:67/88, Alk Phos / T Bili:160/1.3, Albumin:3.8\n g/dL, Ca++:8.5 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SUBDURAL HEMORRHAGE (SDH)\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n 68 y/o M hx EtOH abuse, last drink this morning, now s/p fall resulting\n in SDH and withdrawal symptoms\n .\n #. Withdrawal: his last drink at noon .\n - valium PO Q1H PRN CIWA >10\n - thiamine/folate/MVI\n - social work consult\n - mild transaminitis c/w alcohol\n .\n #. SDH/Intraventricular bleed/headache: Per neurosurg this AM, he does\n have some tracking of blood near MCA raising the possibility that he\n could have bled first, precipitating the fall.\n - repeat head CT in AM to eval interval change\n - will also obtain CTA to eval for aneurysm\n - appreciate neurosurg recs\n - Q4H neuro checks\n - low threshold to re-scan if altered mental status\n - EKG in AM\n - percocet and tylenol for pain\n - goal SBP 140-150's, will start lopressor 12.5 TID\n .\n #. C-spine:\n - follow-up final read to c-spine film and then can clear clinically in\n AM\n .\n # ? hx MI and ?cardiac arrest: Pt states that he \"almost died\" after a\n cardiac event at OSH\n - check lipid panel\n - try to obtain OSH records, but most importantly, he will need to est\n PCP\n hold ASA 81 daily\n - started BB today AM\n .\n # COPD\n - CXR\n - atrovent nebs PRN\n - smoking cessation -> nicotine patch\n .\n FEN: replete lytes prn\n .\n PPX:\n - boots for now, hold SQ heparin until d/w neurosurg\n - no need for PPI\n .\n ACCESS: PIV's\n .\n CODE STATUS: Presumed full\n ICU Care\n Nutrition:\n Comments: regular\n Glycemic Control:\n Lines:\n 20 Gauge - 11:35 PM\n 22 Gauge - 11:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 672429,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Admitted overnight after presenting to an OSH with a fall in the\n context of alcohol use and found to have SAH and SDH with non-displaced\n skull fracture. Transferred to for further management. Seen by\n neurosurgery who recommended frequent neuro checks and a repeat CT +\n CTA this morning (to rule out primary vascular lesion as precipitant\n for this episode).\n Overnight, neuro exam unchanged. Received Valium 5mg po x 1 for CIWA\n scale. Complaining of headach, neck pain and LBP this AM.\n History obtained from Medical records\n Allergies:\n Wellbutrin (Oral) (Bupropion Hcl)\n skin peeling;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:30 AM\n Other medications:\n Valium CIWA scale, IV ativan PRN, MVI, thiamine, nicotine patch,\n metoprolol\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 Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: No(t) Dysuria\n Neurologic: Headache\n Flowsheet Data as of 08:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 95 (94 - 100) bpm\n BP: 158/92(108) {156/71(91) - 171/92(108)} mmHg\n RR: 16 (13 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 2,150 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,000 mL\n Blood products:\n Total out:\n 0 mL\n 1,175 mL\n Urine:\n 1,175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 975 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, C collar in place.\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Purposeful, Tone: Not assessed, Moves all\n extremities.\n Labs / Radiology\n 13.7 g/dL\n 172 K/uL\n 93 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 103 mEq/L\n 137 mEq/L\n 39.0 %\n 6.1 K/uL\n [image002.jpg]\n 04:00 AM\n WBC\n 6.1\n Hct\n 39.0\n Plt\n 172\n Cr\n 0.8\n Glucose\n 93\n Other labs: ALT / AST:67/88, Alk Phos / T Bili:160/1.3, Albumin:3.8\n g/dL, Ca++:8.5 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Imaging: Head CT: L frontal SDH, ?bleeding around MCA.\n Assessment and Plan\n 68 yo M with h/o CAD and etoh abuse presenting with traumatic fall c/b\n skull fracture, SDH.\n SAH/SDH: Thus far, has had stable neuro exam\n -Repeat CT today and CTA to evaluate circle of \n -Holding aspirin\n -Continue frequent neuro checks for 24 hours\n -SBP goal 140-150.\n C spine:\n Await final read of CT before clearance.\n Etoh W/D: Continues on CIWA scale, has required minimal amounts\n -Continue vitamin support\n COPD: Counsel smoking cessation. PRN nebs\n Rest of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 11:35 PM\n 22 Gauge - 11:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672445,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o this am of pain in head, neck and back.\n Action:\n Tx with Tylenol, percocet,morphine, and lido patch\n Response:\n Plan:\n Subdural hemorrhage (SDH)\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672515,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o this am of pain in head, neck and back.\n Action:\n Tx with Tylenol, percocet,morphine, and lido patch\n Response:\n Pain down to 6.5/10 after all these interventions. 1 mg dialudid given\n iv with 6.5/10 pain and pain down to 6/10 which patient said was\n acceptable. Tylenol given at 1730 when pain was to keep pain\n controlled.\n Plan:\n Cont to assess and tx for pain.\n Subdural hemorrhage (SDH)\n Assessment:\n Alert and oriented x3. cooperative with care. Mae. Equal strength.\n Pearl. Main c/o is of headache.\n Action:\n Repeat head ct done without and with contrast. Meds for pain given as\n above.\n Response:\n Stable cat scan.\n Plan:\n Cont neuro checks q 2 hours.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa up to as high as 17 this am.\n Action:\n Given a total of 25mg po valium this am. Seen by social services\n regarding etoh use.\n Response:\n Need to cont prn valium for for withdrawal symptoms.\n Plan:\n Cont po valium for withdrawal symptoms.\n Hypertension, benign\n Assessment:\n Sbp up to 170 this am.\n Action:\n Lopresssor 12.5mg ordered tid.\n Response:\n Sbp went up to 180 after lopressor 12.5 had been given. Dose increased\n to 25mg . Also 10mg iv hydrallazine given x2. sbp down to 138. goal\n for sbp 140-150 for head bleed. Sbp crept back up to 160 pre tid\n lopressor dose. Dose of 25mg po lopressor given. Sbp remained 160 Dr\n made aware. Captopril 6.25mg tid started.\n Plan:\n Continue Lopressor 25mg po tid and captopril 6.25mg tid.\n Social- patient with financial concerns over rent. Seen by social\n services about his etoh issues. Social services told him they were\n available to him for finacial conerns as well. He is aware they are\n available to him should he want their assistance for finacial or etoh\n issues. He does not wish their assistance at this time.\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672395,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal.\n Subdural hemorrhage (SDH)\n Assessment:\n Noted on CT s/p fall @ home. Pt uses cane to ambulate always and has\n unsteady gait @ baseline, but also w/ ETOH abuse.\n Action:\n Q2H neuro checks. PRN pain meds for c/o headache, neck and back pain\n s/p fall. C-collar in place until final read of CT to clear.\n Response:\n PERRL 3mm/brisk, normal strength and sensation in all extremities.\n Pain persists but improving w/ PO meds.\n Plan:\n f/u on final CT scan read, ? repeat CT for reassessment of SDH, treat\n pain prn, Q2H neuro checks.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n CIWA <10, pt states he drinks 60oz of beer per day on average.\n Action:\n Monitor ciwa. Banana bag @ 150cc/hr for 1L.\n Response:\n CIWA remains <10.\n Plan:\n PRN valium for CIWA >10. Start PO Thiamine and MVI in AM.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt w/ frequent c/o pain in neck, lower back and headache ().\n C-collar (Aspen) for cervical pain (no fracture per CT).\n Action:\n Gave Tylenol 650mg, later 1tab percocet and later another tab percocet,\n also repositioning and back rub. Later gave x1dose morphine IV (2mg).\n Response:\n After each intervention pt stated some relief but soon c/o pain again.\n Much discomfort w/ movement/turning and repositioning. Also c/o of\n discomfort w/ the c-collar (repositioned collar as well).\n Plan:\n MD stated waiting for final read of CT scan before we can remove the\n collar. PRN PO meds for pain. ? additional x1 IV doses if unable to\n effectively treat pain.\n"
},
{
"category": "Physician ",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 672603,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 08:15 AM\n \n - CT/CTA Head w/o significant change in bleeding\n - cleared C-spine, Neuro checks OK\n - needed escalating doses of Morphine and then Dilaudid for HA\n - started withdrawing from EtOH (HTN, tachycardia), needing Valium per\n CIWA\n History obtained from Patient\n Allergies:\n History obtained from PatientWellbutrin (Oral) (Bupropion Hcl)\n skin peeling;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 11:46 AM\n Morphine Sulfate - 01:47 PM\n Hydromorphone (Dilaudid) - 05:01 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 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.7\nC (96.3\n HR: 63 (63 - 95) bpm\n BP: 126/61(77) {116/41(60) - 177/6,972(113)} mmHg\n RR: 17 (11 - 22) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 2,705 mL\n 366 mL\n PO:\n 520 mL\n 290 mL\n TF:\n IVF:\n 1,185 mL\n 76 mL\n Blood products:\n Total out:\n 2,750 mL\n 450 mL\n Urine:\n 2,750 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -45 mL\n -84 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n GENERAL: Pleasant, somnolent, mildly tremulous.\n HEENT: Normocephalic, atraumatic. PERRLA/EOMI. MMM. OP clear.\n Neck: supple\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs\n LUNGS: CTA bilaterally\n ABDOMEN: Soft, NT, ND.\n EXTREMITIES: No edema\n NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation\n throughout. 5/5 strength throughout.\n Labs / Radiology\n 157 K/uL\n 13.5 g/dL\n 99 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 17 mg/dL\n 102 mEq/L\n 138 mEq/L\n 38.9 %\n 7.6 K/uL\n [image002.jpg]\n 04:00 AM\n 04:07 AM\n WBC\n 6.1\n 7.6\n Hct\n 39.0\n 38.9\n Plt\n 172\n 157\n Cr\n 0.8\n 0.9\n Glucose\n 93\n 99\n Other labs: PT / PTT / INR:12.5/27.0/1.1, ALT / AST:137/163, Alk Phos /\n T Bili:198/1.2, Albumin:3.8 g/dL, LDH:264 IU/L, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CT/CTA Head - CONCLUSION: Stable appearance of extensive\n subdural hemorrhage, particularly in the subfrontal region. No definite\n vascular pathology seen aside from probable moderate narrowing of the\n cavernous portion of the left internal carotid artery secondary to\n atherosclerotic disease at this locale.\n ECG: NSR @ 60bpm, NA/NI, no acute ST-Twave changes, no prior for\n comparison.\n Assessment and Plan\n HYPERTENSION, BENIGN\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n SUBDURAL HEMORRHAGE (SDH)\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n 68 y/o M hx EtOH abuse, last drink this morning, now s/p fall resulting\n in SDH and withdrawal symptoms\n #. EtOH withdrawal: his last drink at noon . Requiring 10mg Valium\n PO Q3-4hrs currently.\n - cont 5-10mg Valium PO Q3-4hrs PRN CIWA >10\n - thiamine/folate/MVI\n - social work consult\n #. SDH/Intraventricular bleed/headache: Per neurosurg, he has tracking\n of blood near MCA raising possibility that he could have bled first,\n precipitating the fall. Repeat head CT/CTA showed no interval change\n and no source for bleeding. C-spine cleared clinically and per CT from\n admission.\n - appreciate neurosurg recs: keppra m IV BID\n - can decrease frequency of neuro checks as pt is >24hrs since fall\n - low threshold to re-scan if altered mental status\n - Tylenol / Percocet / Dilaudid / Lidoderm patch for pain\n - goal SBP 140s-150s, cont lopressor 12.5 TID\n #. transaminitis: likely EtOH\n - follow daily\n # ? hx MI and ?cardiac arrest: Pt states that he \"almost died\" after a\n cardiac event at OSH. Lipid panel excellent, ECG unremarkable.\n - will need to establish PCP\n holding daily ASA 81mg given ICH\n - cont low-dose BB\n # COPD:\n - cont nebs PRN\n - nicotine patch, smoking cessation\n ICU Care\n Nutrition:\n Comments: Regular (cardiac) diet\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 11:35 PM\n 22 Gauge - 03:26 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: uneccessary\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 672605,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Underwent CT/CTA yesterday morning demsonstrating no change in\n SDH/SAH. No clear vascularly anomaly seen either.\n Some tremulousness yesterday requiring valium per CIWA scale.\n Overnight, required one dose of captopril to keep SBP <150. Some\n desaturations (high 80's) with sleeping overnight.\n This AM complaining of some HA.\n History obtained from Medical records\n Allergies:\n Wellbutrin (Oral) (Bupropion Hcl)\n skin peeling;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 11:46 AM\n Morphine Sulfate - 01:47 PM\n Hydromorphone (Dilaudid) - 05:01 AM\n Other medications:\n MVI, thiamine, folate, nicotine patch, metoprolol, lidocaine patch.\n Valium (total of 55mg) Dilaudid PRN\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 09:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.8\nC (96.5\n HR: 58 (58 - 87) bpm\n BP: 152/72(93) {116/41(60) - 177/6,972(113)} mmHg\n RR: 10 (10 - 22) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n 2,705 mL\n 503 mL\n PO:\n 520 mL\n 410 mL\n TF:\n IVF:\n 1,185 mL\n 93 mL\n Blood products:\n Total out:\n 2,750 mL\n 450 mL\n Urine:\n 2,750 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -45 mL\n 53 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 1 liter\n SpO2: 95%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, Mildly\n tremulous. No focal deficits\n Labs / Radiology\n 13.5 g/dL\n 157 K/uL\n 99 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 17 mg/dL\n 102 mEq/L\n 138 mEq/L\n 38.9 %\n 7.6 K/uL\n [image002.jpg]\n 04:00 AM\n 04:07 AM\n WBC\n 6.1\n 7.6\n Hct\n 39.0\n 38.9\n Plt\n 172\n 157\n Cr\n 0.8\n 0.9\n Glucose\n 93\n 99\n Other labs: PT / PTT / INR:12.5/27.0/1.1, ALT / AST:137/163, Alk Phos /\n T Bili:198/1.2, Albumin:3.8 g/dL, LDH:264 IU/L, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CT/CTA: No change in SDH/SAH, No aneurysms on CTA.\n ECG: NSR @60BPM with nml axis/intervals. No ischemic changes.\n Assessment and Plan\n 68 yo M with h/o CAD and etoh abuse presenting with traumatic fall c/b\n skull fracture, SDH and SAH.\n SAH/SDH: Thus far, has had stable neuro exam\n -Per neurosurgery, they recommend keppra for seizure ppx-->will start\n -Holding aspirin\n -Continue periodic neuro checks, head CT if change.\n -SBP goal 140-150.\n -Judicious opiates for pain control\n C spine: Final read of CT negative for fracture.\n Etoh W/D: Continues on CIWA scale, seems to be well contolled on this\n -Continue CIWA\n -Social work saw patient yesterday, he was not willing to discuss\n alcohol use.\n -Continue vitamin support\n COPD: Counsel smoking cessation. PRN nebs\n Rest of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:35 PM\n 22 Gauge - 03:26 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 672610,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal. Requring iv dilaudid for c/o of ha.\n Requring po valium for withdrawal symptoms.\n Allergy- Wellbutrin\n Hypertension, benign\n Assessment:\n Sbp 130-152.\n Action:\n Cont on lopressor 25mg pot id.\n Response:\n Sbp near goal range of 140-150.\n Plan:\n Cont lopressor as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient with c/o of ha that was this Am which is acceptable to\n him. Pain up to this am.\n Action:\n Tx with 1mg iv dilaudid.\n Response:\n Plan:\n Subdural hemorrhage (SDH)\n Assessment:\n Stable neuro status. Lethargic but oriented x3. at times does not\n remember the name of the hospital but always knows he is in the\n hospital.\n Action:\n Kepra ordered per neuron surgery for prophylaxis\n Response:\n Plan:\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Obstructive sleep apnea (OSA)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 672593,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal.\n Allergy- Wellbutrin\n Hypertension, benign\n Assessment:\n Action:\n Cont on lopressor 25mg pot id.\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Subdural hemorrhage (SDH)\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Obstructive sleep apnea (OSA)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 672675,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Underwent CT/CTA yesterday morning demsonstrating no change in\n SDH/SAH. No clear vascularly anomaly seen either.\n Some tremulousness yesterday requiring valium per CIWA scale.\n Overnight, required one dose of captopril to keep SBP <150. Some\n desaturations (high 80's) with sleeping overnight.\n This AM complaining of some HA.\n History obtained from Medical records\n Allergies:\n Wellbutrin (Oral) (Bupropion Hcl)\n skin peeling;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 11:46 AM\n Morphine Sulfate - 01:47 PM\n Hydromorphone (Dilaudid) - 05:01 AM\n Other medications:\n MVI, thiamine, folate, nicotine patch, metoprolol, lidocaine patch.\n Valium (total of 55mg) Dilaudid PRN\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 09:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.8\nC (96.5\n HR: 58 (58 - 87) bpm\n BP: 152/72(93) {116/41(60) - 177/6,972(113)} mmHg\n RR: 10 (10 - 22) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n 2,705 mL\n 503 mL\n PO:\n 520 mL\n 410 mL\n TF:\n IVF:\n 1,185 mL\n 93 mL\n Blood products:\n Total out:\n 2,750 mL\n 450 mL\n Urine:\n 2,750 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -45 mL\n 53 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 1 liter\n SpO2: 95%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, Mildly\n tremulous. No focal deficits\n Labs / Radiology\n 13.5 g/dL\n 157 K/uL\n 99 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 17 mg/dL\n 102 mEq/L\n 138 mEq/L\n 38.9 %\n 7.6 K/uL\n [image002.jpg]\n 04:00 AM\n 04:07 AM\n WBC\n 6.1\n 7.6\n Hct\n 39.0\n 38.9\n Plt\n 172\n 157\n Cr\n 0.8\n 0.9\n Glucose\n 93\n 99\n Other labs: PT / PTT / INR:12.5/27.0/1.1, ALT / AST:137/163, Alk Phos /\n T Bili:198/1.2, Albumin:3.8 g/dL, LDH:264 IU/L, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CT/CTA: No change in SDH/SAH, No aneurysms on CTA.\n ECG: NSR @60BPM with nml axis/intervals. No ischemic changes.\n Assessment and Plan\n 68 yo M with h/o CAD and etoh abuse presenting with traumatic fall c/b\n skull fracture, SDH and SAH.\n SAH/SDH: Thus far, has had stable neuro exam\n -Per neurosurgery, they recommend keppra for seizure ppx-->will start\n -Holding aspirin\n -Continue periodic neuro checks, head CT if change.\n -SBP goal 140-150.\n -Judicious opiates for pain control\n C spine: Final read of CT negative for fracture.\n Etoh W/D: Continues on CIWA scale, seems to be well contolled on this\n -Continue CIWA\n -Social work saw patient yesterday, he was not willing to discuss\n alcohol use.\n -Continue vitamin support\n COPD: Counsel smoking cessation. PRN nebs\n Rest of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:35 PM\n 22 Gauge - 03:26 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672373,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal.\n Subdural hemorrhage (SDH)\n Assessment:\n Noted on CT s/p fall @ home. Pt uses cane to ambulate always and has\n unsteady gait @ baseline, but also w/ ETOH abuse.\n Action:\n Q2H neuro checks. PRN pain meds for c/o headache, neck and back pain\n s/p fall. C-collar in place until final read of CT to clear.\n Response:\n PERRL 3mm/brisk, normal strength and sensation in all extremities.\n Pain persists but improving w/ PO meds.\n Plan:\n f/u on final CT scan read, ? repeat CT for reassessment of SDH, treat\n pain prn, Q2H neuro checks.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n CIWA <10, pt states he drinks 60oz of beer per day on average.\n Action:\n Monitor ciwa. Banana bag @ 150cc/hr for 1L.\n Response:\n CIWA remains <10.\n Plan:\n PRN valium for CIWA >10. Start PO Thiamine and MVI in AM.\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672480,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o this am of pain in head, neck and back.\n Action:\n Tx with Tylenol, percocet,morphine, and lido patch\n Response:\n Plan:\n Subdural hemorrhage (SDH)\n Assessment:\n Alert and oriented x3. cooperative with care. Mae. Equal strength.\n Pearl. Main c/o is of headache.\n Action:\n Repeat head ct done without and with contrast. Meds for pain given as\n above.\n Response:\n Stable cat scan.\n Plan:\n Cont neuro checks q 2 hours.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa up to as high as 17 this am.\n Action:\n Given a total of 25mg po valium this am. Seen by social services\n regarding etoh use.\n Response:\n Need to cont prn valium for for withdrawal symptoms.\n Plan:\n Cont po valium for withdrawal symptoms.\n Social- patient with financial concerns over rent. Social services up\n to see the patient and let him know they are available if he wants\n there services.\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672481,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o this am of pain in head, neck and back.\n Action:\n Tx with Tylenol, percocet,morphine, and lido patch\n Response:\n Plan:\n Subdural hemorrhage (SDH)\n Assessment:\n Alert and oriented x3. cooperative with care. Mae. Equal strength.\n Pearl. Main c/o is of headache.\n Action:\n Repeat head ct done without and with contrast. Meds for pain given as\n above.\n Response:\n Stable cat scan.\n Plan:\n Cont neuro checks q 2 hours.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa up to as high as 17 this am.\n Action:\n Given a total of 25mg po valium this am. Seen by social services\n regarding etoh use.\n Response:\n Need to cont prn valium for for withdrawal symptoms.\n Plan:\n Cont po valium for withdrawal symptoms.\n Hypertension, benign\n Assessment:\n Sbp up to 170 this am.\n Action:\n Lopresssor 12.5mg ordered tid.\n Response:\n Sbp went up to 180 after lopressor 12.5 had been given. Dose increased\n to 25mg . Also 10mg iv hydrallazine given x2. sbp down to 138. goal\n for sbp 140-150 for head bleed. Sbp crept back up to 160 pre tid\n lopressor dose. Dose of 25mg po lopressor given.\n Plan:\n Lopressor 25mg po tid.\n Social- patient with financial concerns over rent. Seen by social\n services about his etoh issues. Social services told him they were\n available to him for finacial conerns as well. He is aware they are\n available to him should he want their assistance for finacial or etoh\n issues. He does not wish their assistance at this time.\n"
},
{
"category": "Nursing",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 672540,
"text": "68yo pt presented to via EMS s/p fall @ home after\n which he lost consciousness. CT @ OSH cleared C-spine but showed\n subdural hematoma. Transferred to ED where pt c/o back pain\n (chronic) and headache and tender c-spine. Collar placed back on.\n Repeat CT again showed no cervical fracture and multifocal subdural w/\n intraventricular hemorrhage and extension along the tentorium w/ a\n non-displaced L frontal skull fracture. CIWA in ED 11, gave total 10mg\n IV valium and 5mg PO valium. Total 8mg IV morphine for c/o headache and\n neck and back pain. Temp 98.4, HR 90-100's, BP 145/86, rr 20's and on\n room air. Got 1L NS, voiding, and has x2 PIV's. Neuro consulted.\n Plan for repeat CT in AM to assess for changes. To MICU for Q2H neuro\n checks and treatment of withdrawal.\n Pain control (acute pain, chronic pain)\n Assessment:\n C/o this am of pain in head, neck and back.\n Action:\n Tx with Tylenol, percocet,morphine, and lido patch\n Response:\n Pain down to 6.5/10 after all these interventions. 1 mg dialudid given\n iv with 6.5/10 pain and pain down to 6/10 which patient said was\n acceptable. Tylenol given at 1730 when pain was to keep pain\n controlled.\n Plan:\n Cont to assess and tx for pain.\n Subdural hemorrhage (SDH)\n Assessment:\n Alert and oriented x3. cooperative with care. Mae. Equal strength.\n Pearl. Main c/o is of headache.\n Action:\n Repeat head ct done without and with contrast. Meds for pain given as\n above.\n Response:\n Stable cat scan.\n Plan:\n Cont neuro checks q 2 hours.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Ciwa up to as high as 17 this am.\n Action:\n Given a total of 25mg po valium this am. Seen by social services\n regarding etoh use.\n Response:\n Need to cont prn valium for for withdrawal symptoms.\n Plan:\n Cont po valium for withdrawal symptoms.\n Hypertension, benign\n Assessment:\n Sbp up to 170 this am.\n Action:\n Lopresssor 12.5mg ordered tid.\n Response:\n Sbp went up to 180 after lopressor 12.5 had been given. Dose increased\n to 25mg . Also 10mg iv hydrallazine given x2. sbp down to 138. goal\n for sbp 140-150 for head bleed. Sbp crept back up to 160 pre tid\n lopressor dose. Dose of 25mg po lopressor given. Sbp remained 160 Dr\n made aware. Captopril 6.25mg tid started.\n Plan:\n Continue Lopressor 25mg po tid and captopril 6.25mg tid.\n Social- patient with financial concerns over rent. Seen by social\n services about his etoh issues. Social services told him they were\n available to him for finacial conerns as well. He is aware they are\n available to him should he want their assistance for finacial or etoh\n issues. He does not wish their assistance at this time.\n"
},
{
"category": "Physician ",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 672472,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Admitted overnight after presenting to an OSH with a fall in the\n context of alcohol use and found to have SAH and SDH with non-displaced\n skull fracture. Transferred to for further management. Seen by\n neurosurgery who recommended frequent neuro checks and a repeat CT +\n CTA this morning (to rule out primary vascular lesion as precipitant\n for this episode).\n Overnight, neuro exam unchanged. Received Valium 5mg po x 1 for CIWA\n scale. Complaining of headach, neck pain and LBP this AM.\n History obtained from Medical records\n Allergies:\n Wellbutrin (Oral) (Bupropion Hcl)\n skin peeling;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:30 AM\n Other medications:\n Valium CIWA scale, IV ativan PRN, MVI, thiamine, nicotine patch,\n metoprolol\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 Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: No(t) Dysuria\n Neurologic: Headache\n Flowsheet Data as of 08:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 95 (94 - 100) bpm\n BP: 158/92(108) {156/71(91) - 171/92(108)} mmHg\n RR: 16 (13 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 2,150 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,000 mL\n Blood products:\n Total out:\n 0 mL\n 1,175 mL\n Urine:\n 1,175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 975 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n but 2mm bilat\n Head, Ears, Nose, Throat: Normocephalic, C collar in place.\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Neurologic: Attentive, Follows simple commands, Moves all extremities.\n Labs / Radiology\n 13.7 g/dL\n 172 K/uL\n 93 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 103 mEq/L\n 137 mEq/L\n 39.0 %\n 6.1 K/uL\n [image002.jpg]\n 04:00 AM\n WBC\n 6.1\n Hct\n 39.0\n Plt\n 172\n Cr\n 0.8\n Glucose\n 93\n Other labs: ALT / AST:67/88, Alk Phos / T Bili:160/1.3, Albumin:3.8\n g/dL, Ca++:8.5 mg/dL, Mg++:2.3 mg/dL, PO4:3.6 mg/dL\n Imaging: Head CT: L frontal SDH, ?bleeding around MCA.\n Assessment and Plan\n 68 yo M with h/o CAD and etoh abuse presenting with traumatic fall c/b\n skull fracture, SDH.\n SAH/SDH: Thus far, has had stable neuro exam\n -Repeat CT today and CTA to evaluate circle of \n results\n pending\n -Holding aspirin\n -Continue frequent neuro checks for 24 hours\n -SBP goal 140-150.\n C spine:\n Await final read of CT before clearance.\n Etoh W/D: Continues on CIWA scale, has required minimal amounts\n -Continue vitamin support\n COPD: Counsel smoking cessation. PRN nebs\n Rest of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 11:35 PM\n 22 Gauge - 11:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 672352,
"text": "Chief Complaint: ETOH withdrawal, SDH\n HPI:\n 68M who stated that he was in USOH until this afternoon. He was at home\n and had approximately 40 oz of beer. He was outside of his home,\n slipped (unclear if he tripped or just slipped- he notes that he walks\n with a cane at baseline and does have a history of gait unsteadiness),\n and fell striking the back of his head. He lost consciousness for an\n undetermined amount of time.\n The next thing he remembers is waking up at an OSH. There he was\n found to have SAH/SDH on head CT. He was transferred to ED\n for further evaluation.\n .\n In the emergency department, initial vitals: 98.3, 97, 164/80, 20,\n 97%RA. Head CT with nondisplaced skull fracture, several subdural and\n intraventricular bleed. He received valium 5 mg IV X 2 for CIWA>10,\n morphine 4 mg IV X1, tylenol 650 PO X 1, and 1L NS. He was seen by\n neurosurgery who felt that there was no acute indication for\n intervention at this time. He was transferred to MICU for closer\n monitoring of neuro status and withdrawal\n .\n Upon arrival to the floor, he reports worsening headache, neck ache,\n and lower back pain. He denies any chest pain, palpitations, N/V, abd\n pain, diarrhea, melena, BRBPR. He denies ever having seizures from EtOH\n withdrawal. His last drink was noon today and drinks 60 ounces daily.\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 HOME MEDS:\n ASA 81 daily\n MVI\n Past medical history:\n Family history:\n Social History:\n # CAD and? MI: per pt, was recently hospitalized and in coma\n # s/p cataract removal surgery\n # glaucoma.\n # history of alcohol abuse\n # COPD\n NC\n Occupation: in between jobs\n Drugs: none\n Tobacco: 1 pack/day X 60 years\n Alcohol: 40-60 ounces beers daily\n Other:\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, 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 Neurologic: No(t) Numbness / tingling, Headache, No(t) Seizure\n Pain: Moderate\n Pain location: headache, neck pain, back ache\n Flowsheet Data as of 12:56 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 99 (99 - 100) bpm\n BP: 167/86(105) {167/86(105) - 167/86(105)} mmHg\n RR: 17 (14 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\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 -300 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GENERAL: Pleasant, tremulous\n HEENT: Normocephalic, atraumatic. PERRLA/EOMI. MMM. OP clear.\n Neck: c-collar in place\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs\n LUNGS: scarce wheezes bilaterally\n ABDOMEN: Soft, NT, ND.\n EXTREMITIES: No edema\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate.\n CN 2-12 intact.\n Preserved sensation throughout.\n 5/5 strength throughout.\n Labs / Radiology\n 189\n 100\n 0.8\n 12\n 21\n 97\n 3.8\n 133\n 41\n 7.6\n [image002.jpg]\n Other labs: PT / PTT / INR://1.0\n Fluid analysis / Other labs: EtOH: 126\n Imaging: Head CT: Multifocal subdural with small intraventricular\n hemorrhage and extenion along the tentorium with a non-displaced left\n frontal skull fracture. no mass effect\n .\n C-spine: no acute fx. djd with fractured anterior ostephytes\n Assessment and Plan\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n 68 y/o M hx EtOH abuse, last drink this morning, now s/p fall resulting\n in SDH and mild withdrawal symptoms\n .\n #. Withdrawal: his last drink at noon. He has no hx of seizures/severe\n withdrawal\n - valium PO Q3-4H for CIWA >10\n - IV ativan PRN\n - banana bag tonight and then MVI/thiamine in AM\n - social work consult\n - check LFTs given hx alcohol abuse\n .\n #. SDH/Intraventricular bleed/headache: sustained during fall.\n - repeat head CT in AM to eval interval change\n - Q2-4H neuro checks\n - low threshold to re-scan if altered mental status\n - EKG in AM\n - percocet and tylenol for pain\n .\n #. C-spine:\n - follow-up final read to c-spine film and then can clear clinically in\n AM\n .\n # ? hx MI and ?cardiac arrest: Pt states that he \"almost died\" after a\n cardiac event at OSH\n - check lipid panel\n - try to obtain OSH records, but most importantly, he will need to est\n PCP\n hold ASA 81 daily\n .\n # COPD\n - atrovent/albuterol nebs PRN\n - smoking cessation -> nicotine patch\n .\n FEN: replete lytes prn\n .\n PPX:\n - boots for now, hold SQ heparin until d/w neurosurg\n - no need for PPI\n .\n ACCESS: PIV's\n .\n CODE STATUS: Full\n ICU Care\n Nutrition:\n Comments: regular\n Glycemic Control:\n Lines:\n 20 Gauge - 11:35 PM\n 22 Gauge - 11:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "ECG",
"chartdate": "2128-05-12 00:00:00.000",
"description": "Report",
"row_id": 242256,
"text": "Sinus rhythm. Borderline low voltage. Compared to the previous tracing\nof no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2128-05-09 00:00:00.000",
"description": "Report",
"row_id": 242257,
"text": "Sinus rhythm. Compared to the previous tracing of there is no\nsignificant diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2128-05-08 00:00:00.000",
"description": "Report",
"row_id": 242258,
"text": "Sinus rhythm. Findings are within normal limits. No previous tracing available\nfor comparison.\nTRACING #1\n\n"
}
] |
8,302 | 109,404 | In the MICU pt was weaned off dilt drip and restarted on home regimen of dilt and lopressor. She was seen by vascular surgery for her lower ext wound they recommended foot x-ray and podiatry consult. Podiatry debrided the wound and a wound swab was sent for culture. She was put on empiric vanco/levo/metronidazole for broad coverage of her wound infection. She was called out to the floor on later that same day. . On the floor, her metoprolol and diltiazem were titrated up w/ good rate control of her atrial fibrillation. . Podiatry and vascular surgery continued to follow her. Her wound culture grew Methicillin Sensitive S. Aureus. Her antibiotic regimen was changed to Nafcillin only; she went to the OR for debridement of the ulcer by podiatry. She was stable for discharge home. | 2:30 PM CHEST (SINGLE VIEW) Clip # Reason: please evaluate for fluid/intrapulmonary process. Pt aggitated with husband here - but calmed towart 1800.A: Pt stable off dilt drip. Started on diltiazem drip. Pt denies pain.CV: HR a-fib 95-107, cuurently on dilt drip at 15mg/hr, will attempt to wean per Dr. request. Pt with strong, non-productive cough.CV: HR a-fib 80-100 with no ectopy noted, NBP 110-150/50-80. Received vanco/levoflox/flagyl per vascular surgery request. Denies pain at rest - L foot hurts when it is bumped.CV - DIlt drip weaned off. The perihilar edema and engorgement seen on the prior chest x-ray has resolved. Taking PO meds without difficulty.GU: Pt refusing foley cath, using bedpan to void.ID: Pt continues on ABX therapy of vanco/levoflox/flagyl.Skin: IntactEndo: Pt covered with HISS.Social: No contact from family overnight, husband aware of pt's condition, will be in this AM.Plan:c/o to floor?continue ABX therapymonitor HR and rhythmwean dilt gtt as tolerated by ptsupport to pt and familyroutine ICU care and monitoring Received diltiazem IVP x 2 and lopressor x 1 with no effect. Labs revealed lactate 3.0 and troponin 0.3, cards following. Pt ordered for cardiac/heart healthy diet. Routine meds have been ordered, and most started.P: Emotional support to pt. Transferred to MICU for further management.Neuro: Pt alert and oriented x 3, pleasant, cooperative with care, assist with turns. Multiform PVC's.Resp - O2 per nasal cannula at 2 to 4 l/min. In pt noted to be in a-fib (chronic) with RVR with HR up to 140's. Will be in this morning.Plan:called out to floormonitor HR and rhythmdressing to left foot ulcercontinue ABX treatmentsupport to pt and family FINDINGS: Portable chest radiograph demonstrates engorgement of pulmonary vasculature and Kerley B lines indicating mild interstitial edema. Monitor HR and medicate as ordered. REASON FOR THIS EXAMINATION: please eval for chf FINAL REPORT INDICATION: Rapid atrial fibrillation, please evaluate for CHF. 7:31 PM CHEST (PORTABLE AP) Clip # Reason: please eval for chf MEDICAL CONDITION: 79 year old woman with rapid fib . MICU Nursing Progress Note 1900-0700Code: DNR/DNIAllergies: Iodine injectionNeuro: Pt A&O x 3, pleasant, cooperative with care, positions herself independently in bed. IMPRESSION: Mild pulmonary edema. Degenerative changes are present at the tarsal metatarsal region and a small plantar calcaneal spur is noted as well as diffuse vascular calcifications. Pt denies pain.Resp: RR 20-35 with sats >95% on 2-4L NC (4L while sleeping). 12:47 PM ART EXT (REST ONLY) Clip # Reason: r/o PVD, assess flow Admitting Diagnosis: CHEST PAIN MEDICAL CONDITION: 79 year old woman with L foot ulcer REASON FOR THIS EXAMINATION: r/o PVD, assess flow FINAL REPORT ARTERIAL STUDY HISTORY: Left foot ulcer. Passing flatus.GU: Pt refusing foley, asking for bedpan when necessary. Voiding clear, yellow urine.ID: Continues on ABX (Vanco/Levoflox/Flagyl) for left foot ulcer.Skin: Podiatry in to see pt this PM, applied wet to dry dressing to left foot ulcer. FINAL REPORT CLINICAL HISTORY: Increasing O2 requirements. Nursing NOteEvents - to ultrasound for non-invasive arterial study of legs Husband in to visit - pt a bit aggitated/angry with husbandNeuro - A, Ox3, moves all limbs with good strength both spont and to command. QUESTION OSTEOMYELITIS. CHEST: The cardiac size is at the upper limits of normal. Mild, non-productive cough.GI: BS x 4, no stool this shift. Heart and mediastinal contours are within normal limits. REASON FOR THIS EXAMINATION: please evaluate for fluid/intrapulmonary process. CUltures pending.Wound - L foot with abrasion/sore. Blood glucose at 1800 150, so no insulin per new scale.ID - remains on IV vanco, PO flagyl and Levofloxacin. IMPRESSION: Findings as stated above which indicate significant bilateral aortoiliac disease. please evaluate for fluid/intrapulmonary process. 9:01 AM FOOT AP,LAT & OBL LEFT Clip # Reason: r/o osteo Admitting Diagnosis: CHEST PAIN MEDICAL CONDITION: 79 year old woman with foot ulcer and leukocytosis REASON FOR THIS EXAMINATION: r/o osteo FINAL REPORT LEFT FOOT STUDY OF WITH INDICATION OF FOOT ULCER. NBP 130-154/57-94. ABI on the right is 0.79 and on the left is 0.94. IMPRESSION: Resolution of failure. FINDINGS: Monophasic waveforms diffusely and bilaterally. There is likely some right-sided SFA disease. | 7 | [
{
"category": "Radiology",
"chartdate": "2111-05-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 958567,
"text": " 7:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with rapid fib .\n REASON FOR THIS EXAMINATION:\n please eval for chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rapid atrial fibrillation, please evaluate for CHF.\n\n COMPARISON: None.\n\n FINDINGS: Portable chest radiograph demonstrates engorgement of pulmonary\n vasculature and Kerley B lines indicating mild interstitial edema. The lungs\n are otherwise clear. Heart and mediastinal contours are within normal limits.\n\n IMPRESSION: Mild pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-05-30 00:00:00.000",
"description": "L FOOT AP,LAT & OBL LEFT",
"row_id": 958770,
"text": " 9:01 AM\n FOOT AP,LAT & OBL LEFT Clip # \n Reason: r/o osteo\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with foot ulcer and leukocytosis\n REASON FOR THIS EXAMINATION:\n r/o osteo\n ______________________________________________________________________________\n FINAL REPORT\n LEFT FOOT STUDY OF WITH INDICATION OF FOOT ULCER. QUESTION\n OSTEOMYELITIS.\n\n There are no radiographic findings to suggest the presence of osteomyelitis.\n However, the clinical suspicion is strong, correlative bone scan or MRI may be\n considered. Degenerative changes are present at the tarsal metatarsal region\n and a small plantar calcaneal spur is noted as well as diffuse vascular\n calcifications.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-05-29 00:00:00.000",
"description": "ART EXT (REST ONLY)",
"row_id": 958655,
"text": " 12:47 PM\n ART EXT (REST ONLY) Clip # \n Reason: r/o PVD, assess flow\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with L foot ulcer\n\n REASON FOR THIS EXAMINATION:\n r/o PVD, assess flow\n ______________________________________________________________________________\n FINAL REPORT\n ARTERIAL STUDY\n\n HISTORY: Left foot ulcer.\n\n FINDINGS: Monophasic waveforms diffusely and bilaterally. ABI on the right\n is 0.79 and on the left is 0.94. Volume recordings demonstrate waveform\n widening bilaterally, right to a greater extent than the left.\n\n IMPRESSION: Findings as stated above which indicate significant bilateral\n aortoiliac disease. There is likely some right-sided SFA disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-06-03 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 959373,
"text": " 2:30 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: please evaluate for fluid/intrapulmonary process.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with h/o CHF new oxygen requirement. please evaluate for\n fluid/intrapulmonary process.\n REASON FOR THIS EXAMINATION:\n please evaluate for fluid/intrapulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Increasing O2 requirements. Evaluate for failure.\n\n CHEST:\n\n The cardiac size is at the upper limits of normal. No evidence of failure is\n now present. The perihilar edema and engorgement seen on the prior chest\n x-ray has resolved. Costophrenic angles are sharp.\n\n IMPRESSION: Resolution of failure.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-05-30 00:00:00.000",
"description": "Report",
"row_id": 1372288,
"text": "MICU Nursing Progress Note 1900-0700\n\nCode: DNR/DNI\nAllergies: Iodine injection\n\nNeuro: Pt A&O x 3, pleasant, cooperative with care, positions herself independently in bed. Pt denies pain.\n\nResp: RR 20-35 with sats >95% on 2-4L NC (4L while sleeping). Lung sounds clear. Pt with strong, non-productive cough.\n\nCV: HR a-fib 80-100 with no ectopy noted, NBP 110-150/50-80. Peripheral pulses palpable. PIV x 1.\n\nGI: BS x 4, no stool since admission. Tolerating low sodium/heart healthy diet well. Passing flatus.\n\nGU: Pt refusing foley, asking for bedpan when necessary. Voiding clear, yellow urine.\n\nID: Continues on ABX (Vanco/Levoflox/Flagyl) for left foot ulcer.\n\nSkin: Podiatry in to see pt this PM, applied wet to dry dressing to left foot ulcer. Otherwise skin intact.\n\n: covered with HISS\n\nSocial: Husband called in this evening, updated on pt's condition and plan of care. Will be in this morning.\n\nPlan:\ncalled out to floor\nmonitor HR and rhythm\ndressing to left foot ulcer\ncontinue ABX treatment\nsupport to pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-05-29 00:00:00.000",
"description": "Report",
"row_id": 1372286,
"text": "MICU Nursing Admission Note 1900-0700\n\nCode: DNR/DNI\nAllergies: Iodine injection\n\nPt is a pleasant 79 year old woman who presented to ED this morning from her vascular surgeon's office where she was having shaking chills and rigors. Pt has ulcer to left foot to which she has been doing water-peroxide soaks for past week. Infection to ulcer is likely. Received vanco/levoflox/flagyl per vascular surgery request. In pt noted to be in a-fib (chronic) with RVR with HR up to 140's. Received diltiazem IVP x 2 and lopressor x 1 with no effect. Started on diltiazem drip. Labs revealed lactate 3.0 and troponin 0.3, cards following. Transferred to MICU for further management.\n\nNeuro: Pt alert and oriented x 3, pleasant, cooperative with care, assist with turns. Pt denies pain.\n\nCV: HR a-fib 95-107, cuurently on dilt drip at 15mg/hr, will attempt to wean per Dr. request. NBP 130-154/57-94. Pt afebrile. For access pt has PIV x 2, both patent and WNL.\n\nResp: RR 18-32 with sats >95% on 4L NC. Lung sounds clear throughout. Mild, non-productive cough.\n\nGI: BS x 4, no stool this shift. Pt ordered for cardiac/heart healthy diet. Taking PO meds without difficulty.\n\nGU: Pt refusing foley cath, using bedpan to void.\n\nID: Pt continues on ABX therapy of vanco/levoflox/flagyl.\n\nSkin: Intact\n\nEndo: Pt covered with HISS.\n\nSocial: No contact from family overnight, husband aware of pt's condition, will be in this AM.\n\nPlan:\nc/o to floor?\ncontinue ABX therapy\nmonitor HR and rhythm\nwean dilt gtt as tolerated by pt\nsupport to pt and family\nroutine ICU care and monitoring\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-05-29 00:00:00.000",
"description": "Report",
"row_id": 1372287,
"text": "Nursing NOte\nEvents - to ultrasound for non-invasive arterial study of legs\n Husband in to visit - pt a bit aggitated/angry with husband\n\nNeuro - A, Ox3, moves all limbs with good strength both spont and to command. Denies pain at rest - L foot hurts when it is bumped.\n\nCV - DIlt drip weaned off. Second PO dose of dilt at noon, dose up to 60mg. Metoprolol and flecainide started this evening and lisinopril to be started tonight. BP 110-150 sys. Multiform PVC's.\n\nResp - O2 per nasal cannula at 2 to 4 l/min. At times difficult to get a good pleth tracing - pt moves a lot. Wheezing this evening - pt reports not taking any inhalers at home, nor home oxygen.\n\nGU - pt refused foley cath, voiding in bedpan. IV fluids at VKO only.\n\nGI - Pt ate lunch and dinner, taking fluids and meds without difficulty. No stool today.\n\n - pt on new sliding scale insulin. Blood glucose at 1800 150, so no insulin per new scale.\n\nID - remains on IV vanco, PO flagyl and Levofloxacin. Temp only 98.8 PO. CUltures pending.\n\nWound - L foot with abrasion/sore. No drainage, clean, some edema, good pedal pulses, DP palpable.\n\nSocial - pt's husband in to visit - pt & husband arguing. Pt aggitated with husband here - but calmed towart 1800.\n\nA: Pt stable off dilt drip. Ready to transfer out of MICU when bed available. Routine meds have been ordered, and most started.\n\nP: Emotional support to pt. Monitor HR and medicate as ordered. Transfer out of MICU when bed available.\n"
}
] |
97,476 | 189,690 | ============== BRIEF HOSPITAL SUMMARY ============== This is a 62 yo M with a history of a partial bowel rsxn after ruptured appy, hx of "flesh eating infection" of RLE leading to AKA in , who presented with increasing freq and urgency of bowel movements, fever and BRPBR. He was found to have colitis on CT scan in the descending colon and a colonoscopy suspicious for IBD. He was started on prednisone and asacol and will f/u w/ GI as an outpt. . =============== ACTIVE ISSUES =============== BRBPR: Pt with acute anemia to 23, was stabilized w/ blood products to Hct 32 in MICU. After brief stay in MICU, pt transferred to floor w/ stable vitals. Unremarkable EGD is reassuring that bleeding not from proximal of Ligament of Treitz. Colonoscopy showed a large amount of inflammation and irritation from rectum to splenic flexure, likely result of IBD, but infection cannot be ruled out. Biopsies pending. Have started prednisone/asacol for presumed IBD. Pt has realized some relief in abd pain and frequency of bowel movements in past 24 hrs. Stool cxs negative. We appreciated the input of our GI colleagues throughout this admission. . #ALCOHOL ABUSE: Paitent has been drinking 2 bottles of wine a night for several week2 months. Pt had a social work consult. No signs or symptoms of withdrawal. Pt was on CIWA scale. ===================== INACTIVE ISSUES ===================== #CHRONIC PAIN: From AKA will kept patient on his home vicoden regimen per his narcotics contract. ===================== TRANSITIONAL ISSUES ===================== 1. F/u path on /egd biopsies 2. f/u GI 3. f/u PCP 4. prednisone taper 5. added asacol | OSSEOUS STRUCTURES: There is no acute fracture. No fluid collection or abscess detected. Allowing for this, the heart is not enlarged. No mass seen, although detection of a small inflammatory mass is not possible with this technique, and correlation with any recent colonoscopy is recommmended. There is no intrapelvic lymphadenopathy or free fluid. No concerning blastic or lytic lesions are identified. The heart size is normal, and there is no pericardial effusion. There is no CHF, focal infiltrate, or gross effusion. There is no pleural effusion. There is no mesenteric or retroperitoneal lymphadenopathy, and no free air or free fluid. Minimal atelectasis at the right lung base and obscuration and blunting of the right costophrenic angle is noted. Non-specific ST-T waveabnormalities. Probable also minimal left base atelectasis. No nodules or masses are seen. No free air is seen beneath the diaphragm on this upright film. Normal sinus rhythm with delayed R wave transition. CHEST, SINGLE AP PORTABLE VIEW.No previous chest x-rays on PACS record for comparison. No comparison studies available. The remaining large bowel appears normal. TECHNIQUE: MDCT-acquired 5-mm axial images of the abdomen and pelvis were obtained following the uneventful administration of 130 cc of Optiray intravenous contrast. The distribution is less compatible with ischemia. No previous tracing available for comparison. There is mild levoscoliosis of the lumbar spine (601B:30). PELVIS: The rectum, sigmoid colon, urinary bladder, and prostate are normal. (Over) 11:11 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: eval for acute process Admitting Diagnosis: LOWER GI BLEED Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) FINAL REPORT INDICATION: Lower GI bleed and fever. The liver, gallbladder, spleen, pancreas, adrenal glands, kidneys, stomach, and intra-abdominal loops of small bowel are normal. 11:11 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: eval for acute process Admitting Diagnosis: LOWER GI BLEED Contrast: OPTIRAY Amt: 130 MEDICAL CONDITION: 62 year old man with LGIB and fever, TTP LLQ - NO PO Prep please REASON FOR THIS EXAMINATION: eval for acute process No contraindications for IV contrast WET READ: LLTc SUN 1:02 AM Mild wall thickening and neighboring stranding along the descending colon (2:51), which may represent a mild colitis. An old healed left seventh posterior rib fracture is incidentally noted. IMPRESSION: Mild wall thickening and stranding of the distal transverse, descending and sigmoid colon, which may reflect colitis secondary to infection or IBD. ABDOMEN: Included views of the lung bases demonstrate calcified pleural-based plaques bilaterally (2:4, 1). 10:53 PM CHEST (PORTABLE AP) Clip # Reason: eval for infiltrate Admitting Diagnosis: LOWER GI BLEED MEDICAL CONDITION: 62 year old man with GIB REASON FOR THIS EXAMINATION: eval for infiltrate FINAL REPORT HISTORY: GI bleed, evaluate for infiltrate. Rotated positioning. Coronal and sagittal reformations were performed at 5-mm slice thickness. | 3 | [
{
"category": "Radiology",
"chartdate": "2185-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1212732,
"text": " 10:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: LOWER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with GIB\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: GI bleed, evaluate for infiltrate.\n\n CHEST, SINGLE AP PORTABLE VIEW.No previous chest x-rays on PACS record for\n comparison.\n\n Rotated positioning. Allowing for this, the heart is not enlarged. There is\n no CHF, focal infiltrate, or gross effusion. Minimal atelectasis at the right\n lung base and obscuration and blunting of the right costophrenic angle is\n noted. Probable also minimal left base atelectasis. An old healed left\n seventh posterior rib fracture is incidentally noted. No free air is seen\n beneath the diaphragm on this upright film.\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-10-22 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1212735,
"text": " 11:11 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: eval for acute process\n Admitting Diagnosis: LOWER GI BLEED\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with LGIB and fever, TTP LLQ - NO PO Prep please\n REASON FOR THIS EXAMINATION:\n eval for acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc SUN 1:02 AM\n Mild wall thickening and neighboring stranding along the descending colon\n (2:51), which may represent a mild colitis. No fluid collection or abscess\n detected. No mass seen, although detection of a small inflammatory mass is not\n possible with this technique, and correlation with any recent colonoscopy is\n recommmended.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Lower GI bleed and fever.\n\n No comparison studies available.\n\n TECHNIQUE: MDCT-acquired 5-mm axial images of the abdomen and pelvis were\n obtained following the uneventful administration of 130 cc of Optiray\n intravenous contrast. Coronal and sagittal reformations were performed at\n 5-mm slice thickness.\n\n ABDOMEN: Included views of the lung bases demonstrate calcified pleural-based\n plaques bilaterally (2:4, 1). There is no pleural effusion. No nodules or\n masses are seen. The heart size is normal, and there is no pericardial\n effusion.\n\n The liver, gallbladder, spleen, pancreas, adrenal glands, kidneys, stomach,\n and intra-abdominal loops of small bowel are normal. There is no mesenteric\n or retroperitoneal lymphadenopathy, and no free air or free fluid. A long\n segment of the descending colon and proximal sigmoid demonstrates wall\n thickening with neighboring stranding (602B:54, 2:48). The remaining large\n bowel appears normal.\n\n PELVIS: The rectum, sigmoid colon, urinary bladder, and prostate are normal.\n There is no intrapelvic lymphadenopathy or free fluid.\n\n OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or\n lytic lesions are identified. There is mild levoscoliosis of the lumbar spine\n (601B:30).\n\n IMPRESSION: Mild wall thickening and stranding of the distal transverse,\n descending and sigmoid colon, which may reflect colitis secondary to infection\n or IBD. The distribution is less compatible with ischemia.\n (Over)\n\n 11:11 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: eval for acute process\n Admitting Diagnosis: LOWER GI BLEED\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "ECG",
"chartdate": "2185-10-22 00:00:00.000",
"description": "Report",
"row_id": 144959,
"text": "Normal sinus rhythm with delayed R wave transition. Non-specific ST-T wave\nabnormalities. No previous tracing available for comparison.\n\n"
}
] |
18,298 | 156,436 | At the OSH on , EKG showed findings c/w anterolateral STEMI. Cardiac enzymes were elevated. At the OSH she was treated with ASA/NG/BB/plavix/heparin, and after treatment her ST segment elevations resolved. At , cardiac catheterization revealed significant occlusion in the LCx, RCA, and LAD, as well as moderate 2+ MR. In the CCU, the patient was managed on a medical regimen including ASA/BB/nitro gtt/ACEi/heparin/high dose statin. She was evaluated for CABG +/- MVR. On , her nitro gtt was discontinued given lack of symptoms and stable BP. On , an echocardiogram was done, showing small secundum atrial septal defect; mild regional left ventricular systolic dysfunction with focal severe hypokinesis of the distal septum, distal anterior and distal inferior walls; mild dyskinetic/aneurysm at apex; normal RV free wall motion; moderate (2+) mitral regurgitation with an eccentric, inferiorly directed jet. She was taken to the OR on where she underwent an MVR (27mm tissue valve) and CABG X 3 (LIMA > LAD, SVG > OM, SVG > PLV). She was taken to the cardiac surgery recovery unit on NTG & Epi drips. She went into rapid AFib on POD # 1, requiring cardioversion, amiodarone started. She subsequently had some heart block, requiring temporary pacing, and her native conduction recovered in the next few days. On , she was extubated, but required re-intubaltio for tachypnea and hypoxia. Several more attempts were made at weaning her from the ventilator, but each time she was weaned to minimal support, she again became tachypneic and hypoxic. She underwent tracheostomy on . She continued with supportive care, and slow ventilator weaning. On , an infectious disease consult was obtained for fevers to 102. Sputum and urine cultures revealed pseudomonas. There was 1 positive blood culture (out of bottles) for coag. negative staph. Central line culture was negative. Chest & sinus CT scans were negative, as was her lower extremity doppler. The recommendation was to place her on antibiotics for 7-10 days for presumed pseudomonas pneumonia. A midline catheter was placed for antibiotics. She has now remained afebrile since , and has been off the ventilator on a trach collar since . She has intermittantly used a Passey Muir valve for speech. She remains hemodynamically stable, and is ready for transfer to rehab for continued speech, respiratory, and physical therapy. | further diuresis this pm. remains cpap, see flowsheet for additional settings info.gi/gu: abd soft, +bowel sounds. MDI's as ordered W improvement in aeration. BS occ rhonchi. foley to gravity, good huo.endo: fs qid, cover per riss.plan: pulmonary toilet, wean vent as tolerates. Suctioned for thick tan bloody secretions.OOB to ch for several hrs.GI/GU: Remains npo. PSV lowered apneic episodes resolved. CONTINUE TO MONTIOR HEMODYNAMICS. CXR for placement done. Trach site oozy after heparin restarted, team aware, cont with Hep gtt. Rehab screen process. BS coarse rhonchi bilaterally W I&E wheezes on rt. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. ALBUTEROL MDI'S BEINGGIVEN. zantac->protonix,sucrafate as ordered. HYPO BSP. SPOKEN TO BY DUNDEN, PA.FOLLOWING EVENT NEURO STATUS INTACT.GI/GU: OGT TO LCS, ABD SOFT, HYPOACTIVE BS, MARGINAL U/O. epi weaning as tolerated.rt. CVP 9-12.RESP: BS , TUBULAR IN RIGHT BASE, SL DIM IN LEFT. FEBRILE AT 101.7 AT . ett tube repositioned. SHIFT UPDATE 7P-7ASEE CAREVIEW FOR COMPLETE ASSESSMENT.PT LETHARGIC/ WITHDRAWN. PEARRLA.CV: RSR w/o ectopy. Abg 7.35/34/151/20. CSRU UPDATENEURO: LOW DOSE PROPOFOL D/C THIS AM. T MAX 101.RESP: PT TO CPAP +/8 IPS THIS AM. RSBI done =180.BS coarse bil. Residuals WNL. attempt aborted & propofol resumed. AMIODARONE CHANGED TO PO- OKAYED BY EP TEAM. TYLENOL GIVEN, NOW T 99. 3+ GENERAL EDEMA. MDI given as per order.ABGs stable after PSV level increased to pt. CONTINUES ON AMIO -NO BOLUS THIS SHIFT. f/u with PTT results. GU ADEQUATE U/O LASIX/DIAMOX DCD. DEFIB PADS ON PT.CO/CI=4.2/2.8MV02=63,61%.CA+ REPLETED.3+ BLU EXTREMITY EDEMA.RESP-CONTINUES ON SIMV/PS. pt had 1 formed stool -> guiac negative. pp by doppler. ABG~SL MET ACIDOSIS.GI/GU~TOL TF OF PROMOTE W/ FIBER, MIN RESIDUALS. LEFT CAROTID STERI STRIPS D&I. PT STABLE, MIDLINE PLACED, DISCHARGED TO , , MASS. DEPENDANT SIDE DOWN DEVELOPS COURSE RHONCHI AND THE DIFFUSES WHEN RE-POSITIONED. DIURESE. Indwelling foley. SXD MULT. pt continues on heparin gtt. ACTIVE-> ABSENT BS.PLACEMENT CHECKED. pt with + BS. BS TREATED WITH SSINSULIN. PT INITIALLY ON IMV AND COMFORTABLE WHILE ON PROPOPFOL THIS AM. DAILY COUMADIN DOSE DC'D. EXTRA TRACH SENT PER REHAB'S REQUEST. Latest ABG acceptable. + BS - BM.ENDO~SSRI PER CSRU PROTOCOL.SKIN~GENERALIZED BODY EDEMA. abg good.gi; abd soft, bs present, soft bm today, ppi cont. MDI's given. Pt was apnic on vent. Lytes replaced as needed. Mdis given. Required neo while in afib. BS are hypoactive, abd soft, +flatus. BS TREATEDED WITH SSINSULIN. REMAINS IN A-FIB AFTER MEDS WITH STABLE BP. Abd soft hypoactive BS. T MAX 99 ORAL.ABD SOFT WITH POSITIVE BS'S AND FLATULUS, NO BM AS OF YET ON THIS SHIFT. ABG GOOD PLAN TO PSE SUPPORT SLOWLY, SUNCTIONED THICK TAN SECRETIONS. ABGwas wnl. SBP BY CUFF VERY LOW 80'S WITH RADIAL ALINE PLACED SBP UO 120'S. Removed speaking valve and suctioned small amt of thci whte secretions. Pt did convert to nsr shortly after amiodarone bolus. k repleted, glucose rx per protocol. RESP CARE: Pt remains intubated/on vent per carevue. CHEST TUBES DC'D.RESP: RT UPPER/LOWER LS ARE COURSE, LFT UPPER IS CLR, BASE DIM. Brief start on propofol gtt, dc'd per team. ?WEANING OFF PROPOFOL & VENT IN AM IF HEMODYNAMICALLY STABLE. +palpable pulses.Resp: LS clear but diminished. remains on amiodarone, lopressor, and lisinopril. LS Coarse upper, diminshed lower.C-V: HR 70's-80's, NSR, no ectopy; BP 120's-130's; lytes WNL.GI: TF's of ProBalance at goal of 60cc/hr. IV mso4 & PO percocet dc'd per PA . Pressure dsg d+i to trach area. PA aware of pt's current mental status.C/V: When assumed care of pt- pt in 1st degree AV block (PR 0.21) HR 70s. Placed on SIMV overnoc for high RR 36 while on CPAP.GI/GU: Abd soft, NT +BS. Monitor resp. CXR done. resp status. foley to gravity, good huo.endo: fs qid, cover per riss.plan: pulmonary toilet, wean as tolerates. On CPAP overnoc, see carevue for abgs. BS occasional diffuse fine wheezes clear after rx. sbp stable, lisinopril started. BS clear bilaterally W slt dim bases. foley to gravity, good huo, cr 1.2.endo: fs qid, cover per riss.plan: pulmonary toilet, maintain trach collar as tolerates. Monitor resp. Pt became bronchospastic MDI given W good effect. Respiratory Pt presents trached on PSV 10/5 .4. remains intubated via trach. Suctioned for thick/thin via trach. 2min, PA Nilssen notified, amiodarone bolus given, lytes sent, k repleted. Resp CarePt seen for trach X2. sx for sml amts thk secretions. B/P stable.GI/GU: +BS. LUNG SOUNDS CLEAR UPPER AND DIMINISHED BASES. Mild (1+) mitral regurgitation is seen. Mild regional LV systolicdysfunction. There ismild symmetric left ventricular hypertrophy with normal cavity size. Mild mitral annularcalcification. Normal ascending aortadiameter. There is mild symmetric left ventricular hypertrophy with normalcavity size. There is mild aortic valvestenosis. Mild regional LV systolic dysfunction. Normal ascending aorta diameter.AORTIC VALVE: ?# aortic valve leaflets. + pitting generalized edema, esp to BUE.Epicardial pacer wires to box, which is off d/t inappropriate spikes on .Resp: Pt remains on Vent in Cpap+ps mode. There is mild symmetric left ventricularhypertrophy with normal cavity size. There is mildregional left ventricular systolic dysfunction. Focal calcifications in aortic root.Normal ascending aorta diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. Right ventricular chamber size and free wall motion arenormal. Left-to-right shunt across the interatrial septum at rest.Small secundum ASD.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Central venous catheter has been withdrawn in the interval and now terminates in the region of the junction of the superior vena cava and right atrium. There has been, interval removal of a nasogastric tube. The right internal jugular central venous line has been removed. FINDINGS: An endotracheal tube is in place with tip terminating 4.3 cm from the carina. AP SUPINE CHEST RADIOGRAPH: In the interval, there has been removal of the right IJ sheath and associated Swan-Ganz catheter. Stable left pleural effusion. Bilateral pleural effusions and left lower lobe atelectasis as described. IMPRESSION: AP chest compared to and 21: Small bilateral pleural effusion has developed since despite left pleural tube. FINDINGS: An endotracheal tube is in place with tip terminating approximately 5.3 cm from the carina. | 152 | [
{
"category": "Nursing/other",
"chartdate": "2182-02-03 00:00:00.000",
"description": "Report",
"row_id": 1502981,
"text": "CCU Nursing Admission Note\nSee FHPA for complete PMH and allergies. Briefly,patient is an 87 yo woman admitted to from OSH with STEMI with lateral changes and pulmonary edema. To cath lab, where she was found to have 3 VD, EF ~30%, thought to be most amenable to CABG rather than PCI. Came to the CCU 2 930 s/p cath with right femoral sheaths in place.\n\nS: denies CP and SOB. Only c/o pain is with light palpation of L CEA site (done on Friday).\n\nO: CV: arrived with R femoral arterial and venous sheaths in place. Sheaths removed at 1100 with ACT 117. BP initially 160-170/70's by femoral aline, 20-30 points lower by NBP. BP since sheath removal 118-144/53-70, MAP 75-89. BP equal bilaterally. Begun on IV NTG, titrated up to 0.2 mcg/kg/min and IV Heparin 800 U/ hour. HR 80-90 NSR with rare PVC, given lopressor 5mg IV X1 and started on lopressor 25mg po tid. HR now in the 70's. Had one episode of sinus bradycardia down to the 30's. Nurse in room with patient at the time, occurred when clearing her throat while eating her . No dizziness. Dr. informed. Also noted HR drop form 80's to 60's when clearing her throat later. Lungs with crackles ^ bilaterally, comfortable lying flat. O2 sat 100% on 5L NP, titrated down to 2L NP, remains with O2 sat ~ 98%. Given 20 mg IV lasix X1 with ~1100 cc's out thus far. Lungs with decreased crackles. Routine ECG with Q's laterally (unchanged from cath lab). CPK #1 391, #2 PND from 1600. K 4.3 prior to diuresis, K from 1600 PND. Right groin with bleeding nor hematoma. Distal pulses dopplerable-palpable (see flow sheet for details). Feet warm bilaterally with good movement and sensation. Hct 27.9 this am, repeat PND from 1600.\n\nGI: abdomen softly distended, + BS, tolerating po 's with fair appetite for lunch. No stool\n\nGU: foley with clear yellow urine. BUN 28/ Cr 0.8\n\nNeuro: alert and oriented X3, cooperative with care, asking many questions. MAE, upper and lower extremity strength equal bilaterally. Pupils 4mm, briskly reactive bilaterally. +accomodation. Speech with slight mumbling. She states this has been present since her surgery on Friday, and that her Dr. aware and has told her it will resolve. Son notes that during previous hospitalization, she has \"sundowned\" during the night shift--pulling electrodes off, getting combative, requiring family to come to hospital to settle patient down. Son does not feel she does this at home.\n\nSkin: left neck with ecchymotic area from L CEA, tender to touch. Unchanged over course of day. Otherwise skin is intact.\n\nSocial: had patient fill out HCP info, copy placed in chart, family given the original and several copies. Pt. designated son as HCP and son as alternate. Patient has 4 children, all 4 present today. Son states that patient lives in in-law apartment below daughter . That all four children will take turns caring for patient with discharge post CABG. Dr. in to consent patient for surgery. Answered patie\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-03 00:00:00.000",
"description": "Report",
"row_id": 1502982,
"text": "CCU Nursing Admission Note\nAddendum: 1745 went into patient's room to replace ECG leads. Patient swinging legs over side rails attempting to get OOB. Patient becoming beligerant. Patient's room changed to be closer to the central station. Patient swinging her arms at staff, cursing at Nurse. Refusing po Zyprexa. Called patient's son . Updated on status of his mom. Had patient talk with son on cell phone. and in to visit. Patient accepted Zyprexa from @ 1830. Patient now lying calmly in bed with both sons at bedside.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-03 00:00:00.000",
"description": "Report",
"row_id": 1502983,
"text": "CCU Nursing Admission Note\n(Continued)\nnt and families' questions.\n\nAccess: R PIV #20 X2.\n\nA: stable s/p lateral STEMI. 3V Disease, for CABG on Tuesday. Drop in HR with clearing throat, but not during sheath removal. Left CEA site without change since starting on heparin. Potential for sundowning. Oxygen requirement decreased with diuresis, still with crackles. Supportive family.\n\nP: Next CPK due at 12 mn. PTT due at . Monitor HR/BP. Follow u/o and lungs, ? further diuresis this pm. Bed exit alarm on and side rails up, bed in low position. Monitor Left carotid site on heparin. Follow neuro signs. Monitor groin and distal pulses. Continue with pre-op teaching.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-18 00:00:00.000",
"description": "Report",
"row_id": 1503041,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds sl coarse after suct sm th tan sput. MDI given as per order. Pt noted to have 15-20\" periods of apnea which seemed to be caused by iatrogenic hyperventilation with PSV level set too high. PSV lowered apneic episodes resolved. Pt to OR for trach today. Cont PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-18 00:00:00.000",
"description": "Report",
"row_id": 1503042,
"text": "BS coarse crackles; no change with MDI's x 1. #8.0 percutaneous trach placed today by thoracic with minimal blood loss. Pt remains on CPAP but considerably groggy. Attempt to wean PSV tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-19 00:00:00.000",
"description": "Report",
"row_id": 1503048,
"text": "0700-1400:\nneuro: alert, responding appropriately to questions. denies pain.\n\ncv: sr 70-80, no ectopy. sbp remains 110-140. easily palpable pulses bilaterally.\n\nresp: lungs coarse at times, suctioned for moderate amounts thick bloody secretions. remains on cpap 40% 5 PEEP, p support decreased to 10. rr 20-30's. o2sat > 98%. oob -> chair.\n\ngi/gu: abd soft, nd. bs positive. tube feeding via dophoff. foley to gravity, good huo.\n\nendo: fs qid, cover per riss.\n\nplan: pulmonary toilet, wean vent as tolerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-19 00:00:00.000",
"description": "Report",
"row_id": 1503049,
"text": "BS few coarse crackles; no MDI's given. PSV decreased to 10. Pt mod tachypneic, f 30-35 with Vt's starting to decrease. need to increase PSV if pt continues to fatigue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-20 00:00:00.000",
"description": "Report",
"row_id": 1503050,
"text": "D Neuro: Pt alert response appropriately . MAE with noted weekness. sleeps when undisturbed.\n\nPain: denies when asked by mouthing no and shaking head.\n\nCV:RARE PVC. NSR. palp DP feet warm with good cappillary filling. heparin at 900unit at change of shift INR pending.\n\nLungs: coarse through out initially and dense still coarse but much improved. suctioned for thick clear to tan blood tinged sputum.\n\nGI: abd soft BS present. TF via dopoff at goal 60cc promote with fiber.\n\nGU: foley to gravity . clear yellow urine lasix last given at 2400 with effect pt negative.\n\nSkin: still some slight edema in extremities. some redness and bruising of skin. dsg intact. no skin break down skin prep to coccyx .\n\nA/P INR pending titrate heparin as indicated. RISS as ordered. repleat lytes as ordered. turn frequently continue slow ween today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-20 00:00:00.000",
"description": "Report",
"row_id": 1503051,
"text": "Respiratory Therapy\nPt remains orally intubated. PS increased from 10to 15 overnight for adequate MV. BS coarse rhonchi bilaterally W I&E wheezes on rt. Sx for mod thick to frothy bloody secretions. MDI's as ordered W improvement in aeration. RSBI this AM 147. Wean as .\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-18 00:00:00.000",
"description": "Report",
"row_id": 1503043,
"text": "BS occ rhonchi. Pt's PEEP was being weaned but around 1300hr pt self extubated. He is now on a non-rebreather mask. Goal is to keep his sats at 90 or above.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-18 00:00:00.000",
"description": "Report",
"row_id": 1503044,
"text": "7a-7p\nNeuro: pt sleepy all day but responds to voice. Oriented to person and year (month- ). Follows commands. Tylenol for discomfort with effect. Mood withdrawn, social worker aware- will see pt with family tomorrow.\n\nCV: sbp 110's-130's. SR 60's - 70's. Easily palp pulses. Heparin off from 0100- 1330 for trach. Hep on 700 units. PTT sent 1900.\n\nResp: Trach performed at bedside by Dr . No complications, Anes present. Trach site oozy after heparin restarted, team aware, cont with Hep gtt. Remains intubated on cpap 40%, peep 5, ps 12 with 02 sat >98%. Suctioned for thick tan bloody secretions.\nOOB to ch for several hrs.\n\nGI/GU: Remains npo. Dophoff placed lt by NP. CXR for placement done. TF restarted at 1300. +hyperactive bs. Green/brown loose stool in bag. Uop qs.\n\nEndo: Dextrose given for bs 59. BS now 214.\n\nFamily: in to visit today, updated by Dr .\n\nPlan: Cont to monitor hemodynamics and resp status. ?plan to wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-18 00:00:00.000",
"description": "Report",
"row_id": 1503045,
"text": "Above note at 1632 hrs in error. Wrong patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-19 00:00:00.000",
"description": "Report",
"row_id": 1503046,
"text": "Resp Care Note:\n\nPt cont trached and on mech vent as per Carevue. Lung sounds sl coarse after suct sm bldy sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required overnoc. Cont PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-19 00:00:00.000",
"description": "Report",
"row_id": 1503047,
"text": "Pt. very lethargic and distant with interactions. Following commands but with little effort. Began to smile this morning when spoken to as team rounded.\n\nVSS. CPAP with 12 all night with occ. episodes of tachypnea to rate 32. Sx. for thick bloody. Trach stoma cleansed with NS. Sutures intact.\n\nGI: Nasal feeding tube for feedings at 60cc/hr. Fecal bag removed and pt. passing soft stool. Guiac neg.\n\nGU: good response to Lasix. Weight down 1.3 kg.\n\nEndo: BS's elevated covered with SSRI.\n\nPlan: Heparin off in order to d/c pacing wires. Advance to OOB bed today. Social service to eval. re: behavior/withdrawn. Rehab screen process.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-17 00:00:00.000",
"description": "Report",
"row_id": 1503039,
"text": "NEURO: APPEARS INTACT, INTERACTING WELL WITH DAUGHTERS. MAE, FOLLOWING COMMANDS, NAPPING AT PRESENT, SAID SHE SLEPT POOPRLY LAST NIGHT. HOYED OOB TO CHAIR, WELL.\n\nCARDIAC: MP SR WITHOUT ECTOPY. DOPPLERABLE PULSES.\n\nRESP: CS COARSE, DIMINISHED IN BASES, SUCTIONED FOR THICK CREAMY SECRETIONS, ORALLY (WHICH SHE HATES ) FOR THIN CREAMY.\n\nGI: TOLERATING TUBE FDS AT GOAL, MINIMAL RESIDUALS, + BS'S, SMALL AMT LIQUID STOOL, MODERATE AMT FLATUS.\n\nGU: FOLEY IN PLACE, PATENT FOR CLEAR URINE, ^ WITH IV LASIX, LASIX CHANGED TO 40 MG IV BID RATHER THAN 80 .\n\nENDO: FOLLOWING PROTOCOL.\n\nPAIN: DENIES.\n\nDAUGHTERS IN, AWARE OF PLANS FOR TRACH . SON, , CALLED BY HO AND CONSENT FOR PROCEDURE OBTAINED. LONG EXPLANATION GIVEN AND BELIEVE THAT MOST OF HIS QUESTIONS WERE ANSWERED. WOULD LIKE TO KNOW WHEN SPECIFICALLY THAT THE PROCEDURE WILL BE DONE BUT REALISES THAT WE ARE UNABLE AT THIS TIME TO GIVE HIM THAT ANSWER.\n\nPLAN: NPO AFTER MIDNIGHT. HO WILL NOTIFY US WHEN TO STOP HEPARIN, 6H BEFORE PROCEDURE. CONTINUE TO MONTIOR HEMODYNAMICS. SUCTION PATIENT AS NEEDED, OBTAINED SMALL ORAL SUCTION APPLIANCE, PATIENT STILL HATES IT.\nTURN Q 2. CONTINUE SKIN CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-18 00:00:00.000",
"description": "Report",
"row_id": 1503040,
"text": "SEE CAREVUE FOR Q1H VS, IO AND ALL OTHER OBJECTIVE DATA.\n\nNEURO: ORALLY INTUBATED. RECEIVED NO SEDATION/NARCOTICS. OPENS EYES SPONTANEOUSLY, FOLLOWS COMMANDS, NODDING/SHAKING HEAD APPROPRIATELY TO QUESTIONS. MINIMAL MOVEMENT OF LE. SLEEPING SOUNDLY BETWEEN ASSESSMENTS.\n\nPULM: INTUBATED TO CPAP MODE, FIO2 0.4, PS 18/PEEP 5. HAVING FREQUENT PERIODS OF NON-OBSTRUCTIVE APNEA(20 SECS) WHEN SOUND ASLEEP, SATS STAY 99%, HR UNCHANGED. PS DECREASED TO 12 WITH CORRECTION OF APNEA FOR A COUPLE HOURS. SX'D FREQUENTLY FOR SMALL-MODERATE AMTS THICK TAN SECREIONS. LUNGS DIMINSIHED L BASE, ? BRONCHIAL RLL.\n\nCV: NSR 65-78, RARE ECTOPY. HEPARIN GTT INCREASED TO 750 UNITS/HR AT 2230 FOR PTT 48.4 THEN STOPPED AT 0100 MD FOR TRACH/PEG PLACEMENT IN AM. PEDAL PULSED DOPPLED.\n\nENDO: SSRI COVERAGE QID,\n\nGI: TF AT GOAL VIA OGT UNTIL 2400, DC'D FOR TRACH/PEG IN A,. + BS. FIB IN PLACE FOR STOOL.\n\nGU: FOLEY TO CD DRAINING QS AMTS URINE. LASIX 40MG IV AT WITH GOOD RESPONSE.\n\nSOCIAL: SON WANTS TO BE CALLED BY MD .\n\nPLAN: CONTINUE CPAP. TRACH/PEG THIS AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-16 00:00:00.000",
"description": "Report",
"row_id": 1503033,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse improve with suct mod th tan sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required overnoc. Cont mech vent/trach soon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-16 00:00:00.000",
"description": "Report",
"row_id": 1503034,
"text": "7a-7p\nneuro: pt alert and awake throughout the day. MAE with equal strength, attempting to write. Opening eyes spontaneously. +PERRL\n\ncv: remains sr 60-70; sbp 90-118. ptt down 82.3 this am, heparin gtt decreased to 700 units/hr, ptt 57.9 six hours later. heparin gtt remaining at 700 units/hr md.\n\nresp: ls coarse bilat (clear with suction), diminished at bases. suctioning for thick yellow sputum. remains cpap, see flowsheet for additional settings info.\n\ngi/gu: abd soft, +bowel sounds. large liquid yellow stool x2 today, rectal bag placed. tube feeds at goal. indwelling cath draining clear yellow urine, continuing 80mg lasix , diuresing.\n\nendo: continuing RISS per orders.\n\nplan: continue to monitor hemodynamics and resp. continue resp toilet. ?trach monday.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-16 00:00:00.000",
"description": "Report",
"row_id": 1503035,
"text": "Respiratory Therapy\n\nPt remains orally intubated on PSV. Currently +15PSV/+5PEEP w/ Vt ~450 RR ~18 maintaining Ve ~8L. BS slightly coarse, suctioned for small amounts of thick tannish sputum, copious amounts of tan oral secretions. MDIs given as ordered. SpO2 remained 90s. See resp flowsheet for specifics.\n\nPlan: maintain support; ?trach\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-17 00:00:00.000",
"description": "Report",
"row_id": 1503036,
"text": "nursing progress note 7p-7a\nneuro: pt orally intubated. awake and alert, follows commands, perrla, mae - very weak.\n\ncv: sr no ectopy. Hep gtt @700 ptt 54.2. no change per Dr. . Mag, Ca++, k+ repleted. wide pulse pressure - baseline for pt. AM lopressor held sbp 91. 2A/3V wires capped and secure. dressings changed. distal pulses w/ doppler.\n\nresp: vented cpap+ps 500x12, 5, 15, 40%. tolerating well. no attempts to interfer w/ tube. lungs coarse/dim. suctioned multiple times for thick tan secretions sm amts. ett tube repositioned. nystatin s/s for thrush on tongue.\n\ngi: OG tube. Promote w/ fiber @ goal of 60cc/hr,+ placement, no residual. abdomen soft to softly distended. rectal bag in place for scant amount liquid stool and lg amounts flatus.\n\ngu: foley to gravity draining lg amounts clear yellow urine. iv lasix w/ good outputs.\n\nendo: RISS please see insulin flow sheet.\n\nskin: very friable. paper tape. skin protectant ointment applied. multiple old ecchymotic areas bilat legs, left neck.\n\na/p: ? to OR monday for trach and peg. monitor lytes. aggressive respiratory hygiene. continue nystatin to tongue, skin care and multipodis boots. ? OOB to chair.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-17 00:00:00.000",
"description": "Report",
"row_id": 1503037,
"text": "RESPIRATORY CARE: PT W/ A 7.0 ORAL ETT IN PLACE.\nREMAINS ON PS 15/.40/5 PEEP W/ AN SPO2 98 %.\nSX FOR YELLOW SPUTUM. ALBUTEROL MDI'S BEING\nGIVEN. TO OR IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-17 00:00:00.000",
"description": "Report",
"row_id": 1503038,
"text": "RESPIRATORY CARE: PT HAVING A TRACH PLACED IN AM.\nNOT GOING TO OR IN AM AS MISTAKENLY STATED IN MY\nPRIOR NOTE. TEAM WILL ATTEMPT PERCUTANEOUS TRACH IN HIS\nROOM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-14 00:00:00.000",
"description": "Report",
"row_id": 1503028,
"text": "nursing note (7a to 7P)\n\nneuro: unable to access, intubated, able to move extremities & follow commands, poor grip and unable to lift extremities.\n\nresp: intubated currently on CPAP, 5P, 10 PS, rr high 30's, unable to wean off vent RSBI @ 1100 186, suctioned for small, thick, tan secretions, UL coarse, LL crackles @ base, RL diminished, if unable to wean from vent plan to trach possibly by Monday\n\ncv: hemodynamically stable, no gtts, nsr 60-70s, lytes repleted, a/v wires secured, a-line, RIJ, heparin gtt started @ 800units.\n\ngu/gi: good UO w/lasix, abg metabolic alkalosis ? change diurectic, n BM, +BS, t-feeds restarted @ 60cc/hr\n\nendo: ssri\n\ngoal: attempt to extubate, ? shut off t-feeds for extubation, monitor lytes/PTT, con't nursing plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-15 00:00:00.000",
"description": "Report",
"row_id": 1503029,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds rhonchi improving with suct mod th tan sput. MDI given as per order.ABGs stable after PSV level increased to pt. Cont PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-15 00:00:00.000",
"description": "Report",
"row_id": 1503030,
"text": "CSRU NSG:\n\nNEURO: Dozes intermittently, rouses to voice, appropriate, follows commands. Withdrawn.\n\nCV: SR, no ectopy. VSS. PTT 70.3 reported to . Heparine remains at 800U/hr.\n\nPULM: CPAP 5, PSV increased to 15 d/t RR 40's. LS coarse throughout. Suctioned for moderate amount thick, tan secretions prn. ABG WNL. Diamox started for metabolic acidosis.\n\nGU: Urine clr, yellow, output QS.\n\nGI: Abdomen soft, NT. Residuals WNL. Promote with fiber running at goal of 60cc/hr. Tube feeds turned of 0400 hrs pending possible extubation this morning.\n\nCOMFORT: Denies pain.\n\nASSESS: Vent dependent.\n\nPLAN: Wean with intent to extubate. Assess RSBI prior to extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-15 00:00:00.000",
"description": "Report",
"row_id": 1503031,
"text": "a shift\nneuro: opens eyes spontaneously; follows commands; mae; +PERRL. intermittently doses.\n\ncv: remains sr 80-90 without ectopy. sbp 90-110; this am sbp 150-160, treated with prn hydralazine with good effect. 1 unit prbc given for hct of 27.4; repeat hct pending. L radial a-line dc'd per team.\n\nresp: ls resp wheezes this am, cleared with inhalers; coarse, diminished at bases. suctioning for mod amts thick yellow sputum. cpap throughout the day, rr 16-20. rr increased to 40's when cpap 5/5, rsbi 163, unable to wean.\n\ngi/gu: abd soft, +bowel sounds. continues tube feeds at goal. continues lasix 80 mg , indwelling cath draining clear yellow urine.\n\nplan: ?trach on monday; keep on cpap in the meantime. continue pulmonary hygiene.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-16 00:00:00.000",
"description": "Report",
"row_id": 1503032,
"text": "SHIFT UPDATE 7P-7A\nSEE CAREVIEW FOR COMPLETE ASSESSMENT.\n\nPT LETHARGIC/ WITHDRAWN. VERY WEAK. OBSERVED WEAK MOVEMENT OF ARMS, VERY LITTLE MOVEMENT OF LEGS. FOLLOWS SIMPLE COMMANDS, IE; OPENS MOUTH FOR ORAL CARE ETC...\n\nREMAINS ON VENT, NO RESP DISTRESS. COPIOUS SECRETIONS FROM ETT AND ORALLY. OXYGENTATING WELL.\n\nECG SR FOR SHIFT, NO ECTOPY. BP STABLE. FEBRILE AT 101.7 AT . TYLENOL GIVEN, NOW T 99. ON HEPARIN GTT AT 800 U/HR. PTT PENDING.\n\nTOLERATING TF AT GOAL. INCONTINENT X 1 OF LOOSE GOLDEN COLORED STOOL.\nDIURESING WELL AFTER LASIX.\n\nPLAN; PT TO BE TRACHED ON MONDAY. ANESTHESIA OBTAINED CONSENT FROM HCP ) VIA TELEPHONE LAST NIGHT. CHECK LABS AND REPLACE LYTES, ADJUST HEPARIN GTT AS ORDERED. FOLLOW HCT, (PT TX 1 U PRBC'S YESTERDAY). NOTIFY TEAM OF HIGH TEMPS, ? PAN CX.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-10 00:00:00.000",
"description": "Report",
"row_id": 1503008,
"text": "UPDATE\nD: PT REMAINS INTUBATED, WT UP 10 KG FROM , PT WEANED TO CPAP 5 PEEP AND 10 - PT EVENTUALLY WEANED TO 5 WITH TV >300CC, PT APPROX 1 HR THEN RESP RATE >30 CONSISTENTLY.- PLACED BACK TO 10 PT FATIGUED WITH RESP RATE >30 AGAIN- PLACED BACK ON CMV- . AMIODARONE CHANGED TO PO- OKAYED BY EP TEAM. PT GIVEN LASIX THIS AM WITH BLOOD-DIURESED MOD.\nNEURO: PT AWAKE, SOMEWHAT LETHARGIC-RESPONDS TO COMMAND, MAE, NODDIMG TO QUESTIONS APPROP. NO SEDATION GIVEN.\nCARDIAC; PT REMAINS IN NSR WITH NO ECTOPY, AMIODARONE CHANGED TO PO PER CARDIOLOGY. SBP 120-146/50 DEPENDING ON WAKEFULNESS. DOES SETTLE BACK TO 120'S ONCE RELAXED. PALP PEDAL PULSES, LEFT STRONGER THAN RIGHT. FEET WARM BILAT. CVP 9-12.\nRESP: BS , TUBULAR IN RIGHT BASE, SL DIM IN LEFT. SX FOR THIN CLEAR TO TAN SPUTUM, PT APPEARS TO HAVE \"JUICY\" COUGH- YET ONLY SX SMALL AMT. PT WEANED TO CPAP 5 PEEP AND 5 - TV >300CC, RESP RATE 20'S YET AFTER APPROX 30MIN UP TO >30.PT TITRATED UP TO 8 THEN 10 AFTER A TOTAL OF 4 HOURS PLACED BACK ON CMV. SAT REMAINS>99%, ABG GOOD.\nGI: TF'S WELL, ABD SOFT, BS PRESENT, NO BM POST OP- CONT ON COLACE AND PPI.\nGU; CREAT 1.6--LASIX GIVEN PER DR PTU/O DID PICK UP THEREAFTER, PC GIVEN AS WELL, CVP 9-12.\nINC; INTACT, ????D/C STABLES LEFT CAROTID INC.\nPLAN: MONITOR TEMP--F/U ON CULTURES SENT -\nREST ON PT AGAIN ON CPAP WITH PT .\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-26 00:00:00.000",
"description": "Report",
"row_id": 1503079,
"text": "ROS:\n\nneuro: Sedate. Clonazepam decreased. Opens eyes to verbal stim. No spontanious movements of extremities noted. Does not follow commands. PEARRLA.\n\nCV: RSR w/o ectopy. VSS. On metoprolol 12.5 mg , dose decreased yesterday. Peripheral pulses palpable. Sternal wound approxamated, no drng noted, DSD applied. Mediastinal wounds CDI. Has left radial ABP line. Has right IJ, prox port w/o blood return, marked \"Do NOT use\". Heparin sq for dvt prophylasis.\n\nResp: Trached and on CPAP , 40%. Lungs sounds clear and diminished in the bases. Sx mod amt of tan to yellow secreations via trach. No resp distress noted, = rise and fall of chest.\n\nGI: Pedi tube via left w/TF infusing at goal. Abd soft and distended. Flatus noted, no stool. Protonix for GI prophylaxis.\n\nGU: Foley patent draining clear yellow urine in QS.\n\nEndo: FSG covered w/RSSI\n\nID: Tmax 101.4, Zosyn changed to q 8 hrs and dose ^ to 4.5 Gms\n\nLabs: Stable\n\nSocial: no contact from family or friends this shift.\n\nPlan: Pulmonary toileting. Attempt to wean PS. Mobilize. Monitor, tx, support, and comfort.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-26 00:00:00.000",
"description": "Report",
"row_id": 1503080,
"text": "resp care\nPt overnight on psv12/peep5 and 40%. Volumes ranged from 350-450cc and rr . RSBI done =180.BS coarse bil. Suct for thick tan sput. Alb/atr/flov mdi given as ordered.Will cont to follow and wean psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-05 00:00:00.000",
"description": "Report",
"row_id": 1502985,
"text": "low filling pressures,dark scant urine w elevated svr & ci < 2 on low dose epi. add'l volume given,a paced(post reversal drop in rate to the 60's)without much change. svo2 < 60% at present with continued low filling pressures & low huo,cool extremities. add'l fluid bolus infusing then will recheck parameters & labs.opens eyes to voice & mae's to command,grasp equal & consistent bilat.plan to attempt vent weaning once hemodynamics improve pending orientation/agitational level.ogt w brownish material with occas. bloody streaks. zantac->protonix,sucrafate as ordered. glucoses managed w protocol,see flow sheet & comments. family in,questions answered.son is designated spokesperson & recieved icu visitor guidelines.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-05 00:00:00.000",
"description": "Report",
"row_id": 1502986,
"text": "hypertensive to > 200 hg during waking with agitation. attempt aborted & propofol resumed. will reattempt in a.m. low dose dobutamine started for persistent poor hemodynamics/huo with much improvement. epi weaning as tolerated.rt. groin (vein harvest site) still oozing,pressure dsg applied.see flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-06 00:00:00.000",
"description": "Report",
"row_id": 1502987,
"text": "Resp Care\nPt remains on MV in SIMV+PS mode. Unable to wean earlier in shift due to hypertension, but plan to try again this am. Pt breathing spontaneously, but spont VT's <300 with 10 PS at this time. Pt currently hypotensive.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-06 00:00:00.000",
"description": "Report",
"row_id": 1502988,
"text": "neuro: sedated on prop- medicated with morphinex1 with fair effect- pt becomes agitated when prop - has history of sun-downing - pupils\nresp: lsc to dim- ct dng wnl- imv 600/10/40/5- pt acid base balance poor- latest gases poor- seems to do better on higher prop with rate in 's-\ncv: nsr to st- ci/co poor- not much better by fick- on dobut-epi-prop-neo-to maintain b/p abd output- prbc given with lasix for elavated filling pressures and no uo late in shift with fair results- pulses palp bilat- rue- re wrapped to control oozing from access site- pt given large amts of fluid since or-\ngi/gu: abd soft - bs hypoactive- ngt to sx - foley to gravity- uo poor- responded ok to lasix given-\nendo: bg per ss-\nplan: stabalize hemodynamics- wake and wean- cont plan of care\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-06 00:00:00.000",
"description": "Report",
"row_id": 1502989,
"text": "Resp Care\nPt remains intubated on SIMV. Pt had been weaned and prepared for extubation. Had afib/vtach episodes requiring cardioversion. Pt now hemodyn unstable now. Plan to continue with current tx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-06 00:00:00.000",
"description": "Report",
"row_id": 1502990,
"text": "Narrative note\nCV: NSR UNTIL 1600, THEN PT WITH RAPID AFIB IN 150'S W/ DECREASED BP IN 70'S. PT ON DOBUTAMINE AT 2.5MCG/KG/MIN. AND NEO AT 0.6MCG/KG/MIN.\nPT PLACED IN TRENDELENBURG, FLUID BOLUS STARTED, TOTAL 1,000CC NS GIVEN. AMNIODARONE 150MG BOLUS GIVEN. PACER PADS PLACED ON PT, CARDIOVERTED AT 150 JOULES AT 1605. PT BECAME ASYSTOLIC, PT AV PACED BY CARDIOLOGY. RESUMED RAPID AFIB IN THE 150'S. NEO INCREASED TO 2.0MCG/KG/MIN. LOPRESSOR, 2.5MG IVP GIVEN WITH NO EFFECT. CARDIOVERTED AGAIN AT 1615 AT 200JOULES, BRIEF NSR AND THEN R-AFIB IN 140'S, BP STABLE ON NEO GTT. DOBUTAMINE STOPPED. CARDIOVERTED FOR THIRD TIME AT 1620 WITH 250J , BECAME ASYSTOLIC, THEN AV PACED AND THEN BACK INTO R-AFIB. BRIEF RUNS OF V-TACH, LASTING APPROXIMATELY 8-10 BEATS TIMES THREE. LIDOCAINE BOLUS GIVEN, 100MG IVP. EPICARDIAL PACING WIRES TESTED BY CARDIOLOGIST. VPACED IN THE 80'S. NO FURTHER RUNS OF VT. ELECTROLYTES REPLEATED.FICK CARDIAC INDEX REMAINS >2 AFTER DOBUTAMINE STOPPED. PT REMAINS AT THIS TIME. LEFT CAROTID ENDARDARECTOMY INCISION WITH STERI-STRIPS CLEAN AND DRY. HIT PROFILE NEGATIVE. POS PEDAL PULSES BILATERALLY BY DOPPLER.\n\nRESP: TRIALS ON CPAP THIS AFTERNOON WERE SUCCESSFUL, UNTIL CARDIAC EVENT. ABG'S IMPROVED THROUGHOUT THE DAY. PLACED BACK ON SIMV AFTER EVENT, SEE FLOW SHEET. CT DRAINAGE WNL, IN AM LS WITH CRACKLES AT BASES/BILATERALLY.EVE COARSE ON RUL, DIMINISHED BILATERALLY. MAINTAINED O2 SAT WNL, MIXED VENOUS 68, THEN AT 56 FOLLOWING EVENT.\n\n\nNEURO: PRIOR TO EVENT, PT TO VOICE , FOLLOWING COMMANDS, MAE'S PURPOSEFULLY. PERRLA. MORPHINE FOR PAIN X'S 3. DURING EVENT , VERSED GIVEN, 2.5 MG IVP, PRIOR TO CARDIOVERSION. PROPAFOL RESTARTED AT 1800.\nFAMILY AWARE OF EVENT. SPOKEN TO BY DUNDEN, PA.\nFOLLOWING EVENT NEURO STATUS INTACT.\n\nGI/GU: OGT TO LCS, ABD SOFT, HYPOACTIVE BS, MARGINAL U/O. LASIX 10MG X'S ONE\n\nENDO:INSULIN DRIP PER CSRU PROTOCOL\n\nA/P: PT WAS HEMODYNAMICALLY COMPROMISED. R-AFIB/CARDIOVERTED/V-PACED IN 80'S. DOBUTAMINE REMAINS OFF, CARDIAC INDEX >2.0 . BP STABLE ON NEO CURRENTLY AT 1.25MCG/KG/MIN. SEDATED WITH PROPOLFOL , ON SIMV, TO REMAIN INTUBATED THROUGHOUT NIGHT. PLAN FOR LASIX THIS EVE, INSULIN DRIP. CONTINUE TO MONITOR BS Q1H. CONTINUE WITH ICU INTERVENTIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-09 00:00:00.000",
"description": "Report",
"row_id": 1503002,
"text": "CSRU UPDATE\n\nNEURO: LOW DOSE PROPOFOL D/C THIS AM. PT AWAKENING SLOWLY. FOLLOWS COMMANDS BY NOON. ONLY MIN MOVEMENT OF ANY EXTREMS. PERL THOUGH LARGE.\n\nCV: VSS. ON LOW DOSE NEO TO ATTEMPT TO MAINTAIN BP > 110 FOR REANL PERFUSION. HCT 24.4 THIS AM, 1 UNIT PRBC COMPLETED AT PRESENT. NSR 58-70. AMIO DRIP DOWN TO .5MG/MIN. NSR CONT. A WIRES CHECKED BY CARDIOLOGY, THRESHOLD 14. 3+ GENERAL EDEMA. T MAX 101.\n\nRESP: PT TO CPAP +/8 IPS THIS AM. TOL W/ RR IN 30'S THEN RR INCREASING TO 40'S. ABG ACCEPTABLE -> AC FOR REST PERIOD. LUNGS CLEAR TO COARSE AND LARGE AMT SECRETIONS THIS AFTERNOON. SATS 100% THROUGHOUT SHIFT.\n\nGI/GU: UOP MARGINAL, CREAT TO 1.7 THIS AFTERNOON. ABD SOFT. HYPO BSP. PROMOTE W/ FIBER TF BEGAN AT 10CC/HR. INSULIN DRIP TO OFF.\n\nPAIN: NO APPARENT PAIN.\n\nSOCIAL: DAUGHTER IN ROOM, QUITE DISTRESSED MUCH OF TIME.\n\nASSESS: STABLE DAY. TOL CPAP FOR FEW HOURS\n\nPLAN: CONT SUPPORTIVE CARE. WEAN AS TOL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-09 00:00:00.000",
"description": "Report",
"row_id": 1503003,
"text": "Resp Care\n\nPt's mode of ventilation was changed to CPAP/PSV and PS was weaned to 8 for 2.5 hrs. Abg 7.35/34/151/20. RR had increased to low 40's and mode change to A/C. BS remain coarse and suctioning thick sputum.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-09 00:00:00.000",
"description": "Report",
"row_id": 1503004,
"text": "1500-1900 update\nNeuro: Follows commands weakly. Decreasing Temp. No pain meds/sedation given.\nResp: Maintains vent. Sx. , frothy sputum. Lots of oral secretions. BS CTA R, Co L.\nCV: Sinus brady w/ a pacing. Third spacing.\nGI/GU: Promote w/fibre @ 10 ml/hr via OGT. +BS. Indwelling foley. U/O borderline.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-26 00:00:00.000",
"description": "Report",
"row_id": 1503081,
"text": "7A-7P:\nneuro: difficult to arouse, able to follow commands x1 throughout day. perrl, team aware of mental status, klonopin d/c'd. tmax 102, bc x1 sent, np aware. id following , antibiotics changed.\n\ncv: sr 60's, no ectopy. sbp 130-140's throughout day. weakly palpable pedal pulses bilaterally. awaiting iv rn to place picc line and d/c right ij tlc. continue with lopressor and lisinopril. amiodarone changed to 200 mg qd.\n\nresp: lungs clear, diminished bases bilaterally. remains on cpap 40% 5 peep, 5 pressure support. abg wnl. rr 45, tv 200-300. o2sat> 98%. moderate amt thin secretions. team aware.\n\ngi/gu: cr 1.3, foley to gravity, lasix given x 1 with good response. abd softly distended. bs positive. dophoff to feeding, tolerating at goal.\n\nendo: fs qid, cover per riss.\n\nplan: monitor mental status, monitor fever. continue antibiotics and wean as tolerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-20 00:00:00.000",
"description": "Report",
"row_id": 1503052,
"text": "NPN: Review of Systems\nNeuro: Pt alert. Mouthing questions and answers. Denies pain.\n\nResp: Trach msk trial done this morning, but Pt was becoming increasingly tachypneic w/ RR in the upper 40s. Exp wheezing throughout and Pt was bronchospastic.SAO2 remained in the 90s, but Pt looked labored so placed back on Pressure support. Initially up to 15 and then brought down to 10. This afternoon, Pt again looking tired, RR up and copious blood tinged frothy/thin secretions suctioned from tracheostomy. Upper airways sounded CTA and diminished in bases no expiratory wheezing heard like in the morning. Blood oozing from around trach site. Pt placed on assist control and notified to assess patient.\n\nCV: SR. NO ectopy. AMiodarone as ordered. BP has been stable. Please see flowsheet. Skin warm/dry. Chest incision well approximated w/ staples intact. No drainage.\n\nGI: Tubefeedings were infusing at goal rate of 60cc/hr. Approx. 2pm it was observed that dobhoff tube had slipped out from initial mark. Pt suctioned for secretions as noted above. Tubefeedings were stopped. removed dobhoff . LArge soft/formed golden bowel movement today.\n\nGU: Brisk clear yellow urine via foley after lasix given.\n\nID: Tmax=100.1\n\nHeme: Heparin initially infusing at 900units/hr. PTT=94 therefore dose decreased to 850units per hour. PTT pending.\n\nSkin: Bruising noted on extremities, but no pressure wounds observed.\n\nActivity: OOB to chair via lift.\n\nA: Respiratory status guarded. Did not do well on trach mask trial.Increased pulmonary toileting needed.\nElevated PTT out of therapeutic range. Hemodynamics stable. Inadequate nutrition d/t removal of feeding tube.\n\nP: ETT suctioning as needed. PA to assess vent settings. f/u with PTT results. Monitor as orderd.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-20 00:00:00.000",
"description": "Report",
"row_id": 1503053,
"text": "Resp Care\n\nPt had 1 hr off vent via trach collar. PSV was also weaned to . RR did increase to high 40's. PT increase in secretions which are in large amts and blood tinge,\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-20 00:00:00.000",
"description": "Report",
"row_id": 1503054,
"text": "15-19 update\npt sleepy altough easily arousable. pt able MAE and follow commands. PERRL. pt remains NSR, no ectopy noted. Hr in the 70's. SBP 100-120's. pp by doppler. pt continues on heparin gtt. last PTT in the 90's -> heparin gtt decreased to 750 u/hr. pt recieved 1st dose of coumadin this evening -> given 3 mg coumain. Ls coarse -> suctioned frequently for thin blood tinged sputum. bleeding aournd trach site. trach care done x 2. pt started on levaquin d/t incresed secreations today. pt tachypenic this evening -> continues on CPAP -> PS increased to 15 (from 10). once PS increased the pt RR was WNL. pt with + BS. new dobhoff placed at bedside. Abd X ray showed dobhoff was in stomach (per team). TF -> protote with fiber restarted after Xray confirmed placement. pt had 1 formed stool -> guiac negative. foley draining clear yellow urine. Uo adequate. pt remains weak -> hoyered back to bed\n\nplan: rest overnight, wean PS in AM, continue tube feeds, monitor lytes/PTT's/INR, continue heparin gtt and coumadin, pulm toliet\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-10 00:00:00.000",
"description": "Report",
"row_id": 1503005,
"text": "NEURO~ALERT. FC. MAE. RESPONDING APPROPRIATELY TO YES AND NO QUESTIONING. PROPOFOL OFF SINCE EARLY . MED W/ 1 MG MORPHINE SULFATE AND GIVEN 650MG ELIXIR FOR C/O DISCOMFORT. EFFECTIVE.\n\nCARDIAC~REMAINS IN SR~64, NO ECTOPY NOTED. CONT ON AMIODARONE @ .5 MG/MIN. NEO REMAINS OFF. SBP REMAINS > 100. DAILY COUMADIN DOSE DC'D. A WIRES WORKING, V'S ARE NOT. SEE FLOW SHEET. LEFT CAROTID STERI STRIPS D&I. POS PEDAL PULSES BILAT W/ DOPPLER.\n\nRESP~CONT ON CMV. SEE FLOW SHEET FOR SETTINGS. LUNGS~CLEAR/COARSE W/INT INS/EXP WHEEZING BILAT. ALB INHALERS Q4/PRN. MAINTAINING SATS 98-100%. SX FREQ FOR SM AMTS OF THIN SECRETIONS. REPEAT SPUTUM SPECIMEN SENT. ABG~SL MET ACIDOSIS.\n\nGI/GU~TOL TF OF PROMOTE W/ FIBER, MIN RESIDUALS. ^ RATE BY 10 CC'S Q/4 HRS. GOAL 60 CC'S HR. MARGINAL U/O. + BS - BM.\n\nENDO~SSRI PER CSRU PROTOCOL.\n\nSKIN~GENERALIZED BODY EDEMA. SM AMTS OF SS DRAINAGE FROM R ARM AND R LEG INCISION SITES.\n\nA/P~HEMODYNAMICALLY STABLE. CONT ON AMIODARONE @ .5 MG/MIN. CONT TO MAINTAIN SBP >100. COMPROMISE RESP STATUS. TO REMAIN ON CMV FOR TONIGHT AND TO BEGIN CPAP TRIALS AT SOME POINT TOMORROW. CONT TO ADVANCE TF AS TOL ~ GOAL 60 CC'S/HR. CONT W/ ICU INTERVENTIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-10 00:00:00.000",
"description": "Report",
"row_id": 1503006,
"text": "Respiratory Care Note:\n patient remains orally intubated and on ventilatory support. No changes made this shift. Please see carevue for specifics. Latest ABG acceptable. SX'd Q2-4 hours for a small to sometimes scant amount of thin secretions. BS are coarse t/o. Albuterol ordered this shift for I/E wheezes faint. RSBI this am is 107.5 on 0peep/5psv. Patient remained afebrile this shift. Overbreathes vent by 2-3 breaths. CXR showed bilateral pleural effusions and LLL atelectasis. Plan is to continue support and wean to CPAP when tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-25 00:00:00.000",
"description": "Report",
"row_id": 1503073,
"text": "Respiratory Care\nPt. trached on ventilatory support. . CPAP/PS 10 cm until early a.m when pt. spiked temp. to 102, RR increased to 50's, PS increased to 15 cm, responded very well with immediated decrease in RR. RSBI trial not well this a.m. RSBI = 157, unable to return PS to 10 successfully,RR increased to 30's and Vt decreased to 200's. PS. currently at 12cm and well. Sx for mod to lg. amounts blood tinged secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-25 00:00:00.000",
"description": "Report",
"row_id": 1503074,
"text": "ekg nsr, rate 60s, no ectopy. sbp 110-120s, no pressors. temp spike to 102.8, dr, aware, pancultured, tylenol given, temp now 99.9. adequate uo, clear yellow. glucose and k stable. breath sounds clear, decreased at bases, occ suction copious amts thick tan secretions from trach. during temp spike, became tachypneic to 50, ps increased to 15 with immediate resolution, rate dropped to 15. later resp rx tried to drop ps to 10 again, but did not tolerate, is currently at 12. abd soft, tolerating tf at goal, 60cc/hr, no stool tonight. chest dressing dry, changed. skin warm, moist, coccyx slightly pink, as are backs of heels, splints off for now. still lethargic, opens eyes to repeated loud voice, follows commands weakly, appears to sleep when undisturbed, clonipin evening dose held, reported to team this am that it seems to knock her out. plan to monitor mental status, advance weaning as tolerated, review cultures.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-25 00:00:00.000",
"description": "Report",
"row_id": 1503075,
"text": "PATIENT OOB VIA LIFT DID WELL, WEANING PRESSURE SUPPORT TO 8, ABG GOOD RR30-36, RESTING COMFORTABLE.K REPLETED. TUBE FEEDS AT 60CC/HR WITH SOFT FORMED BN. BS ELEVATED 178 8UREGULAR INSULIN SC GIVEN. PLAN TO START NASAL SPRAYS FOR ?? SINUSITIS. TEMP TO 38.3 PO TYLENOL 650 ELIXIR..\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-25 00:00:00.000",
"description": "Report",
"row_id": 1503076,
"text": "Respiratory Therapy\n\nPt remains trached w/ #8.0 Portex on PSV. Remained most of the day on +8PSV/+5PEEP w/ Vt ~200s RR as high as 45BPM. Per team/NP, wanted to \"work/exercise\" pt lungs and would tolerate RR as high as 45. Pt stayed consistently that high so was increased to +12. BS coarse bilaterally, suctioned for copious amounts of thick blood tinged secretions. SpO2 remained 90s. MDIs given as ordered. See resp flowsheet for specific /data/changes.\n\nPlan: maintain support; continue to wean towards trach collar when appropriate...\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-25 00:00:00.000",
"description": "Report",
"row_id": 1503077,
"text": "PATIENT OOB TO CHAIR VIA X3HRS, BACK TO BED FOR CARDIAC ECHO.PER NO ISSUES WITH ECHO. PATIENT BREATHING ON PS 8 FOR APPROX. 6HRS, WITH GOOD ABG RR 30-45 ONCE OVER 45 PLACED BACK ON PS 12, PLAN TO RESTOVERNIGHT WEAN IN AM AGAIN, THICK BROWN SECRETIONS FROM TRACH. TRACH CLEANED, MINIMAL DRAINAGE, CHANGED INNERCANNULA AT 1600 WITH NEW DSG. SR IN THE 60'S LOPRESSOR/LISINOPRIL GIVEN, AMIODARONE AT 400MG QD. SBP 110-130. GU ADEQUATE U/O LASIX/DIAMOX DCD. GI CONTINUES ON PROMOTE WITH FIBER AT 60CC/HR SOFT ABDOMEN, X2 LARGE SOFT FORMED STOOL. K REPLETED. BS TREATED WITH SSINSULIN. CONTINUES ON ZOSYN FOR PSEUDOMONAS IN URINE/SPUTUM. STARTED ON NASAL SPRAY TREATMENT FOR ?? SINUSITIS. PATIENT DOES FOLLOW COMMANDS ALERT FOR BRIEF PERIODS TODAY, BUT OTHERWISE ALEEPING, DID RECEIVE PT X2. CLONAZEPAM NOW .25MG .\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-25 00:00:00.000",
"description": "Report",
"row_id": 1503078,
"text": "TYLENOL 650 MG ELIXIR GIVEN X2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-04 00:00:00.000",
"description": "Report",
"row_id": 1503104,
"text": "Nursing Progress Note\nNeuro: Lethargic to apathetic. Opens eyes with turns, no command following, localizes pain. Tracks well. Non-participatory in turning and care. Withdraws to pain. Multipodus booths to BLEs. Perla 3 brisk. Strong cough, weak gag.\n\nCVS: HR sinus brady to sinus rythm no ectopy. ABP >100, line positional and dampens, but has blood return. Skin warm dry and intact. Pulses present x 4 ext. piv x 2, outdated, left because anticipated dc tomorrow and appears to be a difficult needle stick, will discuss with team at rounds. scd.s to BLEs.\n\nResp: LS coarse throughout. Trach with mask at .4 with sats 100 %. sxn for thin to frothy secretions. CPT x 2. Cough productive but remains congested.\n\nGI: abd soft bs hypo. receiving pro balance tube feeing via small ng tube at 60 cc hour.\n\nGU: Foley cath with sedimented urine, occasionally cloudy.\n\nPain: no apparent.\n\nRestraints: not utilized.\n\nActivity: range of motion, passive done. Plan to get oob with lift in am.\n\nSee flow sheet for further details and values, awaiting notification of rehab bed and transfer time.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-04 00:00:00.000",
"description": "Report",
"row_id": 1503105,
"text": "PT STABLE, MIDLINE PLACED, DISCHARGED TO , , MASS. AT 1315 BY ACLS AMBULANCE. SON NOTIFIED BY CASE MANAGER. PAGE 1, 2, 3 AND DISCHARGE SUMMARY COMPLETED AND SENT WITH PATIENT. EXTRA TRACH SENT PER REHAB'S REQUEST.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-08 00:00:00.000",
"description": "Report",
"row_id": 1502996,
"text": "NEURO-SEDATED ON 25MCGKGMIN PROPOFOL. NO SPONTANEOUS MOVEMENT OF EXTREMITIES. OCC.BITES DOWN ON TUBE AND FURROWS BROW WHEN SXD.PERLA @ 4MM. CORNEAL EDEMA.\n\nCV- 2 EPISODES OF AFIB @ 2200 LASTING TOTAL OF 15MINS.INCREASING FREQUENCY AND LONGER LASTING EPISODES IN EARLY AM. HEMODYNMAICALLY STABLE WHEN IN AFIB. CONTINUES ON AMIO -NO BOLUS THIS SHIFT. PACER SET FOR A-DEMAND @ 80. PACER STILL PACING DIAPHRAGM. A& V WIRES S/C APPR.NO LOSS WHEN REPOSITIONED OR DURING TOTAL HYGEINE CARE.UNDERLYING RHTHYM =SB/SR 58-63. DEFIB PADS ON PT.CO/CI=4.2/2.8\nMV02=63,61%.CA+ REPLETED.3+ BLU EXTREMITY EDEMA.\n\n\nRESP-CONTINUES ON SIMV/PS. DEPENDANT SIDE DOWN DEVELOPS COURSE RHONCHI AND THE DIFFUSES WHEN RE-POSITIONED. SXD MULT. X'S FOR THICK SPUTUM.SATS=99%.CT SITE CLEAN/RE-DRESSED.FOUL SMELLING ORAL CAVITY,MOUTHWASH SWABS PRN.\n\nGI- ABD SOFT. ACTIVE-> ABSENT BS.PLACEMENT CHECKED. OGT DRG BILIOUS->BROWN-> BILIOUS SECRETIONS. NO STOOL.\n\nGU-DECREASING U/O. 20MG IVP LASIX WITH FAIR DIURESES. NP NOTIFIED. 40MG IVP LASIX X1 WITH INCREASING U/O.BUN/CR=28/1.2\n\nENDO-INSULIN GTT RE-STARTED AT 2U/HR WITH 2U BOLUS FOR GLUCOSE =143. CSRU PROTOCOL FOLLOWED FOR SUBSEQUENT GLUCOSE LEVELS.\n\nPLAN- ? CHANGE LINE OVER WIRE TODAY? EP CONSULT FOR AFIB. DIURESE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-08 00:00:00.000",
"description": "Report",
"row_id": 1502997,
"text": "Resp Care\n\nPt's sedation was lighten and rr increase to high 30's. Mode changed to A/C and rr deceased to low teens to mid 20's. Bs are coarse and suctioning thick tan sputum\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-08 00:00:00.000",
"description": "Report",
"row_id": 1502998,
"text": "NEURO: PT INITIALLY SEDATED ON PROPOPFOL & UNRESPONSIVE; PROPOFOL WEANED AND TURNED OFF FOR LINE CHANGE. PT AWAKENED AFTER LINE CHANGE, MAES & FOLLOWED COMMANDS, BUT PT REMAINS SLEEPY. +PERRL.\n\nCV: PACER TURNED OFF TO ASSESS UNDERLYING RHYTHM-SB/SR 50S. PACER SET FOR ADEMAND OF 60. CI VIA FICK >2 WHILE PT IN OWN RHYTHM. HIT SCREEN SENT~NEGATIVE. BP MAINTAINED >90 WHILE IN SB. SWAN DC'D, MULTILUMEN HEPARIN FREE PLACED VIA GUIDEWIRE. NEO & PROP OFF DURING LINE CHANGE AND PT'S OWN HR INCREASED TO 60S. TITRATED NEO TO MAINTAIN SYSTOLIC BP >90. HIT SCREEN SENT D/T CONSISTENT LOW PLTS <40, RESULTS NEGATIVE. LYTES REPLETED. IN/OUT OF AFIB THIS EVENING, REBOLUSED WITH AMIO, CONVERTED TO SB/SR 54-61 WITH GOOD BP, NOW SET FOR ADEMAND OF 51. PRESSURE DIPS SLIGHLTY WHILE IN AFIB TO 90S.\n\nRESP: RT LS ARE COURSE UPPER LOBE, CRACKLES HEARD @ BASE, LEFT UPPER IS CLR, BASE IS DIM. SXN'D THICK SPUTUM X3. PT INITIALLY ON IMV AND COMFORTABLE WHILE ON PROPOPFOL THIS AM. AFTER PROPOFOL TURNED OFF, PT DID NOT TOLERATE, BECAME TACHYPNIC. ATTEMPTED CPAP W/PS OF 17 WHICH PT DID NOT TOLERATE, BECAME TACHYPNIC VENT CHANGED TO AC, PT MORE COMFORTABLE. ATTEMPTED CPAP THIS AFTERNOON W/PS INITIALLY OF 12 AND DID NOT TOLERATE, BECAME TACHYPNIC AGAIN, RSBI WAS 150. PT NOT EXTUBATED TODAY D/T INABILITY TO RAISE HEAD OFF PILLOW, AND RSBI OF 150. PS CHANGED TO 15 AND PT NOW MORE COMFORTABLE. O2SATS CONSISTENTLY >97%.\n\nGI/GU: BS PRESENT AFTER PROPOFOL OFF. NO BM; OGT PATENT-PLACEMENT CHECK DONE. FOLEY DRNG CLR LIGHT YELLOW URINE-OUTPUT WAS 15CC FOR 1HR, 40 LASIX GIVEN WITH MARGINAL RESULTS. CREATININE RISING, METABOLIC ALKALOSIS.\n\nENDO: BS MONITORED PER CSRU SS PROTOCOL; INS GTT OFF DURING LINE CHANGE, GTT BACK ON DUE TO BS OF 116.\n\nSOCIAL: PT'S CHILDREN VISITED THROUGHOUT THE DAY.\n\nPLAN: CONTINUE MONITORING CARDIORESPIRATORY STATUS. MONITOR HEMODYNAMICS. START PROPOFOL @5MCG FOR IF NECESSARY. PT TO REMAIN ON CPAP OVERNIGHT IF PT IS COMFORTABLE, BUT CAN BE CHANGED TO AC IF NECESSARY. ? NUTRITION ORDER FOR TF.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-11 00:00:00.000",
"description": "Report",
"row_id": 1503014,
"text": "Resp Care\nPt remains intubated on A/C. Pt was extubated and reintubated due to increased stridor, declining sats, and increased resp distress. Pt stated taht she did not want tube out prior to extubation. Pt suctioned for copious amt of thick frothy secretions. ALB MDI given.\nNo other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-09 00:00:00.000",
"description": "Report",
"row_id": 1502999,
"text": "7p-7a\nPt initially awake and alert. Tracking with eyes and able to nod yes and no to questions. PERRL. Started on Prop 5 mcgkg/min for comfort when tired on c-pap and changed to AC to rest for night. Increase to 10 when pt frequently coughs and fighting the vent. Non purposeful movements of legs. PT in Sinus brady throughout shift except 1 episode of controlled A-fib around 2100 lasting approx 15 minutes. Converted on own. Maps remained in 60's throughout episode. Crit trending down, at 24.4. Platelets up from 30 to 76. Will alert team on rounds.\nTitrating NEO for goal of SBP above 90. PT's urine output increase when Sbp above 100. Neo at present .5mcgkg/min. Pacer set for A demand of 50. Paces diaphram when on.V wires not capturing. Needs frequent suctioning of thick whitish yellow sputum. Afebrile this shift. WBC down to 17.7 Sats 100% on AC and ABG unchanged from previous. See Carevue. Foul smelling oral cavity cleaned, Nystatin via swab prn. Abd soft hypoactive BS. OG to low suction with minimal brown bilious secretions. Placement checked. No stool. Urine QS. Insulin gtt as per protocol. Lytes replaced as needed. Slight increase BUN/Creat.\n\nPlan: Question nutrition status. Monitor cardiovascular status. Question extubation in am. Comfort measures.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-09 00:00:00.000",
"description": "Report",
"row_id": 1503000,
"text": "RESP CARE: Pt remains intubated/on vent per carevue. Placed on AC at , to rest overnight in anticipation of extubating pt today. lungs coarse. Sxd thick pale yellow/ sputum. RSBI this am 118.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-09 00:00:00.000",
"description": "Report",
"row_id": 1503001,
"text": "Addendum:\nDr of drop in crit at 0500. No orders at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-23 00:00:00.000",
"description": "Report",
"row_id": 1503068,
"text": "PATIENT VERY LETHARGIC ALL DAY TEMP UP TO 38.6 TYLENOL 650 MG VIA NGT X2.. MAE TO COMMAND WITH RN SPEAKING LOUD, ALLEXTREMITIES WEAKLY, PUPILS EQUAL/REACTIVE. AWAKE TO PAINFUL STIMULI. CHILDREN INTO VISIT TODAY, SR IN THE 60'S LOPRESSOR DOSE HELD, ALSO LISINOPRIL HELD D/T SBP 100. SBP BY CUFF VERY LOW 80'S WITH RADIAL ALINE PLACED SBP UO 120'S. SENTIL AWARE OF HR 60, HOLD LOPRESSOR PER PARAMETERS, CONTINUE AMIODARONE 400MG QD,??IN AM TO DECREASE AMIODARONE TO 200MG QD. K/CA REPLETED. BS TREATEDED WITH SSINSULIN. GU ADEQUATE RESPONSE TO LASIX, PLAN TO GIVE PM DOSE AS ORDERED. GI TOLERATING TUBE FEEDS AT 60CC/HR. POSITIVE BS NO BM TODAY. MULTIPODIS BOOTS OVER X2HRS, BACK ON 1800. ABG GOOD PLAN TO PSE SUPPORT SLOWLY, SUNCTIONED THICK TAN SECRETIONS. ZOSYN STARTED THIS AM FOR ?PNEUMONIA, PLAN 24HR. RUN THEN REVEALUATE WITH I/D. OOB TO CHAIR VIA TOLERATED X3HRS..\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-24 00:00:00.000",
"description": "Report",
"row_id": 1503069,
"text": "ekg nsr, rate 60s, no ectopy. sbp 100-120s. afebrile. brisk diuresis with lasix, continued good uo all night. k repleted, glucose rx per protocol. breath sounds usually clear, ett suctioned for scant secretions. no changes overnight, abgs are acceptable. stoma dry. abd soft, active bowel sounds, tolerating tf via pedi feeding tube at 60cc/hr. no stool overnight. chest incision and ct sites dry, dressings changed. opens eyes to voice, nods approp to questions, smiles a little, but seems lethargic and withdrawn. plan to advance weaning as , monitor recent cultures, get oob, screen for rehab when ready.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-12 00:00:00.000",
"description": "Report",
"row_id": 1503015,
"text": "Nursing Progress Note for 7p-7a:\nNeuro: Pt awakens easily to voice. Mae to command, very weak hand grasps. Very minimal movement/wriggling of toes.\n\nCV: Pt had an episode of AFIB with rate up to 145 and also required neo gtt while in afib. Pt did convert to nsr shortly after amiodarone bolus. Pt in and out of nsr with 1st degree av block and afib 65-105\nthroughout night. Required neo while in afib. Now in NSR, no gtt's.\nSkin is very warm and dry. + pitting edema to bil upper extremities and + edema to BLE as well as some generalized edema. PPP-weakly.\nT-max was 102.5. blood and sputum cultures sent. Urine culture to be sent this am. Team needs to be notified of any + results/they will only start antibiotics at that time. Epicardial pacer wires to box. V-wires x3 don't work. 2-A wires. Pacer turned off early last night at d/t a few inappropriate pacer spikes nited and diaphramatic pacing noted, which stopped after pacer turned off.\n\nResp: Pt remains on the vent. AC mode with rate 14/fio2 40%/peep. ABG\nwas wnl. Team requested pt to be trialed on CPAP+PS 10 this am. Pt was apnic on vent. Returned to AC mode. Pt has increased pink tinged thick sputum obtained via ett. Large amts of oral secretions as well. Team requests rate to be decreased to 12 bpm.\n\nGU/GI: Pt has an oral gastric tube placed for meds. TF off. PT is NPO for ? trach. BS are hypoactive, abd soft, +flatus. No BM yet.\nFoley to bsd with low huo. Pt was given one dose of lasix 20mg iv last night with minimal response. HUO now at approx 40 ml/hr.\n\nEndo: BS were covered with RISS and K+ repleated as per protocol.\n\nContinue to monitor and provide support. Attempt to wean vent as possible and withhold sedation to keep pt alert during cpap trials.\n? trach today. Keep pt npo until further notice.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-01 00:00:00.000",
"description": "Report",
"row_id": 1503094,
"text": "NPN 0700-1500;\nNEURO; ALERT OPENS EYES FOLLOWS COMMANDS MAE BUT WEAKLY TO COMMANDS\nNODS Y/N OCASS. VERY LETHARGIC AND WEAK.\n\nRESP; TRACH COLLAR THROUGHOUT DAY.STRONG PRODUCTIVE COUGH. SATS 100%RR18-24.\n\nCVS; TMAC 97.7 PO, NSR 65-75. BP 130/70\n\nGU; PASSING FOLEY.\n\nGI; T/F AT GOAL BELLY SOFT POS BS SMALL AMOUNTS SOFT STOOL. COVERED ON RISS.\n\nCONTINUES ON CEFTAZIDIME.\n\nSKIN AS IN PREVIOUS NOTES.\n\nFAMILY INTO VISIT AND UPDATED WITH PTS CURRENT CONDITION\n\nA/P STABLE CONTINUE WITH PULMONARY TOILET\nFOR SP/SW WITH EVALUATION FOR PASSE MUIR VALVE.\nCONTINUE TO MONITOR HEMODYNAMICS.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-01 00:00:00.000",
"description": "Report",
"row_id": 1503095,
"text": "Respiratory Therapist\nBreath sounds diminished, suctioned subsequently for moderate thick , sat in a chair most of the day, regular inhaler treatments given, at 1630 patient has a Passy-Muir Valve on. Still doing fine on Trach collar cool aerosol set-up.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-01 00:00:00.000",
"description": "Report",
"row_id": 1503096,
"text": "PATIENT RESTING WITH VALVE IN PLACE TRACHCOLLAR THRU THE DAY, DOING WELL. SON INTO VISIT. REHAB IN NEAR FUTURE. BS ELEVATED AT 140'S PLAN TO GIVE 4UREGULAR INSULIN SC..\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-02 00:00:00.000",
"description": "Report",
"row_id": 1503097,
"text": "Resp Care\nPt received on trach collar. Removed speaking valve and suctioned small amt of thci whte secretions. Mdis given. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-24 00:00:00.000",
"description": "Report",
"row_id": 1503070,
"text": "Respiratory Therapist\nBreath sounds diminished slight rhonchi, suctioned for small thick tan, inhaler given,RSBI 132, uneventful night, patient will continue to receive mechanical ventilation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-24 00:00:00.000",
"description": "Report",
"row_id": 1503071,
"text": "Resp Care\nPt remains trached on CPAP. Placed pt on , but pt did not tolerate.\nMDI's given. Plan is to continue weaning towards trach collar trial.\nNo other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-24 00:00:00.000",
"description": "Report",
"row_id": 1503072,
"text": "update\nD: pt progressing well, cont with persistent temp, sx tan sputum, priliminary sputum culture reveal- gm neg rods-pending sensitivity results. wbc remain in 7 range. pt receieved clonazepam this am- very sedate thereafter- please have team re-eval need or dose or change.\nneuro: sedate after po med--pupils equal and rx, as day progressed more awake, yet still very lethargic- mae\ncardiac; pt remains in nsr- sbp stable, extremities warm\nresp: weaned to cpap with 5 peep and 5 -due to sedation did not place on trach collar--hopefully with med or no med pt will wean better in am. sx thick tan sputum- pending results of culture. abg good.\ngi; abd soft, bs present, soft bm today, ppi cont. tf well.\ngu: foley draining yellow urine in 30cc/hr, added diamox to regieme and lasix to qd- pt bun/creat up slightly.\nskin: intact\nplan: wean to trach collar on am- hold all sedatives\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-02 00:00:00.000",
"description": "Report",
"row_id": 1503098,
"text": "nursing note (7p-7a):\n\nneuro: A&Ox3, MAE's\n\nresp:trach collar on @ 50%x 12l, sucx for sm. thin secretions, rr 25-30, PMV off for night shift\n\ncv: hr 60's nsr, a-line in left radial, bp 100-120's\n\ngu/gi: decreased UO, ? dehydrated BUN 64, cr 0.8, tube feeds @ goal 60 cc/hr\n\nendo: ssri\n\nplan: ?? rehab, con't nursing goals\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-02 00:00:00.000",
"description": "Report",
"row_id": 1503099,
"text": "Respiratory Care\nPatient remains on a Trach Collar with 40% O2. Patient required frequent suctioning. Patient has thick /tan sputum. PMV was placed on for a couple of hours. Patient remains comfortable. MDI's given.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-12 00:00:00.000",
"description": "Report",
"row_id": 1503017,
"text": "7a-7p, shift update\nSEE CAREVIEW FOR COMPLETE ASSESSMENT.\n\nPT APPEARS VERY WEAK AND SLEEPY. WHEN AWAKE FOLLOWS ALL COMMANDS. WEAK MOVEMENT OF EXTREMITIES X4. NODS NO TO PAIN. MULTI PODUS BOOTS ON BLE'S.\n\nWEANED VENT FROM IMV 14 TO CPAP 5/5. ABG LOOKS GOOD BUT PT APPEARS TOO WEAK TO BE EXTUBATED. ALSO, RR INCREASING TO 30, RSBI 118, PS INCREASED TO 10 AT 1300 WITH RR DECREASING TO 22. OXYGENATING WELL, SXNING THICK TAN MUCUS ORALLY. LUNG SOUNDS MOSTLY CLEAR WITH SOME BILAT UPPER LOBE EXPIRATORY CRACKLES.\n\nECG SR UNTIL 1325 WHEN PT WENT INTO A-FIB WITH A VARIED RATE FROM 80-120. HOLDING SBP GREATER THAN 95. TEAM NOTIFIED AND PT GIVEN 150MG AMIO BOLUS AND 2GMS MAG SULFATE. REMAINS IN A-FIB AFTER MEDS WITH STABLE BP. PT ON AMIO 400MG PO BID. T MAX 99 ORAL.\n\nABD SOFT WITH POSITIVE BS'S AND FLATULUS, NO BM AS OF YET ON THIS SHIFT. NPO LAST NIGHT AND THIS AM FOR POSS TRACH/EXTUBATION. (TRACH ON HOLD FOR NOW). TF RESTARTED AT 1330, GOAL RATE 60CC/HR.\n\nFC TO DD WITH CLEAR YELLOW URINE. DIURESING WELL AFTER 40MG LASIX.\n\nALL DRSGS CURRENT, C,D,I.\n\nPLAN: CONTINUE TO WEAN FROM VENT AS TOLERATED. PER TEAM LEAVE INTUBATED OVERNIGHT, PLACE BACK ON RATE IF NEEDED AND BACK TO CPAP IN AM FOR ANOTHER ATTEMPT AT EXTUBATING. DAUGHTERS UPDATED ON PTS CONDITION AND PROGNOSIS BY MD.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-12 00:00:00.000",
"description": "Report",
"row_id": 1503018,
"text": "Respiratory Care\nPt continues to be orally intubated/ventilated at this time. BS: clear bilaterally. Suctioned for small amounts of thick tan secretions. MDI's given as ordered. Pt trialed on PSV 5/5 today x's 1 hour. RR increasing to the 30's and tidal volumes 250-300cc's. RSBI = 118 at this time. CXR: left sided pleural effusions persist. Lasix given. PSV increased to 12cm with RR decreasing to the 20's Plan to rest NOC on higher levels of PSV or A/C and trial SBT again in the am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-12 00:00:00.000",
"description": "Report",
"row_id": 1503019,
"text": "ADDENDUM, 7A-7P\nPER TEAM, WILL ATTEMPT EXTUBATION AGAIN TOMORROW. PT RESTING COMFORTABLY ON VENT: CPAP , BACK IN A-FIB AT 1840 WITH STABLE BP. TURNED AND PAD CHANGED AT 1800 WITH PERI/BACK CARE DONE. PT \"SHOES OFF\" AT 1830, MP BOOTS REMOVED. PROMOTE WITH FIBER TF STARTED, CURRENTLY AT 40CC/HR, GOAL 60CC/HR. ETT ROTATED AND RETAPED AT 1800 WITHOUT COMPLICATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-13 00:00:00.000",
"description": "Report",
"row_id": 1503020,
"text": "Respiratory Care:\n\nPatient intubated on Psv. Psv 12, Peep 5, Fio2 40%. Tolerating well with spont vols 400's, RR high teens to mid 20's. Bs clear bilaterally. Sx'd for moderate amounts of thick secretions.\nAlbuterol MDI given Q4hr. Bs remain clear. Increased secretions. Fluid positive. Plan: Will repeat RSBI later this morning. Continue to wean Psv as tolerated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-12 00:00:00.000",
"description": "Report",
"row_id": 1503016,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. No vent changes made overnight. BS's coarse, sxing blood tinged secretions. Administering Albuterol MDI in line Q4prn. Attempted CPAP trial this am, pt without any spontaineous respirations, placed back on AC. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-02 00:00:00.000",
"description": "Report",
"row_id": 1503100,
"text": "TRACH SECRETIONS AND VERY LIMITED USE OF MUSCLES\nCARDIAC: VSS. HR 60'S. NSR. NO ECTOPY. AFEBRILE.\n\nRESP: TRACH COLLAR WEANED TO 40% O2SAT > 95%. TACHYPNEIC RR 25-35. FREQUENT SUCX COPIOUS SECRETIONS. UPPER LUNGS CLEAR. PASSE MUIR VALVE ON ABOUT 5HRS. PT VOICE SOFT AND HOARSE. CRACKLES NOTED IN L BASES. CONTINUE TO MONITOR PT STATUS OFF . TRACH STOMA NO EVIDENCE OF REDNESS OR DRAINAGE.\n\nGI/GU: FOLEY. DECREASED U/O 45-60CC Q 2HRS. BS PRESENT. NO BM. TUBE FEEDINGS @ 60ML/HR NO RESIDUALS.\n\nNEURO: A&OX2. NOT ORIENTED TO PLACE. PT STATED SHE WAS ON HER PORCH IN . FAMILY REPORTED SUNDOWNING.\n\n\nBLOOD SUGAR 139 @ 6P SSRI. PT OOB TO CHAIR W/ . ATTEMPTED TO PIVOT/STAND PT LIFTED TO CHAIR UNABLE TO STAND. UNABLE TO ACCESS PHYSICAL MOBILITY. PT NOT FULLY PARTICIPATING IN ACTIVITY. FOR EXAMPLE WHEN ASKED TO WAVE SHE MOVED HER FINGERS AND LEFT HER ARM RESTING ON LAP. DID NOT ASSIST IN MOVING ANY EXTREMITIES WHEN GETTING OOB OR BENDING LEGS TO TURN. CONTINUE TO ENCOURAGE MOVEMENT. PROVIDE ROM EXERCISES. PHYSICAL THERAPIST UNABLE TO WORK W/ PT TODAY. ROM EXERCISE PROVIDED THROUGH NURSING. ENCOURAGE AND STRESS PT MOVEMENT AND ACTIVITY.\n\nFAMILY AT BEDSIDE. DISCUSSED PLAN TO EVALUATE PT RESP STATUS OVER WEEKEND W/ POSSIBLE TX TO REHAB ON MONDAY. DISCUSSED WITH CASE MANAGER IN AFTER FAMILY REQUESTED SOMEWHERE CLOSE BY. FAMLIY ANXIOUS ABOUT PT D/C FROM CSRU TO REHAB.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-03 00:00:00.000",
"description": "Report",
"row_id": 1503101,
"text": "Resp Care\nPt remains on 40% ATC in NAD distress overnight. BBS-rhonchi, improving with sx for copious amts tenacious, thick, secretions, and exp wheeze, esp on cough, but improving with BD . Bag and mask at bedside. Continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-03 00:00:00.000",
"description": "Report",
"row_id": 1503102,
"text": "nursing note (7p-7a):\n\nperipheral lines from eccymotic due to changed\n\nneuro: a&ox3, very weak unable to lift extremities, awake most of night\n\nresp: trached, suction for lots of mod thin secretions, inhalers given by respiratory\n\ncv: hemodynamically stable, hr 60-70's nsr, bp 110-120, weak palpable pulse using pneumo boots\n\ngu/gi: decreased UO Dr. aware 500cc bolus NS given @ 0400 w/no effect averaging 15cc/hr, +BS, no BM\n\nendo: subc injections\n\nplan: discharge to rehab, con't pulm toilet, change lines\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-03 00:00:00.000",
"description": "Report",
"row_id": 1503103,
"text": "NURSING NOTE 7A-7P REVIEW OF SYSTEMS:\nNEURO: AWAKE ALERT, FOLLOWS SIMPLE COMMANDS, MOUTHING WORDS. MEDICATED X1 WITH TYLENOL FOR DISCOMFORT. PERRLA, MOVES ALL EXTREMIITES VERY WEAKLY. TRANSFERED OOB TO CHAIR WITHING \nC/V: NSR RATE 63-69, BP 95-118/32-45.\nRESP: 40% TRACH MASK ON, CONTINUES WITH CONGESTIVE COUGH, SUCTIONED THICK YELLOW/ SECRETIONS. LUNG SOUNDS COURSE THROUGHOUT. O2 SAT 99-100%.\nGI: TUBE FEEDINGS OF PROBALANCE CONTINUES AT 60CC (GOAL RATE). POSITIVE BOWEL SOUNDS NO STOOLS THIS SHIFT.\nGU: FOLEY CATH DRAINING CLEAR YELLOW URINE.\nLINES: CONTINUES WITH ALINE LEFT RADIAL SOMETIMES DAMPENED. TWO PIV LINES ONE DAY OUTDATED BUT LEFT INTACT AS PATIENT DIFFICULT TO ACCESS, NO REDNESS OR SWELLING.\nSOCIAL: PATIENTS SONS AND DAUGHTERS INTO VISIT TODAY AND ALL WERE UPDATED ON PATIENTS STATUS.\nPLAN: ? TRANSFER TO REHAB TOMMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-07 00:00:00.000",
"description": "Report",
"row_id": 1502993,
"text": "NEURO: PT IS INTUBATED, LIGHTLY SEDATED ON PROPOFOL. DECREASED PROPOFOL TO 5MCG TO ASSESS NEURO STATUS. PT NODDED TO QUESTIONS, MAES AND BLINKED TO COMMAND. +PERRL. PROPOFOL INCREASED TO KEEP SEDATED OVERNIGHT.\n\nCV: IN/OUT OF AF ALL DAY WITH SPONTANEOUS CONVERSIONS TO SR. HR WHILE IN AFIB 110s-120s. AMIO BOLUS X2 & GTT INCREASED FROM 0.5 TO 1MG/MIN THIS EVENING. LYTES REPLETED. PACER SET FOR ADEMAND OF 80->PT ON DIAPHRAM. A-WIRE THRESHOLDS: MA 11, BUT ONLY SET FOR 13 D/T INCREASED DIAPHRAGMATIC MOVEMENT. A WIRES DO NOT CAPTURE ON RT SIDE. V-WIRES DO NOT SENSE, BUT CAN OVERRIDE CAPTURE WITH MA OF 23; TRANSCUTANEOUS PADS ON FOR BACKUP. UNDERLYING RHYTHM IS SINUS LOW 60s. MIXED VENOUS IMPROVED THROUGHOUT THE DAY FROM 61 TO 70 WHICH IMPROVED CI VIA FICK >3. MIXED VENOUS DRAWN WHILE PT IN SR. PT MAINTAINS BP 90s WHILE IN AFIB, BP 120S-130S IN SR. NEO TITRATED TO KEEP MAPS >60. RT RADIAL A-LINE DC'D D/T EXCESSIVE DAMPENING, POOR WAVE FORM, INABILITY TO DRAW BLOOD, LFT RADIAL A-LINE PLACED. BLOOD AND URINE CULTURES SENT FOR INCREASED COUNT. CHEST TUBES DC'D.\n\nRESP: RT UPPER/LOWER LS ARE COURSE, LFT UPPER IS CLR, BASE DIM. SXN'D THICK TAN-YELLOW SPUTUM X3. SENT SPUTUM CULTURES THIS EVENING. O2SATS >97%. PT ON SAME VENT SETTINGS, BUT DECREASED FIO2 TO .40. PT OVERBREATHING VENT WITH RATES HIGH 20S-LOW 30S.\n\nGI/GU: BS INITIALLY ABSENT, NOW ARE PRESENT. OGT PLACEMENT CHECKED. FOLEY DRAINING ADEQUATE CLR YELLOW URINE QH. 20MG LASIX GIVEN X1 WITH MARGINAL RESULTS-UO NOW TAPERING OFF.\n\nENDO: BS MONITORED PER CSRU SS PROTOCOL. INS GTT OFF AFTER BLOOD SUGAR OF 66.\n\nSOCIAL: DAUGHTER VISITED X3; MORE FAMILY MEMBERS VISITING THIS EVENING.\n\nPLAN: KEEP SEDATED OVERNIGHT. CONTINUE MONITORING CARDIORESPIRATORY STATUS. MONITOR HEMODYNAMICS. ?WEANING OFF PROPOFOL & VENT IN AM IF HEMODYNAMICALLY STABLE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-11 00:00:00.000",
"description": "Report",
"row_id": 1503012,
"text": "Nursing 11a-7p\nNeuro: Lethargic. Arouses to voice. Tracks w/eyes briefly, then loses focus. PERRLA. Equal bilat hand grasps, moves toes to command. No spontaneous movement. Not able to hold head up. PA aware of pt's current mental status.\n\nC/V: When assumed care of pt- pt in 1st degree AV block (PR 0.21) HR 70s. One burst of Afib 100-115 (no drop in BP during afib), amio bolus & 2gm IV mag admin per PA . Lytes repleated. Converted back to 1st degree AV block 70s. SBP 110-120s, briefly increases to 140s during cough/suctioning. Pacer set @ a-demand 50 (v's not sensing/capturing). Generalized 2+ edema, w/3+ R hand edema. Both arms elevated on pillows. Palpable pedal pulses. Skin warm & dry. Tmax 100.9 oral.\n\nResp: Initially pt on cpap 5/5. RR 30s-to low 40s w/tidal volume of ~250. Not able to extubate at beginning of this shift d/t pt's mental status. Placed back on PS 10 d/t resp rate, tidal volumes per PA . ABGs good. Diminished in bases, cta in upper lobes. sxn scan amt yellow sputum\n\nGi/Gu: Hypoactive BSx4. TF remained off, pt NPO this shift per team. No BM, +flatus. OGT clamped. Creat 1.4, BUN 44. +diuresis from dose admin prior to this shift.\n\nEndo: Montoring blood sugars per CSRU protocol/sliding scale.\nSkin: See carevue for incisions.\nComfort: No c/o pain this shift. IV mso4 & PO percocet dc'd per PA . Daughter at bs visiting. Support given to pt and family member.\n\nA/P: Plan to extubate pt this shift MD . MD to be present in room during extubation. resp status. Pulmonary toilet. Advance diet as once extubated. ?pain management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-11 00:00:00.000",
"description": "Report",
"row_id": 1503013,
"text": "Add: Pt on CPAP 40% PS 10/peep 5, tachypnic 30s, breathing unlabored. Easily aroused to voice. When MD asked pt if she wanted ETT out pt shook her head \"no\". ABG MD-proceed to extubate. Extubated to FT 50%, sats decreased to 90%, stridor/coarse rhonchi/wheezes throughout lung fields. Strong cough, expect. copious amts blood tinged sputum. Albuterol neb admin per resp, SBP increasing. Pt quickly tachypnic 40s, increased FT to 100%. Sats cont declining to 88%, SBP 210. Hydralazine 10mg IVP x2 w/no effect MD . Anesthesia called to bs for stat intubation. MD aware, at bs. Briefly started on nitro gtt for hypertension w/good effect. CXR done. Brief start on propofol gtt, dc'd per team. No sedation order. Pt on CMV 50% 550/14/peep 5. Will send ABG. MD aware of blood tinged sputum. Family updated by MD , into visit w/pt briefly after intubation, updated by RN.\nA/P: Follow up w/CXR, ABG. Plan to rest pt overnight and attempt weaning/extubation in am per PA .\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-07 00:00:00.000",
"description": "Report",
"row_id": 1502994,
"text": "Resp Care\nPt remains intubated on SIMV, had a stable shift today, no vent changes. Plan to wean and extubate tomm if pt hemo-dyn are stabalized.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-08 00:00:00.000",
"description": "Report",
"row_id": 1502995,
"text": "RESP CARE: Pt remains intubated/on vent per carevue. No changes in vent settings overnight. Lungs coarse on R/dim on L. sxd small amts thick /pale yellow sputum. ETT rotated to L/21 Lip. RSBI this am on 0/5 PS was 150. Continue on SIMV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-22 00:00:00.000",
"description": "Report",
"row_id": 1503062,
"text": "6p-6a\nNeuro: Pt alert, following all commands, perrla, denies pain.\n\nCV: HR 60-70s SR w/ 1st degree AVB. SBP >90. +palpable pulses.\n\nResp: LS clear but diminished. Suctioned for rusty thick scant secretions via trach. Pressure dsg d+i to trach area. Sats >97%. Placed on SIMV overnoc for high RR 36 while on CPAP.\n\nGI/GU: Abd soft, NT +BS. +flatus. Foley draining adequate amts of clear yellow urine. See carevue.\n\nEndo: Monitor blood glucose and covered per own scale.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Follow labs. Rehab in near future. Wean as pt tolerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-22 00:00:00.000",
"description": "Report",
"row_id": 1503063,
"text": "7a-11a:\nno changes, pressure dressing removed from trach site, trach care done, wnl.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-22 00:00:00.000",
"description": "Report",
"row_id": 1503064,
"text": "NURSING NOTE: REVIEW OF SYSTEMS:\nNEURO: AWAKE BUT VERY SLEEPY SITTING IN CHAIR. FOLLOWS SIMPLE COMMANDS.\nC/V: NSR RATE IN THE 70'S, BP 110-120'S/ 38-50'S.\nRESP: CONTINUES WITH TACHYPNEIA RATE SOMETIMES IN THE 40'S. SAT 98-100%. LUNG SOUNDS CLEAR. NO FURTHER BLEEDING NOTED AT TRACH SITE.\nGI: CONTINUES ON TUBE FEEDINGS PROMOTE WITH FIBER INFUSING AT GOAL RATE. INC SMALL AMOUNT SOFT STOOL. SPEECH AND SWALLOW DEFERRED TODAY.\nGU: FOLEY CATH INTACT DRAINING YELLOW URINE QS, LASIX 40MG GIVEN THIS EVENING.\nLINES: RIGHT IJ INTACT.\nSOCIAL: PATENTS SON AND DAUGHTER INTO VISIT EARILER TODAY, UPDATE ON PLAN OF CARE.\nPLAN: ? POSSIBLE TRANSFER TO REHAB NEXT WEEK.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-23 00:00:00.000",
"description": "Report",
"row_id": 1503065,
"text": "resp care\nPt initially on psv8/peep5 and 40% with volumes of 200cc and rr 40. BS coarse bil . Suct for sml amts of thin bloody sput. Alb/atr/flov mdi given as ordered. Psv inc to 12 with rr to 20's and volumes inc to 350-400cc. RSBI done-200. Will cont to follow and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-23 00:00:00.000",
"description": "Report",
"row_id": 1503066,
"text": "CSRU PROGRESS NOTE\nS:TRACHED\nO:S/P CABG/MVR/PORCINE , TRACHED , AWAITING PLACEMENT.\nAT THIS TIME PT FEBRILE TROUGH THE NOC, NOT RESPONDING TO TYLENOL. COOL BATH GIVEN THIS AM. T MAX 102.7AX, PAN CX'D.\n\nPT'S AFFECT FLAT, REFUSING MOUTH CARE. FOLLOWING MOST COMMANDS. SLEEPING WELL INBETWEEN CARE.\n\nRESP:COARSE BS AT LEFT BASE. SATS 975, SUCTIONED FOR PINK TINGED THICK SECRETIONS SM AMT. STOMA SITE W/O FURTHER BLEEDING. TRACH CARE DONE THIS AM.\n\nCV:MHR SR , SBP WNL, DP VERY WEAKLY PALPABLE.\n\nGI: TF, UNABLE TO ASPIRATE SIGNIF RESIDUAL, TAN FORMED STOOL.\n\nGU:GOOD U/O, DIURESING.\n\nSKIN:INCISIONS WELL APPROXIMATED. NO DRG, DSD APPLIED.\n\nA/P:CONTINUE ANTIBIOTICS, TYLENOL FOR TEMP. CONSIDER PEG, UNLESS PT IS ABLE TO PARTICIPATE IN SWALLOWING EVAL. HOLD ON TRANSFER TO REHAB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-23 00:00:00.000",
"description": "Report",
"row_id": 1503067,
"text": "Resp Care\nPt remains trached on CPAP 12/5. Pt appears very lethargic at times, but continues to ventilate well. MDI's given, no other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-28 00:00:00.000",
"description": "Report",
"row_id": 1503088,
"text": "NPN 1900-0700:\n\nROS:\nNEURO: Remains withdrawn lethargic. At times wil open eyes spontaneously, smile, nod head; at other times she is difficult to arouse and makes minimal eye contact. Very little spontaneous movement of extremities; does not f/c.\nRESP: Remains on % with excellent ABG's and sats; tachypneic at times. Suctioned q2-4 hours for small amts thick secretions. LS Coarse upper, diminshed lower.\nC-V: HR 70's-80's, NSR, no ectopy; BP 120's-130's; lytes WNL.\nGI: TF's of ProBalance at goal of 60cc/hr. Belly benign; small BM X 2.\nGU: Adequate UO. BUN/creat 63/1.1 (67/1.2).\nHEME: Hct 29.2, INR 1.2, plt 161; all stable from previous counts. No evidence of bleeding.\nID: Temp spike to 102.3ax this AM; given Tylenol 650mg PR; WBC stable at 9.5. Remains on Ceftaz; awaiting team's input on whether to re-culture her.\nENDO: SSRI as ordered.\nSKIN: incisions healing well; no other issues.\nACCESS: PIV X 2, L radial a-line\nSOCIAL: son called for update this AM\n\nA: temp spike; otherwise stable\n\nP: ? further w/u for source of temp; TM trials as tolerated; OOB to chair daily; continue ICU level of care; ? rehab soon when temps are resolved.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-28 00:00:00.000",
"description": "Report",
"row_id": 1503089,
"text": "0700-1900:\nneuro: withdrawn, responds to painful stimuli. not following commands. perrl.\n\ncv: sr 70-80, no ectopy. electrolytes wnl. sbp 100-130. easily palpable pedal pulses bilaterally. remains on amiodarone, lopressor, and lisinopril. tmax 102.6, tylenol given. np aware.\n\nresp: lungs coarse at times, lungs clear with coughing and suctioning. o2sat >98%. weaned to trach collar, with rr 40's. oob-> chair with .\n\ngi/gu: abd soft, nd. bs positive. tolerating probalance @ 60 cc/hr via dophoff. foley to gravity, good huo.\n\nendo: fs qid, cover per riss.\n\nplan: pulmonary toilet, monitor fevers. monitor mental status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-28 00:00:00.000",
"description": "Report",
"row_id": 1503090,
"text": "Respiratory Therapist\nBreath sounds coarse, suctioned for copious amount of thick , regular inhaler treatments given, weaned to 50% trach collar since 1110 am, sat in a chair since 1600 up to now respiratory rate in the 40s.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-01 00:00:00.000",
"description": "Report",
"row_id": 1503091,
"text": "ASSESSMENT AS NOTED\n\nRES: OFF OVERNIGHT, ON 50% TACH MASK MAINTAINS SO2>98, STRONG PROD COUGH FOR THICK SPUTUM, LS CLEAR/DIM AT BASES, TACHIPNEIC AT TIMES\n\nID: NO FEVER OVERNIGHT, CBC WITH DIFF WAS DRAWN -SEE CAREVUE, CONT ON FORTAZ\n\nCV:STABLE BP, IN NSR, +PLSES, PNEUMOBOOTS STARTED\n\nNEURO: OPENS YES TO VOICE, DOES NOT FOLLOW, W/D TO PAIN, +GAG, +COUGH\n\nGI: TOLERATES TF AT 60/H, NO STOOL BM, +BS, SOFT ABD,\n\nENDO: RISS IN USE\n\nPLAN: PULM TOILET, SUPPORT OFF REHAB SCREENING\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-01 00:00:00.000",
"description": "Report",
"row_id": 1503092,
"text": "Resp Care\nPt seen for trach X2. Nurse suctioning. all equipment at bedside. filled. No resp diatress.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-03-01 00:00:00.000",
"description": "Report",
"row_id": 1503093,
"text": "correction to above note breathing 28-38 on trach collar.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-11 00:00:00.000",
"description": "Report",
"row_id": 1503009,
"text": "Respiratory Care Note:\n Patient remains orally intubated and on ventilatory support. Patient on CPAP/PS, tolerating well. Vt's 400-600cc's, MV 7-10L. SX'd for a scant to small amount of thin secretions, often lavaging. BS are diminished at the bases. MDI's administered as ordered. RSBI improving over the past 4 days: - 150, - 117.8, - 107.5, - 90.1. Plan is to continue CPAP trial as tolerated and monitor ABG's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-11 00:00:00.000",
"description": "Report",
"row_id": 1503010,
"text": "Nursing Progress Note for 7p-7a:\nNeuro: Pt opens her eyes and tracks speaker, able to mae and follows commands.\n\nCV: HR was NSR with rare pvc and rate 65-85 for most of the night. Had a brief episode of afib with rate controlled <115 and minimal change in sbp at 0440 this am. Converted back into nsr after receiving lopressor 1mg iv.( 5mg were ordered) Sbp tolerating lopressor 12.5mg per ng. See strips on chart.\n\nResp: Pt on the vent in AC mode for most of the night. Changed to CPAP+PS Mode(ps@15, peep@5, Fio2@40%) ABG'S show metabolic acidosis this am. No vent changes at this time. Awaiting re-peat abg results.\nSats are > 94%, small amts of clear and whitish secretion sx via ett. Large amts of clear oral secretions noted. RR at 16-28.\n\nGU/GI: Foley to bsd with huo down to 30ml per hour. Lasix 40mg iv given with increased huo to approx. 200ml per hour. Creatine is 1.6 this am. BS x4. No BM. Tolerating TF at goal of 60 ml per hour. Residuals < ml.\n\nEndo: BS coverage with SSRI per protocol. Mag and K+ repleated as per protocol.\n\nPln to continue to provide support and hemodynamic monitoring. Continue to wean vent as tolerated. Assist pt with pulmonary toileting\nand to increase activity level.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-11 00:00:00.000",
"description": "Report",
"row_id": 1503011,
"text": "NURSING NOTE 7A-11A REVIEW OF SYSTEMS:\nNEURO: AWAKE ALERT, NODDING HEAD APPROPRIATELY TO YES AND NO QUESTIONS. MEDICATED X1 WITH MORPHINE SULFATE 1MG GIVEN IVP.\nC/V: NSR RATE HIGH 60'S TO 70'S. BP 110-150'S/ 40-50'S.\nRESP: CONTINUES ON CPAP PEEP AND PS CURRENTLY DOWN TO 5/5 FIO2= 40%. ABG PENDING AT 1045. LUNG SOUNDS CLEAR UPPER AND DIMINISHED BASES. SUCTIONED ORALLY FOR SCANT CLEAR SECRETIONS AND SMALL AMOUNT VIA ET TUBE. O2 SAT 98-100%\nGI: TUBE FEEDING HELD AT 0830 FOR PENDING EXTUBATION. ABD SOFT NONTENDER POSITIVE BOWEL SOUNDS. NO STOOLS THIS SHIFT POSITIVE FLATUS.\nGU: FOLEY PATENT DRAINING CLEAR YELLOW URINE. LASIX GIVEN 40MG X1 WITH GOOD DIURESIS. PLEASE SEE CAREVUE.\nLINES: RIGHT SC MULTILUMEN INTACT CVP 12-14 GOOD WAVE FORM. ALINE LEFT RADIAL INTACT.\nSOCIAL: NO CONTACT FROM FAMILY MEMBER THIS AM.\nPLAN: EXTUBATE PENDING ABG RESULTS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-27 00:00:00.000",
"description": "Report",
"row_id": 1503082,
"text": "7p-7a\nNeuro: Pt lethargic, does open eyes to loud commands, does not follow commands. Perrla. No facial grimacing noted indicating pain.\n\nCV: HR 60-70s SR 1st degree AVB no ectopy. Short run of RAF, converted on own lasted approx. 2min, PA Nilssen notified, amiodarone bolus given, lytes sent, k repleted. No further episodes noted. SBP >100. See carevue for details.\n\nResp: Trach care done. Suctioned for thick/thin via trach. Sats 99-100%. On CPAP overnoc, see carevue for abgs. LS clear but diminished.\n\nGI/GU: Abd softly distended, +BS. No BM. +flatus. Dophoff intact, no residuals, TF at 60cc/hr. Foley draining adequate amts of clear yellow urine.\n\nSkin: Back of head noted to be reddened, turn on side, continue to monitor.\n\nTemp: T max 102.7 po, tylenol given. Temp continued most of noc in 102s, PA Nilssen aware, RIJ TLC dc'd and culture sent. Present temp 100.3.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Monitor labs. Monitor mental status. Skin care. Monitor temps.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-27 00:00:00.000",
"description": "Report",
"row_id": 1503083,
"text": "Respiratory \nPt presents trached on PSV. BS clear bilaterally W slt dim bases. Sx mod thick creamy secretions W SPC. Plan trach mask trials during the day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-27 00:00:00.000",
"description": "Report",
"row_id": 1503084,
"text": "Resp Care\n\npt received on PSV 12/5 and was weaned to during the day with Vt around 250-300cc and RR in the mid to upper 30s. BS clear to slightly course sxing for small to mod amts of loose secretions. Bronchodilators given t/o shift as ordered with improved aeration noted. Pt currently on 50% trach collar trial and will cont as . Pt expectorating small to mod amts of secretions on own as well. Will cont with t/c trials and rest on as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-27 00:00:00.000",
"description": "Report",
"row_id": 1503085,
"text": "7a-7p:\nneuro: opens eyes spontaneously. appears withdrawn. perrl. follows commands. denies pain.\n\ncv: sr 70-80's, no ectopy. sbp 130's. continue with lopressor, lisinopril, and amiodarone. easily palpable bilateral pulses. tmax 102.\n\nresp: lungs coarse at times, clear with suctioning. copious thick tan to secretions. weaned to trach collar with abg wnl. o2sat 98-100%.\n\ngi/gu: abd soft, nd. bs positive. tube feeding changed to probalance at 60 cc/hr via dophoff. foley to gravity, good huo, cr 1.2.\n\nendo: fs qid, cover per riss.\n\nplan: pulmonary toilet, maintain trach collar as tolerates. monitor fevers.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-07 00:00:00.000",
"description": "Report",
"row_id": 1502991,
"text": "Neuro: pt unresponsive to voice, responsive to painful stimuli, sedated on propofol per flow sheet\n\nResp: vented on IMV all night, setting per flow sheet, when suctioned pt has frequent to constant monitor pattern changes including pauses, bundle blocking and non captured beats with slight changes in perfusion for the worse\n\nCardiac: 100% V paced with occasional to frequent noncapture beats without perfusion, underlying rythm initially was 1st degree AVB rate in upper 50's, when interrogating pacer D/T noncapture beats underlying rythm found to be asystole, Dr. and Dr. aware and reviewed ECG strips, adjustments to pacemaker made( mv adjusted up and down, ma adjusted to max)see flow sheet for details, Cardiac Fellow notified by Dr. , no new orders, continue to monitor heart rythm closely, weaning neo down, CO and CI poor via SWAN, CO and CI OK via fick\n\nEndo: insulin gtt, max 4.5 units/hr, BS low of 56, gtt off for 1 hour, amp D50 given IVP with good results, insulin restarted at 2 units/hr\n\nGI: sluggish BS, + flatus no BM\n\nGU: foley to gravity draining clear yellow urine, quantity borderline, one time dose of lasix for poor output with some effect\n\nActivity: minmimal adjustments in position D/T unstable ECG pattern and the uncertainty of how secure the epi wires are at this time concidering that the underlying rythm is asystole, MD aware\n\nPlan: follow ficks for CO/CI, keep sedated on propofol and vented on IMV, keep pt flat in bed with minimal movement until problem is resolved, minimal suctioning D/T irritable monitor pattern, keep external pacer pads on with portable defib attached and ready to go, ? trans venous pacer or PPM need, to be seen by cardiology today for evaluation, ? wean vent to D/C, D/C CT's, wean neo to off as tolerated, follow labs and vitals and treat as indicated and as ordered, wean isulin gtt per protocol\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-27 00:00:00.000",
"description": "Report",
"row_id": 1503086,
"text": "Resp Care Addendum:\n\nPt placed back on PSV 10/5 to rest overnoc due to increased wob. Vt ranging around 300-330cc with RR in the mid to low 30s. Will cont to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-28 00:00:00.000",
"description": "Report",
"row_id": 1503087,
"text": "Respiratory \nPt presents trached on PSV 10/5 .4. BS occasional diffuse fine wheezes clear after rx. sx for sml amts thk secretions. Plan: return to TM today as tolerated. rest on @ night.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-07 00:00:00.000",
"description": "Report",
"row_id": 1502992,
"text": "Resp Care: Pt continues intubated and on ventilatory support with simv, fio2 down overnoc maintaining good oxygenation; bs scattered crackles, sxn thick tan secretions with some ectopy, rsbi not done d/t hemodynamic instability, will cont full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-20 00:00:00.000",
"description": "Report",
"row_id": 1503055,
"text": "7 PM to 7 AM\nPt febrile, 101.6. Blood cultures, urine and sputum cultures sent. Tylenol via DHT. Pt. bleeding from trach site and suctioning large amounts of blood and blood clots. Pt tachypneic, placed on SIMV, increased PEEP. Trach dressing changed several times. Total trach care deferred in hopes of clot forming at trach site.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-21 00:00:00.000",
"description": "Report",
"row_id": 1503056,
"text": "7PM to 7AM \\\nThoracic surgery to bedside to evaluate trach/bleeding. Pressure dressing applied by MD. Heparin drip to remain off.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-21 00:00:00.000",
"description": "Report",
"row_id": 1503057,
"text": "7PM to 7AM\nNeuro: Alert, follows commands, MAE. Febrile, Tylenol given. Denies pain.\nResp: On SIMV for noc. Bloody secretions decreased. Bleeding from trach site also decreased. BS coarse.\nCV: NSR w/o ectopy. Weak pulses palpable. B/P stable.\nGI/GU: +BS. Promote w/fibre via DHT, tolerating w/o difficulty. Large BM, heme neg.\nSKIN: Coccyx reddened, Aloe Vesta applied. See carevue for incisions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-21 00:00:00.000",
"description": "Report",
"row_id": 1503058,
"text": "Respiratory Therapy\nPt presents W #8 Perc trach. On PSV W RR in low 40's. Mod amt frank red blood oozing from trach site, in airway and in tubing requiring frequent sx for copious amts frank blood. Pt became bronchospastic MDI given W good effect. Pt on Heparin GTT. MD in to see pt, Heparin on hold Trach site packed by MD. changed to SIMV 500X16 .4. Bleeding diminished RR 16-18. Pt resting comfortably @ this time. Plan Continue to monitor secretions closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-21 00:00:00.000",
"description": "Report",
"row_id": 1503059,
"text": "7a-6p:\nneuro: appears alert, mouthing answers to questions. perrl. denies pain.\n\ncv: sr 70-90, no ectopy. sbp stable, lisinopril started. easily palpable pedal pulses bilaterally.\n\nresp: lungs clear, diminished at bases. o2sat 98-100%. remains intubated via trach. cpap 40% 5 peep, 10 pressure support. goal wean pressure support to maintain tidal volumes of 300. weaned to 8 pressure support with increased rr 40's. oob-> chair x 3 hours.\n\ngi/gu: abd soft, nd. bs positive. tube feedings at goal. foley to gravity, good huo.\n\nendo: fs qid, cover per riss.\n\nplan: pulmonary toilet, wean as tolerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-21 00:00:00.000",
"description": "Report",
"row_id": 1503060,
"text": "Respiratory Therapist\npatient switched from simv to cpap + ps , attempts made to decrease ps from 10 to 8 to 5, patient does not tolerate 8, became tachypneic had to be put back to 10,now at 1650 patient is being tried on 8 of ps again. Sat in a chair for about three hours then back to bed, breath sounds clear but expiratory grunting heard, suctioned for small thick bloody, regular inhaler treatments given.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-22 00:00:00.000",
"description": "Report",
"row_id": 1503061,
"text": "Respiratory therapy\n Pt remains trached on SIMV, had a much more comfortable night tonight. BS slightly coarse Sx for sml to mod amt thick tan to rusty secretions. MDI's as ordered. No changes overnight. Plan: resume TM trials today\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-10 00:00:00.000",
"description": "Report",
"row_id": 1503007,
"text": "Resp Care\n\nPt weaned for 5 hrs on CPAP/PSv. PS range from 5 to 10. ABG on 7.41/34/184/22. BS are with scattered rhonchi. Suctioning thick sputum\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-13 00:00:00.000",
"description": "Report",
"row_id": 1503021,
"text": "Nursing Progress note for 7p-7a:\nNeuro: Pt is much more awake today. Able to follow commands by very weak movements of extremities(BLE with foot/toe wriggle only) Able to mouth words appropriately.\nCV: HR is mostly NSR, no VEA. Occ change to afib in rates 80-100 and minimal decrease to sbp, for a few minutes here and there, spontaneous return to nsr. Off all vasopressors/gtts. SBP 87-130's. Skin warm and dry. PPP-weakly. + pitting generalized edema, esp to BUE.\nEpicardial pacer wires to box, which is off d/t inappropriate spikes on .\nResp: Pt remains on Vent in Cpap+ps mode. (fio2 @40%, peep-5,PS-12)\n>100 today. Sats>94%, abg wnl. Pt is having copious amts of clear thin secretions sx'd from ett and also fair amt of thick sputum sx'd via ett. Increased cough and secretions with any stimulation.\nGU/GI: Foley to bsd with good huo. Pt on lasix . TF held since 0400 for ? extubation or trach. BS x4, passed mod. amt of soft brown stool.\nENDO: BS covered with RISS per protocol. K+ repleated also per protocol.\nPlan: Continue to hold sedation/pain meds to assist with vent wean as possible. Continue to monitor & provide support, assist with pulmonary toilet and to encourage pt to begin to increase activity level/rom.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-13 00:00:00.000",
"description": "Report",
"row_id": 1503022,
"text": "NEURO: PT IS INTUBATED AND ALERT. FOLLOWS COMMANDS AND MAES, BUT HAS WEAK RT HAND GRASP. +PERRL. NO C/O PAIN. ATTEMPTED WRITING TO COMMUNICATE BUT UNABLE D/T RT HAND EDEMA; MOUTHES WORDS AND USES LETTER/WORD SHEET TO COMMUNICATE.\n\nACTIVITY: PT OOB FIRST TIME VIA LIFT FOR 1.5HRS-SLIGHT INCREASE IN BP BUT OTHERWISE WELL TOLERATED.\n\nCV: HR 70S-80S, 1ST DEG AVB WITH PR INT. 0.24-0.28. PACER IS OFF, SEE CAREVUE FOR THRESHOLDS. PO AMIO GIVEN IN AM. BP 110S-140S. BP INCREASED TO 180S DURING BRONCH IN AM THEN QUICKLY RETURNED TO BASELINE. +BLOOD CULTURES FROM ALINE. ADDIT'L BLOOD CULTURES FROM MLRIJ AND VENIPUNCTURE SENT, PER . VANCO STARTED. 10MG IV HYRALAZINE GIVEN THIS AFTERNOON FOR SBP INCREASE TO 150S AFTER RETURNING PT TO BED. DOPPLERABLE PULSES. LYTES REPLETED. TMAX 100.4~>650MG TYLENOL GIVEN.\n\nRESP: BILAT LS COURSE UPPER, BASES DIM. FREQ SXN'G MOD-COPIES THK YELLOW SECRETIONS THROUGHOUT THE DAY IMPROVES LUNG SOUNDS. RR 30s. 02SATS CONSISTENTLY >96%. ATTEMPTED TO WEAN TO EXTUBATE. INITIAL VENT SETTING ON CPAP . BRONCHOSCOPY PERFORMED BY MD-DURING WHICH THK WHITISH/YELLOW SPUTUM WAS SXN'D & TRACH MALAISIA ALSO NOTED BY DR. . VENT WEANED TO , ABS OKAY, BUT BUT RATE & RSBI HIGH. VENT THEN SET AT 5/12. ABGS SHOW RESP. ALKALOSIS THIS AFTERNOON. VENT NOW SET AT 5/15.\n\nGI/GU: BS PRESENT ALL QUADS. SM SOFT BROWN BM X1. PT NPO IN ANTICIPATION OF EXTUBATION. OGT CLAMPED, PLACEMENT CHECKED. TF PROMOTE W/FIBER BACK ON AT 60CC/HR. FOLEY DRAINING ADEQUATE CLR YELLOW URINE , PT DIURESING WELL AFTER 40 IV LASIX GIVEN.\n\nENDO: BS MONITORED PER CSRU SS PROTOCOL. NO COVERAGE NEEDED WHILE TF OFF.\n\nPLAN: CONTINUE MONITORING CARDIO RESPIRATORY STATUS. MONITOR LUNGS SOUNDS, SECRETIONS, ABGS AND LYTES. CONTINUE GETTING PT OOB AS TOLERATED. WEAN VENT SETTINGS FOR POSSIBLE EXTUBATION IN AM IF APPROPRIATE. FOLLOW BLOOD CULTURES. TF OFF AT 2400 FOR ATTEMPT AT EXTUBTION IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-13 00:00:00.000",
"description": "Report",
"row_id": 1503023,
"text": "BS one episode of wheezing clearing with ALbuterol MDI; otherwise CTAB. PSV wean during the day but with mod-severe tachypnea (RSBI-121). Placed back of PSV 12 and then raised to 15 due to tachypnea. Pt unsure about extubating. WIll try to wean tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-14 00:00:00.000",
"description": "Report",
"row_id": 1503024,
"text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and ventilated on PS settings this AM. BLBS are coarse. Sxn for thick moderate amount yellow secretions. ABG shows adequate ventilation and oxygenation. RSBI completed on PS 5=133.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-14 00:00:00.000",
"description": "Report",
"row_id": 1503025,
"text": "CSRU NSG:\n\nNEURO: Alert when awake, dozes intermittently. Appropriate. Febrile to 100.8 po.\n\nCV: SR, no ectopy. VSS. K 4.1, will replete. Mg 1.9, will replete.\n\nPULM: CPAP 5, PSV 15. ABG WNL. Suctioned prn for moderate, thick, tan secretions.\n\nGU: Urine clr, yellow, output QS.\n\nGI: Abdomen soft, NT, +BSX4Q. Tube feeds at goal of 60cc/hr, turned of 0400hrs for possible extubation.\n\nASSESS: Ventilated patient, mild fever.\n\nPLAN: Wean vent as tolerates, assess RSBI prior to extubation attempt. Encourage C/DB once extubated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-14 00:00:00.000",
"description": "Report",
"row_id": 1503026,
"text": "CSRU ADDENDUM TO ABOVE:\nLiquid, foul-smelling, brown stool X 2, specimen sent for ? c-diff. Fecal bag applied.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-14 00:00:00.000",
"description": "Report",
"row_id": 1503027,
"text": "BS coarse crackles; one episode of wheezing clearing with MDI Albuterol.PSV decreased to 10 with mod-severe tachypnea. Plan is to continue to wean PSV as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-02-04 00:00:00.000",
"description": "Report",
"row_id": 1502984,
"text": "Nursing Progress Note\n3VD\nPRE-OP CABG\n2100-0700\nS \" Get Away \"\nO PLs see careview for all obj/numerical data\nCV hr 60-70's...sinus K 3.7 ..repletion with 40 MEQ in 500 NS in progress. SBP 90-120's/40-50's..low dose IV NTG off at 0100 when SBP dropped to the 90's..CPK's trending down. Heparin at 800 u/hr with a ptt of 97 ..infusion decreased to 700 u/hr ..\nResp\nPatient refusing to wear 02..02 sat 98%..RR 18-24 ..Lungs with cxs 2/3 up bilat.\nGI tolerating sips of water. No stool\nGU 1400 cc negative at midnight. Urine output 40-60 cc q2 .\nAgitation and confusion continued despite the presence of her 2 sons. Attempting to climb out of bed, using call light in attempt to strike RN. Given haldol 2.5 mg iv times 2, with good affect. All four siderails up and bed alarm on\n"
},
{
"category": "Echo",
"chartdate": "2182-02-25 00:00:00.000",
"description": "Report",
"row_id": 80071,
"text": "PATIENT/TEST INFORMATION:\nIndication: Porcine MVR and CABG. Assess LV function. ?endocarditis.\nHeight: (in) 62\nWeight (lb): 123\nBSA (m2): 1.56 m2\nBP (mm Hg): 122/49\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 13:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -\nakinetic; lateral apex - akinetic; apex - dyskinetic;\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nNormal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Mild AS. No AR.\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR well seated,\nwith normal leaflet/disc motion and transvalvular gradients. Calcified tips of\npapillary muscles. Mild (1+) MR. [Due to acoustic shadowing, the severity of\nMR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Based on \nAHA endocarditis prophylaxis recommendations, the echo findings indicate a\nhigh risk (prophylaxis strongly recommended). Clinical decisions regarding the\nneed for prophylaxis should be based on clinical and echocardiographic data.\nLeft pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild regional left ventricular\nsystolic dysfunction with focal akinesis of the distal lateral and anterior\nwalls with mild dyskinesis of the apex. The remaining segments contract well.\nThe aortic valve leaflets are mildly thickened. There is mild aortic valve\nstenosis. No aortic regurgitation is seen. A bioprosthetic mitral valve\nprosthesis is present. The prosthesis is well seated with mobile leaflets and\nnormal gradient. Mild (1+) mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] The pulmonary artery systolic pressure could not be\nquantified. There is a very small inferolateral pericardial effusion.\n\nCompared with the prior TEE study (images unavailable for review) of\n, the mitral valve has been replaced with a well-funcioning mitral\nvalve prosthesis. The aortic valve gradient is similar.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a high risk (prophylaxis strongly recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2182-02-05 00:00:00.000",
"description": "Report",
"row_id": 80072,
"text": "PATIENT/TEST INFORMATION:\nIndication: evaluate mv, av, systolic function\nStatus: Inpatient\nDate/Time: at 08:44\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.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous hypertrophy of the\ninteratrial septum. Left-to-right shunt across the interatrial septum at rest.\nSmall secundum ASD.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild symmetric\nLVH. Normal LV cavity size. Mild regional LV systolic dysfunction. Mildly\ndepressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -\nakinetic; septal apex- akinetic; lateral apex - akinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. Normal aortic root diameter. Normal ascending aorta\ndiameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Mild AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Abnormal mitral valve.\nModerate to severe (3+) MR. Eccentric MR jet.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure.\n\nConclusions:\nPREBYPASS\nThe left atrium is normal in size. A left-to-right shunt across the\ninteratrial septum is seen at rest. A small secundum atrial septal defect is\npresent. There is mild symmetric left ventricular hypertrophy with normal\ncavity size. The left ventricular cavity size is normal. There is mild\nregional left ventricular systolic dysfunction. Overall left ventricular\nsystolic function is mildly depressed. LVEF~45% Resting regional wall motion\nabnormalities include distal anterior was and apex. The remaining left\nventricular segments contract normally. Right ventricular chamber size and\nfree wall motion are normal. The ascending is normal in diameter. There are\nsimple atheroma in the descending thoracic aorta. There are three aortic valve\nleaflets. The aortic valve leaflets are moderately thickened, particularly the\nnon-coronary cusp. There is mild aortic valve stenosis. ~1.2sq. Cm by\nplanimetry and Continuity equation. No aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. The mitral valve is abnormal (The\ntip of the anterior leaflet is moderately thickened and prolapses with\nabnormal coaptation. Moderate to severe (3+) mitral regurgitation is seen\nwhich increase to severe MR when the SBP is raised to 140mm HG and\nTredelenberg position The mitral regurgitation jet is eccentric.\n\nPOST BYPASS #1 (after MV repair)\nLimited examination of the mitral valve revealed persistent moderate to severe\nMR\n\nPOST BYPASS #2 (after MVR) Pt is on epinephrine 0.08 ucg/kg/min\nLV systolic function is slightly more depressed. LVEF~35-40% RV systolic\nfunction is preserved. There is well seated, well functioning bioprostheis in\nthe mitral position. There is trace valvular and trace perivalvular(along IAS)\nMR. The study is otherwise unchanged from pre-bypass\n\n\n"
},
{
"category": "Echo",
"chartdate": "2182-02-04 00:00:00.000",
"description": "Report",
"row_id": 80073,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pre-op CABG, s/p STEMI. Left ventricular function.\nHeight: (in) 62\nWeight (lb): 123\nBSA (m2): 1.56 m2\nBP (mm Hg): 132/51\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 10:21\nTest: Portable TTE (Congenital, complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nAdditional images were obtained to evaluate for a ventricular septal defect.,\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous hypertrophy of\nthe interatrial septum. Left-to-right shunt across the interatrial septum at\nrest. Small secundum ASD.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Mild symmetric LVH with normal cavity size. Mild regional LV systolic\ndysfunction. No LV mass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; apex - dyskinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Moderate AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Moderate (2+) MR. Eccentric MR jet.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\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: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is normal in size. A small left-to-right shunt is seen across\nthe interatrial septum c/w a small secundum atrial septal defect. There is\nmild symmetric left ventricular hypertrophy with normal cavity size. There is\nmild regional left ventricular systolic dysfunction with focal severe\nhypokinesis of the distal septum, distal anterior and distal inferior walls.\nThe apex is mildly dyskinetic/aneurysmal. No masses or thrombi are seen in the\nleft ventricle. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (?#)are moderately thickened. There is\nmoderate aortic valve stenosis. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is\nseen with an eccentric, inferiorly directed jet. The pulmonary artery systolic\npressure could not be determined. There is an anterior space which most likely\nrepresents a fat pad.\n\nIMPRESSION: Regional left ventricular systolic dysfunction c/w CAD (distal LAD\nlesion). Small secundum type atrial septal defect.\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": "2182-02-07 00:00:00.000",
"description": "Report",
"row_id": 205354,
"text": "Sinus rhythm\n*** arm lead reversal - only aVF, V1 - V6 analyzed ***\nProbable extensive anterior infarct - age undetermined\nSince previous tracing, anterior wall myocardial infarction has extended\n\n"
},
{
"category": "ECG",
"chartdate": "2182-02-05 00:00:00.000",
"description": "Report",
"row_id": 205355,
"text": "Sinus rhythm. Left atrial abnormality. Inferior myocardial infarction of\nindeterminate age. Anterolateral myocardial infarction with ST-T wave\nconfiguration suggest acute process. Consider left ventricular hypertrophy.\nSince the previous tracing of pattern of inferior myocardial infarction\nis now present and the lateral ST-T wave changes are more prominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2182-02-04 00:00:00.000",
"description": "Report",
"row_id": 205356,
"text": "Sinus rhythm. Possible left atrial abnormality. Lateral myocardial infarction\nof indeterminate age. Compared to the previous tracing of no\nsignificant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2182-02-03 00:00:00.000",
"description": "Report",
"row_id": 205357,
"text": "Sinus rhythm. Possible left atrial abnormality. Lateral myocardial infarction.\nCompared to the previous tracing of no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2182-02-03 00:00:00.000",
"description": "Report",
"row_id": 205358,
"text": "Sinus rhythm. Borderline first degree A-V block. Possible left atrial\nabnormality. Old lateral myocardial infarction. Inferior ST-T wave changes are\nnon-specific. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 902670,
"text": " 1:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p bronch, eval post op\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with acute MI with +3 MR s/p CABG/MV repair.\n\n REASON FOR THIS EXAMINATION:\n s/p bronch, eval post op\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of CABG.\n\n Status post CABG. Endotracheal tube is 5 cm above carina. Jugular CV line is\n in upper right atrium and suggest withdrawal for approximately 3 cm. Tip of\n NG tube overlies proximal antrum of stomach. No pneumothorax. There are\n bilateral pleural effusions, left greater than right with associated\n atelectasis in the left lower lobe.\n\n IMPRESSION: No pneumothorax. CV line is in upper right atrium and\n approximately 3 cm withdrawal is suggested. Bilateral pleural effusions and\n left lower lobe atelectasis as described.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 903243,
"text": " 9:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for trach placement, pneumo, etc\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with acute MI with +3 MR s/p CABG/MV repair. Now\n s/p trach insertion percutaneously\n REASON FOR THIS EXAMINATION:\n assess for trach placement, pneumo, etc\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST \n\n COMPARISON: .\n\n INDICATION: Trach placement.\n\n A tracheostomy tube has been placed, with the tip terminating approximately\n 4.5 cm above the carina. There is no evidence of pneumomediastinum. Several\n overlying structures partially obscure the left upper hemithorax limiting\n assessment for apical pneumothorax. With this limitation in mind, there is no\n evidence of pneumothorax.\n\n A feeding tube has been placed, coiling within the stomach. Central venous\n catheter has been withdrawn in the interval and now terminates in the region\n of the junction of the superior vena cava and right atrium. Cardiac and\n mediastinal contours are stable. There remains a moderate left pleural\n effusion. There is interval improving aeration in the left retrocardiac\n region. A right pleural effusion has decreased in size in the interval.\n\n IMPRESSION:\n 1. Tracheostomy tube in satisfactory position. Feeding tube coils in\n stomach.\n\n 2. Bilateral pleural effusions, nearly resolved on the right.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 902038,
"text": " 11:44 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p line change\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with acute MI with +3 MR s/p CABG/MV repair.\n\n REASON FOR THIS EXAMINATION:\n s/p line change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG with mitral valve repair now with line change.\n\n COMPARISON: .\n\n AP SUPINE CHEST RADIOGRAPH: In the interval, there has been removal of the\n right IJ sheath and associated Swan-Ganz catheter. In its place, a right IJ\n line has been placed with its tip at the distal SVC right atrial junction.\n\n The endotracheal tube and NG tube tips are in stable position. There are skin\n staples, sternal wires and mediastinal clips indicative of a recent CABG with\n associated mediastinal changes which are unchanged.\n\n There is no pneumothorax. Small bilateral pleural effusions and left\n basilar atelectasis is unchanged.\n\n IMPRESSION: Right IJ line tip at the distal SVC right atrial junction without\n pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 901661,
"text": " 3:20 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx, effusion\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with acute MI with +3 MR s/p CABG/MV repair.\n\n REASON FOR THIS EXAMINATION:\n ptx, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute MI with mitral regurgitation status post CABG and mitral\n valve repair.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: An endotracheal tube is in place with tip terminating approximately\n 5.3 cm from the carina. Internal jugular venous access catheter with\n pulmonary artery catheter in main pulmonary artery. Nasogastric tube extends\n below the diaphragm and below the borders of the radiograph. Two left-sided\n chest tubes and mediastinal drain in place. Heart size and mediastinal\n contours are within normal limits for patient's postoperative state. There is\n left lower lobe atelectasis and left pleural effusion. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 901730,
"text": " 7:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval post op\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with acute MI with +3 MR s/p CABG/MV repair.\n\n REASON FOR THIS EXAMINATION:\n eval post op\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:40 A.M.\n\n HISTORY: Acute MI. Status post CABG and MVR.\n\n IMPRESSION: AP chest compared to and 21:\n\n Small bilateral pleural effusion has developed since despite left\n pleural tube. There is no pneumothorax. Mild left lower lobe atelectasis is\n increased. Mediastinum has a normal postoperative appearance. Tip of the\n Swan-Ganz line projects over the main pulmonary artery. ET tube in standard\n placement. Nasogastric tube passes below the diaphragm and out of view. No\n pulmonary edema. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-28 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 904697,
"text": " 8:51 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: lower extremity DVT\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with s/p cabg and mvr\n REASON FOR THIS EXAMINATION:\n lower extremity DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 78-year-old woman status post coronary artery bypass graft\n surgery and mitral valve replacement.\n\n TECHNIQUE: Bilateral lower extremity venous ultrasound and Doppler\n examinations.\n\n FINDINGS: Bilateral grayscale and Doppler son of the common femoral,\n superficial femoral, and popliteal veins were performed. These show normal\n compressibility, augmentation, and Doppler flow and waveforms. No\n intraluminal thrombus is identified.\n\n IMPRESSION: No evidence of deep vein thrombosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 903948,
"text": " 12:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusion/infiltrates\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with acute MI with +3 MR s/p CABG/MV repair. Now\n s/p trach insertion percutaneously\n REASON FOR THIS EXAMINATION:\n pleural effusion/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old woman with acute MI status post CABG and mitral valve\n repair now status post trach insertion.\n\n CHEST PORTABLE: Comparison is made to a prior study of . The heart is\n normal in size. The mediastinal and hilar contours are unremarkable. The\n pulmonary vasculature is normal. There is a left pleural effusion and\n atelectasis of the left lower lobe. This is unchanged in comparison to the\n prior study. A tracheal stoma is identified 5.3 cm from the carina. There is\n a central venous line with its tip at the junction of the SVC to the right\n atrium. An NG tube is seen with its tip in the stomach where it is coiled.\n\n IMPRESSION: No change in comparison to the prior study of . Persistent\n retrocardiac opacity which might represent atelectasis of the left lower lobe,\n however, superinfection cannot be excluded.\n\n 2) Small left pleural effusion, stable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 904223,
"text": " 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrates\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old W s/p CABG/MV repair. Now w/fever\n REASON FOR THIS EXAMINATION:\n assess for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post CABG. Fever.\n\n CXR, PORTABLE AP 7:35AM\n\n Compared to , tracheostomy tube, orogastric tube, right IJ CVL, and\n midline sternotomy wires and staples are stable. The patient is status post\n CABG. Left pleural effusion has decreased and is now small in size. There is\n no pulmonary edema. The right lung is clear.\n\n IMPRESSION: Interval decrease in left pleural effusion. Left basilar\n atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-03-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 905226,
"text": " 8:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrates\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old W s/p CABG/MV repair.\n REASON FOR THIS EXAMINATION:\n assess for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE-VIEW CHEST\n\n INDICATION: CABG and mitral valve replacement. Assess for infiltrate.\n\n COMPARISON: .\n\n FINDINGS: Tracheostomy tube is unchanged. The feeding tube tip overlies the\n stomach. The right internal jugular central venous line has been removed. The\n patient is status post sternotomy. Pleural effusion of increasing size in the\n interval, and there is increased opacity in the retrocardiac region,\n consistent with atelectasis or infiltrate. no evidence of CHF. There is no\n pneumothorax.\n\n IMPRESSION: Opacity at the left lung base may represent atelectasis or\n developing pneumonia. Increase in size of left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-26 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 904381,
"text": " 8:54 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate for infiltrates/effusion\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n Field of view: 30\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM.\n\n Finding of a tiny catheter fragment or vascular clip in the left pleural space\n or at the base of the region of atelectasis in the left lung was discussed by\n telephone with on Tuesday, at 3:30 p.m.\n\n\n\n 8:54 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate for infiltrates/effusion\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n Field of view: 30\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman s/p cabg MVR\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates/effusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG and mitral valve repair, evaluate for infiltrate or\n effusions. History of fever one day prior.\n\n COMPARISON: There are no prior CT studies available for comparison.\n\n TECHNIQUE: Multidetector contiguous CT images of the chest were obtained\n without intravenous contrast with axial images presented for review with 1.25-\n and 5-mm collimation.\n\n FINDINGS: The central airways are patent. A small peripheral rounded nodule\n measuring 4 mm in the right middle lobe (3:40), and in the right lower lobe\n measuring 4 mm (3:33) are noted. There is bibasilar atelectasis as well as an\n adjacent area of consolidation in the right lower lobe (3:42). The quality of\n lung detail is slightly compromised by motion/breathing artifact. There are\n scattered areas of ground-glass opacity in the lower lobes, right greater than\n left.\n\n There are no pleural or pericardial effusions. There is cardiomegaly, and an\n enlarged left atrium is noted.\n\n Within the area of left lower lobe atelectasis, there is an increased\n attenuation tubular linear structure measuring approximately 1.4 cm in length.\n Sagittal and coronal reformatted images confiirm this finding. It could\n represent a piece of catheter.\n\n No pathologically enlarged axillary, mediastinal, or hilar lymph nodes are\n identified. There is demonstrable air-fluid level in the supraglottic\n trachea, and a tracheostomy tube is identified in satisfactory position.\n\n In the left lobe of the liver, there is a 1.4-cm area of low attenuation that\n is likely a simple cyst. Cholestasis is demonstrated in the gallbladder.\n Degenerative changes in the right shoulder with calcific loose bodies are\n identified.\n\n IMPRESSION:\n 1. Bibasilar atelectasis, with more focal rounded opacity which could\n represent focus of consolidation in the right lower lobe. There are no\n bilateral pleural effusions or pulmonary edema.\n 2. Linear dense tubular structure in the left lower lobe, likely\n catheter/drain fragment.\n (Over)\n\n 8:54 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate for infiltrates/effusion\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n Field of view: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Cholestasis.\n 4. Degenerative changes at the right shoulder.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-26 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 904382,
"text": " 8:55 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: evaluate for infection\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman s/p cabg MVR\n REASON FOR THIS EXAMINATION:\n evaluate for infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Status post CABG, question infection.\n\n NONCONTRAST CT OF THE SINUSES IN AXIAL PROJECTION WITH CORONAL REFORMATED\n IMAGES\n\n The frontal sinuses are clear. There is increased density in the posterior\n ethmoid cells, and in particular, there is increased density with aerosolized\n secretions in the sphenoid sinus. The maxillary sinuses are clear. The left\n mastoid tip is identified, and there appears to be some soft tissue density\n within it. A nasogastric tube is in place.\n\n IMPRESSION: Increased soft tissue density in posterior ethmoid cells and\n sphenoid sinus. With the presence of a nasogastric tube, the significance of\n this is not certain.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 902804,
"text": " 8:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check CHF\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with acute MI with +3 MR s/p CABG/MV repair.\n\n REASON FOR THIS EXAMINATION:\n check CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of acute MI status post CABG and MV repair. Check CHF.\n\n Comparison is made to .\n\n PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: The endotracheal tube is now\n located approximately 5.6 cm above the carina. A right internal jugular\n central venous catheter is located with the tip in the right atrium. There is\n stable opacification of the left heart border which is likely due to pleural\n effusions and/or atelectasis. The right lung is clear.\n\n IMPRESSION: No significant interval change in the left pleural\n effusions/atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 902361,
"text": " 10:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check CHF\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with acute MI with +3 MR s/p CABG/MV repair.\n\n REASON FOR THIS EXAMINATION:\n check CHF\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: An evaluation for congestive heart failure.\n\n Portable AP chest x-ray was compared to the previous study from .\n\n The patient is after median sternotomy and marked mitral valve replacement due\n to severe mitral regurgitation after myocardial infarction. An endotracheal\n tube, a right internal jugular vein and nasogastric tube remain in the same\n position. The heart size is enlarged. A large amount of left pleural fluid\n is demonstrated, which is now of a moderate amount. No evidence of congestive\n heart failure or new pulmonary infiltrates is present. No evidence of\n pneumothorax is present.\n\n IMPRESSION:\n 1. Large amount of left pleural fluid.\n 2. The patient is status post median sternotomy and mitral valve replacement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 901900,
"text": " 12:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct d/c, r/o ptx\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with acute MI with +3 MR s/p CABG/MV repair.\n\n REASON FOR THIS EXAMINATION:\n s/p ct d/c, r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute MI with CABG and mitral valve repair status post removal of\n chest tube, evaluate for pneumothorax.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable semi-upright chest.\n\n FINDINGS: An endotracheal tube is in place with tip terminating 4.3 cm from\n the carina. Right internal jugular venous access sheath with pulmonary artery\n catheter terminating in main pulmonary artery. Nasogastric tube terminates in\n stomach. Sternal suture wires, mediastinal clips, and metallic skin staples\n in unchanged position. The heart size and mediastinal contours are unchanged\n allowing for differences in patient positioning. Stable left pleural\n effusion. The right pleural effusion is less well visualized, possibly due to\n layering as patient is now positioned in the semi-upright position. There is\n no evidence of pulmonary edema or new pneumonic consolidation. Two left-sided\n chest tubes have been removed in the interval. No pneumothorax.\n\n IMPRESSION: 1) No pneumothorax.\n\n 2) Lines and tubes in satisfactory position.\n\n 3) Bilateral pleural effusions and left lower lobe atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-20 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 903670,
"text": " 3:32 PM\n PORTABLE ABDOMEN Clip # \n Reason: s/p feeding tube placement evaluation\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman s/p CABG, MVR, Trach\n REASON FOR THIS EXAMINATION:\n s/p feeding tube placement evaluation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate feeding tube placement.\n\n COMPARISON: Chest x-ray from .\n\n SINGLE PORTABLE AP UPRIGHT ABDOMINAL RADIOGRAPH: The patient is status post\n median sternotomy, skin staples are seen along the midline. A central venous\n line tip appears to terminate at the cavoatrial junction. The visualized\n right lung appears clear. There is a persistent retrocardiac opacity seen in\n the left lung with an associated small left pleural effusion. A feeding tube\n is seen coiling within the stomach with its tip in the antrum.\n\n IMPRESSION: Appropriate placement of a feeding tube with its tip in the\n antrum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-04 00:00:00.000",
"description": "TEETH (PANOREX FOR DENTAL)",
"row_id": 901556,
"text": " 6:46 PM\n TEETH (PANOREX FOR DENTAL) Clip # \n Reason: preop MVR\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with preop for CABG and MVR\n REASON FOR THIS EXAMINATION:\n preop MVR\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dental assessment, preoperative for CABG and MVR.\n\n Exam consist of two similarly positioned Panorex views of the mandible. Exam\n is markedly suboptimal due to patient's inability to bite down or sit up\n straight for positioning. All molar teeth have been removed with the\n exception of a single upper maxillary tooth on the right. All visualized\n teeth have a metallic surface cap. No bone destruction identified and the\n partially visualized TM joints are WNL. There is a vague lucency around the\n root of the lateral most left mandibular tooth but this assessment as well as\n entire assessment of teeth is suboptimal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 902434,
"text": " 5:49 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Intubated\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with acute MI with +3 MR s/p CABG/MV repair.\n\n REASON FOR THIS EXAMINATION:\n Intubated\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old with acute MI, now status post CABG and mitral valve\n repair, intubated.\n\n COMPARISON: at 10:45 a.m.\n\n SUPINE CHEST RADIOGRAPH: Technical factors limit evaluation of the lung\n apices. The patient is status post median sternotomy and mitral valve\n replacement. An endotracheal tube and right internal jugular central venous\n catheter remain in unchanged position. There has been, interval removal of a\n nasogastric tube. The heart size is stablly enlarged. There is decreased size\n of the left retrocardiac opacity likely representing improving left pleural\n effusion. There is no evidence of pneumothorax.\n\n IMPRESSION:\n 1. Interval decrease in left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 901538,
"text": " 3:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with acute MI with +3 MR waiting for surgery and now with low\n grade temp.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Low-grade temperatures.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH: The cardiac, mediastinal and hilar contours are\n unchanged. The pulmonary vascularity is normal in appearance without\n redistribution. Left basilar atelectasis is unchanged. No definite\n consolidation is seen. Again seen are surgical skin clips projecting over the\n left neck.\n\n IMPRESSION: No CHF or focal consolidations. Left basilar atelectasis is\n unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-02-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 901417,
"text": " 9:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chf?\n Admitting Diagnosis: MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with acute MI and some SOB.\n REASON FOR THIS EXAMINATION:\n chf?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of myocardial infarct and shortness of breath.\n\n No previous films for comparison. Heart size is within upper limits of normal\n for technique. No definite CHF or pulmonary edema. The lungs are grossly\n clear in this single view. Skin clips overlie the left neck\n\n IMPRESSION: No evidence for CHF.\n\n\n"
}
] |
65,592 | 122,210 | Presented to ER for eval of 14days heavy menses and nausea/chills/abdominal pain. Pelvic exam in ED was unremarkable. In ER, tremulous with remote history of seizures from ETOH w/drawal, thus admitted to MICU, got a couple doses of valium per CIWA. HCT stable and pt otw stable, thus transfered to Gen Med for continued management. Intially still with bleeding, thus got TVUS and gyne consulted, however pt's bleeding stopped prior to formal gyne eval and final results (prelim unremarkable). HCT also stable. Pt wanted to go home so was decided she would follow up with Gyne as on (appt made). She did have a TVUS done in that was unremarkable and her INR was 1.4 this admission, which suggested that her current bleeding diasthesis may have been coagulopathy from liver disease. Was given a couple doses of oral Vit K. Her electrolytes (K, Mag, phos) were low likely refeeding syndrome which suggests that pt was minimizing how much she is drinking. On further history, pt states that she lives at a safe house domestic violence. Was seen by social worker regarding ETOh abuse and given treatment program information (). She would benefit from psych eval as well but wanted to defer at this time. . see progress note below for details: 38 year old female with h/o HTN, EtoH abuse with h/o withdrawal seizures, dysfunctional uterine bleeding requiring transfusions in past admitted with prolonged menses X14days and tremors in setting of excessive EtoH use concerning for ETOH withdrawal. . . EtoH Abuse/Withdrawal: seizures 10years ago. Some tremulousness and elevated BP concerning for w/drawal on admission, s/p few doses of valium, no more requirement -note, has low K/mag/phos (refeeding?), elevated INR all of which suggest her etoh intake is more than she admits to. - cont MVI, thiamine, and folate. -social work provided info on treatment programs (), pt has f/u with PCP, as well -emphasized to patient long term effects of heavy ETOH use . . Dsyfunctional uterine bleeding/mennorrhagia: in tail end of her normal menstral cycle (normal 7-8days), but has lasted >14days. last transfusion to same at which time transvag U/S was performed which was unremarkable. -had repeat TVUS, prelim unremarkable -HCT stable and bleeding finally stopped today -may have happened in setting of excessive ETOH->coagulopathy/liver disease -per Gyne, send prolactin, DHEAS, , need to f/u results as , make appt . . Anemia, acute on chronic blood loss: as above DUB -cont Fe supp TID . . ETOH hepatitis: heavy ETOH use, malnutrition (low mag, K, phos, elevated INR) -monitor LFTs -Vit K 5mg PO X2days for elevated INR likely nutritional -aggressively replete K, Mag, Phos (likely refeeding syndrome) . . Abdominal Pain: admitted with abd pain and nausea, has since resolved. has mild ETOh hepatitis and asymptomatic pyuria. . . Asymptomatic pyuria: UA +nitrites and many bacteria but 0-2 wbc and no dysuria. Will not treat. . . HTN: cont Atenolol 25mg qd . . . FEN/proph: HLIV, monitor/replete lytes, Gen diet as tolerated, no AC given recent heavy bleeding, ambulation, no need for PPI . . Code: Full code . dispo: pt wanting to go back to her shelter , complete w/u as , gyne appt made for . | maintenance ivf d/c since pt taking in adequate amts of liqs. maintenance ivf d/c since pt taking in adequate amts of liqs. maintenance ivf d/c since pt taking in adequate amts of liqs. Continue to assess for possible etoh withdrawal since pts last drink was . Continue to assess for possible etoh withdrawal since pts last drink was . Continue to assess for possible etoh withdrawal since pts last drink was . She does have a history () of vaginal blding requiring a 1u PRBC transfusion (Hct was 26.3). Amt of vaginal bleeding has slowed down since her admit to micu. Amt of vaginal bleeding has slowed down since her admit to micu. Amt of vaginal bleeding has slowed down since her admit to micu. She was given valium in the emergency room with improvement but still has a marked resting tremor, no hallucinations. She endorses lower abdominal pain x 1 day which is consistent with her usual menstrual cramping. We will treat her with valium guided by CWA scale. - Trend Hct - Will monitor pt's vaginal blding with the number of pads she uses - Will consider OB/GYN consult if blding continues for possible D&C - Will set up outpatient gynecology follow up - Transfuse for Hct < 21 # Abdominal Pain: Pt's abdominal pain is consistent with her menses cramping, now is resolved. Also, of note, after receiving the valium, her abdominal pain resolved. Pt was noted to have a mildly elevated lipase, given her lack of clinical findings Pancreatitis is very unlikely. vaginal bld requiring transfusions who presents with sub acute chills, nausea, vaginal blding w/ stable Hct and resting tremors in the setting of recent excessive EtoH use. Action: On CIWA scale, received one dose of PO valium on admission,started on banana bag, can have normal diet in AM Response: Pt was comfortable CIWA 7- Plan: Monitor DT,s CIWA scale,PRN Valiumsocial work consult,follow up crit, transfusion for crit <21, monitor vaginal bleeding and number of pads As far as the vaginal bleeding and anemia (presumed iron deficiency), has had this once before and evaluation at that time did not reveal fibroids. Due to the concern for etoh withdrawal, she was admitted to the ICU for further management. Pt is trmulous at rest and with tongue protrusion she does have brisk tremor that does not appear to be fasculations. Pt is trmulous at rest and with tongue protrusion she does have brisk tremor that does not appear to be fasculations. Allergies: Bactrim (Oral) (Sulfamethoxazole/Trimethoprim) Hives; Shellfish Hives; Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 05:55 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 37.4C (99.3 Tcurrent: 37.2C (98.9 HR: 62 (60 - 86) bpm BP: 134/86(98) {133/80(93) - 142/100(114)} mmHg RR: 13 (13 - 18) insp/min SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Height: 69 Inch Total In: 55 mL 592 mL PO: TF: IVF: 55 mL 592 mL Blood products: Total out: 0 mL 550 mL Urine: 550 mL NG: Stool: Drains: Balance: 55 mL 42 mL Respiratory support O2 Delivery Device: None SpO2: 99% ABG: //// Physical Examination Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 127 K/uL 8.4 g/dL 24.9 % 3.4 K/uL [image002.jpg] 04:40 AM WBC 3.4 Hct 24.9 Plt 127 Other labs: PT / PTT / INR:15.7/27.4/1.3, Differential-Neuts:64.8 %, Lymph:26.1 %, Mono:7.1 %, Eos:1.3 % Assessment and Plan ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES) Young adult Female with a history of EtoH abuse w/ seizures, h.o. | 21 | [
{
"category": "Physician ",
"chartdate": "2130-03-05 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 553276,
"text": "TITLE:\n Chief Complaint:\n HPI:\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Atenolol 25 mg daily\n Folic acid 1 mg daily\n Ferrous Sulfate 325mg t.i.d.\n Past medical history:\n Family history:\n Social History:\n HSIL s/p electric loop excision\n Etoh Abuse\n EtoH w/drawal with seziures (approx 10 years ago)\n Alcoholic Hepatitis\n HL\n HTN\n Sickle Cell Trait\n h.o. Vaginal bleeding\n L knee medial meniscal tear\n Congenital hearing Impairment\n Pt lives at home with her two sons, aged 16, 17. She currently works at\n a law firm. She denies any tobacco or recreational drug use history.\n She does endorse drinking 1/5th Vodka over the weekend, she does not\n use alcohol during the week day as she is concerned it may interfere\n with her employment. She is currently sexually active with one partner,\n she uses condoms for every sexual experience. She denies any history of\n STD, does have documented history of Trichomonas.\n Review of systems:\n Flowsheet Data as of 10:40 PM\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: 68 (62 - 68) bpm\n BP: 141/94(105) {141/94(103) - 142/100(114)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n GEN: Well-nourished, A. American Female with resting tremors in no\n acute distress\n HEENT: EOMI, sclera anicteric, MMM, lingular tremors noted.\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\n PULM: Lungs CTAB, no W/R/R\n ABD: Soft, NT, ND, +BS, no HSM, no masses\n EXT: No C/C/E, no palpable cords\n NEURO: Alert, oriented to person, place, and time. CN II\n, , XII\n grossly intact. Moves all 4 extremities. No intention tremor noted on\n FTN test. No asterixis noted.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:51 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2130-03-05 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 553277,
"text": "TITLE:\n Chief Complaint:\n HPI: This is a 38 year-old Female with a history of etoh abuse, vaginal\n bleeding requiring bld transfusion, HSIL s/p loop excision who presents\n with 14 day history of vaginal bleeding (approx 6 pads a day), reported\n chills, nausea. Admission to ICU for concern of EtoH withdrawal.\n Pt's last EtoH drink was a 1/5th of vodka last night. While she also\n notes she had been drinking the night before, she denies any daily\n drinking. She believes she goes through a fifth of vodka per week.\n She endorses lower abdominal pain x 1 day which is consistent with\n her usual menstrual cramping. She had an episode of non-bloody,\n non-bilious emesis x 1 at home this morning. She also endorses 3 day\n history of watery, non-bloody diarrhea.\n In the , pt was noted to be shaking in the bed and required 2 x 5mg\n Diazepam per CIWA scale. A pelvic exam was performed which did not\n show any CMT or adnexal tenderness. GC/Chlamydia swabs were sent. No\n vaginal discharge was noted other than menstrual bleeding. Also, of\n note, after receiving the valium, her abdominal pain resolved. Due to\n the concern for etoh withdrawal, she was admitted to the ICU for\n further management.\n ROS: The patient denies any fevers, weight change, constipation,\n melena, hematochezia, chest pain, shortness of breath, orthopnea, PND,\n lower extremity oedema, cough, urinary frequency, urgency, dysuria,\n lightheadedness, gait unsteadiness, focal weakness, vision changes,\n headache, rash or skin changes.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Home medications:\n Atenolol 25 mg daily\n Folic acid 1 mg daily\n Ferrous Sulfate 325mg t.i.d.\n Past medical history:\n Family history:\n Social History:\n HSIL s/p electric loop excision\n Etoh Abuse\n EtoH w/drawal with seziures (approx 10 years ago)\n Alcoholic Hepatitis\n HL\n HTN\n Sickle Cell Trait\n h.o. Vaginal bleeding\n L knee medial meniscal tear\n Congenital hearing Impairment\n Pt lives at home with her two sons, aged 16, 17. She currently works at\n a law firm. She denies any tobacco or recreational drug use history.\n She does endorse drinking 1/5th Vodka over the weekend, she does not\n use alcohol during the week day as she is concerned it may interfere\n with her employment. She is currently sexually active with one partner,\n she uses condoms for every sexual experience. She denies any history of\n STD, does have documented history of Trichomonas.\n Review of systems:\n Flowsheet Data as of 10:40 PM\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: 68 (62 - 68) bpm\n BP: 141/94(105) {141/94(103) - 142/100(114)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n GEN: Well-nourished, A. American Female with resting tremors in no\n acute distress\n HEENT: EOMI, sclera anicteric, MMM, lingular tremors noted.\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\n PULM: Lungs CTAB, no W/R/R\n ABD: Soft, NT, ND, +BS, no HSM, no masses\n EXT: No C/C/E, no palpable cords\n NEURO: Alert, oriented to person, place, and time. CN II\n, , XII\n grossly intact. Moves all 4 extremities. No intention tremor noted on\n FTN test. No asterixis noted.\n Labs / Radiology\n 157\n 9.2\n 0.5\n 6\n 27\n 101\n 3.5\n 144\n 27.4\n 3.9\n [image002.jpg]\n Assessment and Plan\n Young adult Female with a history of EtoH abuse w/ seizures, h.o.\n vaginal bld requiring transfusions who presents with sub acute chills,\n nausea, vaginal blding w/ stable Hct and resting tremors in the setting\n of recent excessive EtoH use.\n Plan:\n # EtoH Withdrawal: Pt has a history of EtoH abuse with seizures 10\n years ago. Her current clinical tremulous state is interesting given\n that she has never presented in withdrawal like this, she also is not\n tachycardic and has only mild hypertension. However she does take\n Atenolol which would blunt the adrenergic state of withdrawal, her\n tremors also appeared to improve with Diazepam. Other cause of tremors\n to consider would include infectious state however given her\n unremarkable U/A and lack of clinical findings this is unlikely. Etoh\n level in the ED 16.\n - will continue CIWA scale\n - Will monitor for DTs\n - Will start Banana bag, daily MVI, thiamine, folate\n - Social work/addictions consult\n # DUB: Pt currently on her regular menstrual cycle. She reports an\n increase in length of blding from her usual menses cycle. She does have\n a history () of vaginal blding requiring a 1u PRBC transfusion\n (Hct was 26.3). At the time a transvag U/S was performed and showed\n and unremarkable pelvic son. Currently her Hct is 27.4 which is\n close to her prior baseline of 26-32 over the past year. Currently she\n is hemodynamically stable and her blding is not profuse given that it\n is only 6 pads. Will also check coags as pt may be coagulopathic given\n EtoH history.\n - Trend Hct\n - Will monitor pt's vaginal blding with the number of pads she uses\n - Will consider OB/GYN consult if blding continues for possible D&C\n - Will set up outpatient gynecology follow up\n - Transfuse for Hct < 21\n # Abdominal Pain: Pt's abdominal pain is consistent with her menses\n cramping, now is resolved. Pt was noted to have a mildly elevated\n lipase, given her lack of clinical findings Pancreatitis is very\n unlikely.\n - Continue to follow exam\n # Elevated AST: AST elevated consistent with history of pt\ns EtoH\n abuse, pt does complain of increased bld as mentioned above will add on\n coags.\n # HTN: Will continue pt on home regimen of Atenolol.\n # FEN: Regular diet\n # Access: PIV\n # PPx: Heparin SQ TID, PPI\n # Code: FULL (Presumed)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:51 PM\n Prophylaxis:\n DVT: Heparin SC 5,000 TID\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL CODE\n Disposition: Likely call out in the AM\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 553287,
"text": "Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 553288,
"text": "38 year-old Female with a history of etoh abuse, vaginal bleeding\n requiring bld transfusion, HSIL s/p loop excision who presents with 14\n day history of vaginal bleeding (approx 6 pads a day), reported chills,\n nausea. Admission to ICU for concern of EtoH withdrawal,pt's last EtoH\n drink was a 1/5th of vodka Saturday night.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 553289,
"text": "38 year-old Female with a history of etoh abuse, vaginal bleeding\n requiring bld transfusion, HSIL s/p loop excision who presents with 14\n day history of vaginal bleeding (approx 6 pads a day), reported chills,\n nausea. Admission to ICU for concern of EtoH withdrawal,pt's last EtoH\n drink was a 1/5th of vodka Saturday night associated with abdominal\n pain\nmenstrual cramping , vomiting and diarrhea.\n Pt did reciev 10 mg of Valium IV in ED\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n New admission from ED,lethargic and tremulous oriented X 3 last drink\n was on Saturday night ^th of vodka, ,MAE,denies any pain or\n discomfort,revieved with 2L NC from ED on RA since admission sats\n 100%.very minimal vaginal bleeding after admission.\n Action:\n On CIWA scale, received one dose of PO valium on admission,started on\n banana bag, can have normal diet in AM\n Response:\n Pt was comfortable CIWA 7-\n Plan:\n Monitor DT,s CIWA scale,PRN Valiumsocial work consult,follow up crit,\n transfusion for crit <21, monitor vaginal bleeding and number of pads\n"
},
{
"category": "General",
"chartdate": "2130-03-05 00:00:00.000",
"description": "ICU Event Note",
"row_id": 553273,
"text": "Clinician: Attending\n I have seen and examined the patient. I have discussed the case with\n the team and agree with the findings and plan as documented in Dr.\n time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 553372,
"text": "38 year-old Female with a history of etoh abuse, vaginal bleeding\n requiring bld transfusion, HSIL s/p loop excision who presents with 14\n day history of vaginal bleeding (approx 6 pads a day), reported chills,\n nausea. Admission to ICU for concern of EtoH withdrawal,pt's last EtoH\n drink was a 1/5th of vodka Saturday night associated with abdominal\n pain\nmenstrual cramping , vomiting and diarrhea.\n Pt did recieve 10 mg of Valium IV in ED\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt has received a total of 15 mg of valium since her arrival here to\n . Pt a&o x3. no auditory or visual hallucinations and no\n diaphoresis. Pt follows simple commands and is appropriate. Pt is\n trmulous at rest and with tongue protrusion she does have brisk tremor\n that does not appear to be fasculations. Ciwa scale < 10 and has not\n required any additional valium. Now tolerating reg heart healthy diet.\n Pt oob to commode with steady gait. Pt normotensive and not\n tachycardic. Amt of vaginal bleeding has slowed down since her admit to\n micu.\n Action:\n Pt\ns neurologial status assessed. Frequnecy of ciwa scale checks has\n dropped. Social w orker consulted to follow pt. maintenance ivf d/c\n since pt taking in adequate amts of liqs. Sc heparin d/c\nd since pt now\n oob.\n Response:\n Pt hemodynamically stable as well as her hct.\n Plan:\n Transfer to medical floor bed. Continue to assess for possible etoh\n withdrawal since pt\ns last drink was . follow continue to assess\n pt\ns neurological status. Will need gyn/ob follow up outpt. Increase pt\ns activity level as pt tolerates. Recheck hct and coags this\n evenening.\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 553373,
"text": "38 year-old Female with a history of etoh abuse, vaginal bleeding\n requiring bld transfusion, HSIL s/p loop excision who presents with 14\n day history of vaginal bleeding (approx 6 pads a day), reported chills,\n nausea. Admission to ICU for concern of EtoH withdrawal,pt's last EtoH\n drink was a 1/5th of vodka Saturday night associated with abdominal\n pain\nmenstrual cramping , vomiting and diarrhea.\n Pt did recieve 10 mg of Valium IV in ED\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt has received a total of 15 mg of valium since her arrival here to\n . Pt a&o x3. no auditory or visual hallucinations and no\n diaphoresis. Pt follows simple commands and is appropriate. Pt is\n trmulous at rest and with tongue protrusion she does have brisk tremor\n that does not appear to be fasculations. Ciwa scale < 10 and has not\n required any additional valium. Now tolerating reg heart healthy diet.\n Pt oob to commode with steady gait. Pt normotensive and not\n tachycardic. Amt of vaginal bleeding has slowed down since her admit to\n micu.\n Action:\n Pt\ns neurologial status assessed. Frequnecy of ciwa scale checks has\n dropped. Social w orker consulted to follow pt. maintenance ivf d/c\n since pt taking in adequate amts of liqs. Sc heparin d/c\nd since pt now\n oob.\n Response:\n Pt hemodynamically stable as well as her hct.\n Plan:\n Transfer to medical floor bed. Continue to assess for possible etoh\n withdrawal since pt\ns last drink was . follow continue to assess\n pt\ns neurological status. Will need gyn/ob follow up outpt. Increase pt\ns activity level as pt tolerates. Recheck hct and coags this\n evenening.\n"
},
{
"category": "General",
"chartdate": "2130-03-05 00:00:00.000",
"description": "ICU Event Note",
"row_id": 553272,
"text": "Clinician: Attending\n I have seen and examined the patient. I have discussed the case with\n the team and agree with the findings and plan as documented in Dr.\n time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "General",
"chartdate": "2130-03-05 00:00:00.000",
"description": "ICU Event Note",
"row_id": 553275,
"text": "Clinician: Attending\n I have seen and examined the patient. I have discussed the case with\n the team and agree with the findings and plan as documented in Dr.\n \ns note. Briefly, 38 year old woman with a history of alcohol\n abuse and history of withdrawal seizures who presented with\n uncontrollable tremor and 14 days of vaginal bleeding. Usual menses\n lasts 10 days and usually lightens by the end of her cycle. Also has\n diarrhea and some abdominal cramping. Her last drink was Saturday\n night , drinks about a fifth of alcohol a week (much less than in the\n past). She was given valium in the emergency room with improvement but\n still has a marked resting tremor, no hallucinations. She not\n tachycardic, afebrile and hemodynamically stable. Pelvic exam, by\n report, without cervical motion tenderness. Urine HCG is negative.\n HCT 27.4. She appears to be in alcohol withdrawal with early DTs\n although it is not a classic picture. We will treat her with valium\n guided by CWA scale. Also give MVI/thiamine/folate. Will have SW see\n her. As far as the vaginal bleeding and anemia (presumed iron\n deficiency), has had this once before and evaluation at that time did\n not reveal fibroids. Will place 2 large bore IVs and send a clot but\n hold off on further evaluation for now. Will call gyn depending on how\n much she bleeds overnight and discuss the use of estrogen. Will check\n coags as well. Will culture her if she spikes.\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 553355,
"text": "38 year-old Female with a history of etoh abuse, vaginal bleeding\n requiring bld transfusion, HSIL s/p loop excision who presents with 14\n day history of vaginal bleeding (approx 6 pads a day), reported chills,\n nausea. Admission to ICU for concern of EtoH withdrawal,pt's last EtoH\n drink was a 1/5th of vodka Saturday night associated with abdominal\n pain\nmenstrual cramping , vomiting and diarrhea.\n Pt did recieve 10 mg of Valium IV in ED\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt has received a total of 15 mg of valium since her arrival here to\n . Pt a&o x3. no auditory or visual hallucinations and no\n diaphoresis. Pt follows simple commands and is appropriate. Pt is\n trmulous at rest and with tongue protrusion she does have brisk tremor\n that does not appear to be fasculations. Ciwa scale < 10 and has not\n required any additional valium. Now tolerating reg heart healthy diet.\n Pt oob to commode with steady gait. Pt normotensive and not\n tachycardic. Amt of vaginal bleeding has slowed down since her admit to\n micu.\n Action:\n Pt\ns neurologial status assessed. Frequnecy of ciwa scale checks has\n dropped. Social w orker consulted to follow pt. maintenance ivf d/c\n since pt taking in adequate amts of liqs. Sc heparin d/c\nd since pt now\n oob.\n Response:\n Pt hemodynamically stable as well as her hct.\n Plan:\n Transfer to medical floor bed. Continue to assess for possible etoh\n withdrawal since pt\ns last drink was . follow continue to assess\n pt\ns neurological status. Will need gyn/ob follow up outpt. Increase pt\ns activity level as pt tolerates. Recheck hct and coags this\n evenening.\n"
},
{
"category": "Physician ",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 553363,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Since admission last night pt has required 5mg Diazepam x 1.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:55 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: 37.2\nC (98.9\n HR: 62 (60 - 86) bpm\n BP: 134/86(98) {133/80(93) - 142/100(114)} mmHg\n RR: 13 (13 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 55 mL\n 592 mL\n PO:\n TF:\n IVF:\n 55 mL\n 592 mL\n Blood products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 55 mL\n 42 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ////\n Physical Examination\n GEN: Well-nourished, A. American Female with resting tremors in no\n acute distress\n HEENT: EOMI, sclera anicteric, MMM, lingular tremors still present but\n not as pronounced.\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\n PULM: Lungs CTAB, no W/R/R\n ABD: Soft, NT, ND, +BS, no HSM, no masses\n EXT: No C/C/E, no palpable cords\n NEURO: Alert, oriented to person, place, and time. CN II\n, , XII\n grossly intact. Moves all 4 extremities. No intention tremor noted on\n FTN test. No asterixis noted. Resting tremor still present but less\n pronounced.\n Labs / Radiology\n 127 K/uL\n 8.4 g/dL\n 24.9 %\n 3.4 K/uL\n [image002.jpg]\n 04:40 AM\n WBC\n 3.4\n Hct\n 24.9\n Plt\n 127\n Other labs: PT / PTT / INR:15.7/27.4/1.3, Differential-Neuts:64.8 %,\n Lymph:26.1 %, Mono:7.1 %, Eos:1.3 %\n Assessment and Plan\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Young adult Female with a history of EtoH abuse w/ seizures, h.o.\n vaginal bld requiring transfusions who presents with sub acute chills,\n nausea, vaginal blding w/ stable Hct and resting tremors in the setting\n of recent excessive EtoH use.\n Plan:\n # EtoH Withdrawal: Pt has a history of EtoH abuse with seizures 10\n years ago. Her current clinical tremulous state is interesting given\n that she has never presented in withdrawal like this, she also is not\n tachycardic and has only mild hypertension. However she does take\n Atenolol which would blunt the adrenergic state of withdrawal, her\n tremors also appeared to improve with Diazepam. Other cause of tremors\n to consider would include infectious state however given her\n unremarkable U/A and lack of clinical findings this is unlikely. Etoh\n level in the ED 16. Overnight pt required only 5mg PO Diazepam, has had\n low CIWA requirements. Pt finished Banana bag this AM/\n - will continue CIWA scale, can continue on floor due to low\n requirements\n - Will monitor for DTs\n - Will transition topstart Banana bag, daily MVI, thiamine, folate\n - Social work/addictions consult\n # DUB: Pt currently on her regular menstrual cycle. She reports an\n increase in length of blding from her usual menses cycle. She does have\n a history () of vaginal blding requiring a 1u PRBC transfusion\n (Hct was 26.3). At the time a transvag U/S was performed and showed\n and unremarkable pelvic son. Currently her Hct is 27.4 which is\n close to her prior baseline of 26-32 over the past year. Currently she\n is hemodynamically stable and her blding is not profuse given that it\n is only 6 pads. Will also check coags as pt may be coagulopathic given\n EtoH history.\n - Trend Hct\n - Will monitor pt's vaginal blding with the number of pads she uses\n - Will consider OB/GYN consult if blding continues for possible D&C\n - Will set up outpatient gynecology follow up\n - Transfuse for Hct < 21\n # Abdominal Pain: Pt's abdominal pain is consistent with her menses\n cramping, now is resolved. Pt was noted to have a mildly elevated\n lipase, given her lack of clinical findings Pancreatitis is very\n unlikely.\n - Continue to follow exam\n # Elevated AST: AST elevated consistent with history of pt\ns EtoH\n abuse, pt does complain of increased bld as mentioned above will add on\n coags.\n # HTN: Will continue pt on home regimen of Atenolol.\n # FEN: Regular diet\n # Access: PIV\n # PPx: Heparin SQ TID, PPI\n # Code: FULL (Presumed)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:02 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 553366,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Since admission last night pt has required 5mg Diazepam x 1.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:55 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: 37.2\nC (98.9\n HR: 62 (60 - 86) bpm\n BP: 134/86(98) {133/80(93) - 142/100(114)} mmHg\n RR: 13 (13 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 55 mL\n 592 mL\n PO:\n TF:\n IVF:\n 55 mL\n 592 mL\n Blood products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 55 mL\n 42 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ////\n Physical Examination\n GEN: Well-nourished, A. American Female with resting tremors in no\n acute distress\n HEENT: EOMI, sclera anicteric, MMM, lingular tremors still present but\n not as pronounced.\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\n PULM: Lungs CTAB, no W/R/R\n ABD: Soft, NT, ND, +BS, no HSM, no masses\n EXT: No C/C/E, no palpable cords\n NEURO: Alert, oriented to person, place, and time. CN II\n, , XII\n grossly intact. Moves all 4 extremities. No intention tremor noted on\n FTN test. No asterixis noted. Resting tremor still present but less\n pronounced.\n Labs / Radiology\n 127 K/uL\n 8.4 g/dL\n 24.9 %\n 3.4 K/uL\n [image002.jpg]\n 04:40 AM\n WBC\n 3.4\n Hct\n 24.9\n Plt\n 127\n Other labs: PT / PTT / INR:15.7/27.4/1.3, Differential-Neuts:64.8 %,\n Lymph:26.1 %, Mono:7.1 %, Eos:1.3 %\n Assessment and Plan\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Young adult Female with a history of EtoH abuse w/ seizures, h.o.\n vaginal bld requiring transfusions who presents with sub acute chills,\n nausea, vaginal blding w/ stable Hct and resting tremors in the setting\n of recent excessive EtoH use.\n Plan:\n # EtoH Withdrawal: Pt has a history of EtoH abuse with seizures 10\n years ago. Her current clinical tremulous state is interesting given\n that she has never presented in withdrawal like this, she also is not\n tachycardic and has only mild hypertension. However she does take\n Atenolol which would blunt the adrenergic state of withdrawal, her\n tremors also appeared to improve with Diazepam. Other cause of tremors\n to consider would include infectious state however given her\n unremarkable U/A and lack of clinical findings this is unlikely. Etoh\n level in the ED 16. Overnight pt required only 5mg PO Diazepam, has had\n low CIWA requirements. Pt finished Banana bag this AM/\n - will continue CIWA scale, can continue on floor due to low\n requirements\n - Will monitor for DTs\n - Will transition to start PO MVI, thiamine, folate\n - Social work/addictions consult\n # DUB: Pt currently on her regular menstrual cycle. She reports an\n increase in length of blding from her usual menses cycle. She does have\n a history () of vaginal blding requiring a 1u PRBC transfusion\n (Hct was 26.3). At the time a transvag U/S was performed and showed\n and unremarkable pelvic son. Currently her Hct is 24.9 which is\n decreased from her admission Hct of 27.4 Most likely dilutional given\n the amount of fluid she received from the banana bag and in the ED, her\n prior baseline of 26-32 over the past year. Overnight RN she has\n not had any soaked pads. Coags showed slight coagulopathy last night\n most likely Etoh history, her PTT this AM is notably higher than\n last night, unclear as to why this is. be a blood draw from a line\n that had a heprin flush?, will follow PM coags, Hct.\n - Following 3 pt Hct drop will recheck Hct at 1800\n - Will monitor pt's vaginal blding with the number of pads she uses\n - Will consider OB/GYN consult if blding continues for possible D&C\n - Will need outpatient gynecology follow up\n - Transfuse for Hct < 21\n # Abdominal Pain: Pt's abdominal pain is consistent with her menses\n cramping, now is resolved. Pt was noted to have a mildly elevated\n lipase, given her lack of clinical findings Pancreatitis is very\n unlikely.\n - Continue to follow exam\n # Elevated AST: AST elevated consistent with history of pt\ns EtoH\n abuse, pt does complain of increased bld as mentioned above will add on\n coags.\n # HTN: Will continue pt on home regimen of Atenolol.\n # FEN: Regular diet\n # Access: PIV\n # PPx: Will switch from Heparin SQ TID to Pneumoboots, PPI\n # Code: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:02 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition: Call out to floor\n"
},
{
"category": "Physician ",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 553367,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Since admission last night pt has required 5mg Diazepam x 1.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:55 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: 37.2\nC (98.9\n HR: 62 (60 - 86) bpm\n BP: 134/86(98) {133/80(93) - 142/100(114)} mmHg\n RR: 13 (13 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 55 mL\n 592 mL\n PO:\n TF:\n IVF:\n 55 mL\n 592 mL\n Blood products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 55 mL\n 42 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ////\n Physical Examination\n GEN: Well-nourished, A. American Female with resting tremors in no\n acute distress\n HEENT: EOMI, sclera anicteric, MMM, lingular tremors still present but\n not as pronounced.\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\n PULM: Lungs CTAB, no W/R/R\n ABD: Soft, NT, ND, +BS, no HSM, no masses\n EXT: No C/C/E, no palpable cords\n NEURO: Alert, oriented to person, place, and time. CN II\n, , XII\n grossly intact. Moves all 4 extremities. No intention tremor noted on\n FTN test. No asterixis noted. Resting tremor still present but less\n pronounced.\n Labs / Radiology\n 127 K/uL\n 8.4 g/dL\n 24.9 %\n 3.4 K/uL\n [image002.jpg]\n 04:40 AM\n WBC\n 3.4\n Hct\n 24.9\n Plt\n 127\n Other labs: PT / PTT / INR:15.7/27.4/1.3, Differential-Neuts:64.8 %,\n Lymph:26.1 %, Mono:7.1 %, Eos:1.3 %\n Assessment and Plan\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Young adult Female with a history of EtoH abuse w/ seizures, h.o.\n vaginal bld requiring transfusions who presents with sub acute chills,\n nausea, vaginal blding w/ stable Hct and resting tremors in the setting\n of recent excessive EtoH use.\n Plan:\n # EtoH Withdrawal: Pt has a history of EtoH abuse with seizures 10\n years ago. Her current clinical tremulous state is interesting given\n that she has never presented in withdrawal like this, she also is not\n tachycardic and has only mild hypertension. However she does take\n Atenolol which would blunt the adrenergic state of withdrawal, her\n tremors also appeared to improve with Diazepam. Other cause of tremors\n to consider would include infectious state however given her\n unremarkable U/A and lack of clinical findings this is unlikely. Etoh\n level in the ED 16. Overnight pt required only 5mg PO Diazepam, has had\n low CIWA requirements. Pt finished Banana bag this AM/\n - will continue CIWA scale, can continue on floor due to low\n requirements\n - Will monitor for DTs\n - Will transition to start PO MVI, thiamine, folate\n - Social work/addictions consult\n # DUB: Pt currently on her regular menstrual cycle. She reports an\n increase in length of blding from her usual menses cycle. She does have\n a history () of vaginal blding requiring a 1u PRBC transfusion\n (Hct was 26.3). At the time a transvag U/S was performed and showed\n and unremarkable pelvic son. Currently her Hct is 24.9 which is\n decreased from her admission Hct of 27.4 Most likely dilutional given\n the amount of fluid she received from the banana bag and in the ED, her\n prior baseline of 26-32 over the past year. Overnight RN she has\n not had any soaked pads. Coags showed slight coagulopathy last night\n most likely Etoh history, her PTT this AM is notably higher than\n last night, unclear as to why this is. be a blood draw from a line\n that had a heprin flush?, will follow PM coags, Hct.\n - Following 3 pt Hct drop will recheck Hct at 1800\n - Will monitor pt's vaginal blding with the number of pads she uses\n - Will consider OB/GYN consult if blding continues for possible D&C\n - Will need outpatient gynecology follow up\n - Transfuse for Hct < 21\n # Abdominal Pain: Pt's abdominal pain is consistent with her menses\n cramping, now is resolved. Pt was noted to have a mildly elevated\n lipase, given her lack of clinical findings Pancreatitis is very\n unlikely.\n - Continue to follow exam\n # Elevated AST: AST elevated consistent with history of pt\ns EtoH\n abuse, pt does complain of increased bld as mentioned above will add on\n coags.\n # HTN: Will continue pt on home regimen of Atenolol.\n # FEN: Regular diet\n # Access: PIV\n # PPx: Will switch from Heparin SQ TID to Pneumoboots, PPI\n # Code: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:02 AM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition: Call out to floor\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 553368,
"text": "38 year-old Female with a history of etoh abuse, vaginal bleeding\n requiring bld transfusion, HSIL s/p loop excision who presents with 14\n day history of vaginal bleeding (approx 6 pads a day), reported chills,\n nausea. Admission to ICU for concern of EtoH withdrawal,pt's last EtoH\n drink was a 1/5th of vodka Saturday night associated with abdominal\n pain\nmenstrual cramping , vomiting and diarrhea.\n Pt did recieve 10 mg of Valium IV in ED\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt has received a total of 15 mg of valium since her arrival here to\n . Pt a&o x3. no auditory or visual hallucinations and no\n diaphoresis. Pt follows simple commands and is appropriate. Pt is\n trmulous at rest and with tongue protrusion she does have brisk tremor\n that does not appear to be fasculations. Ciwa scale < 10 and has not\n required any additional valium. Now tolerating reg heart healthy diet.\n Pt oob to commode with steady gait. Pt normotensive and not\n tachycardic. Amt of vaginal bleeding has slowed down since her admit to\n micu.\n Action:\n Pt\ns neurologial status assessed. Frequnecy of ciwa scale checks has\n dropped. Social w orker consulted to follow pt. maintenance ivf d/c\n since pt taking in adequate amts of liqs. Sc heparin d/c\nd since pt now\n oob.\n Response:\n Pt hemodynamically stable as well as her hct.\n Plan:\n Transfer to medical floor bed. Continue to assess for possible etoh\n withdrawal since pt\ns last drink was . follow continue to assess\n pt\ns neurological status. Will need gyn/ob follow up outpt. Increase pt\ns activity level as pt tolerates. Recheck hct and coags this\n evenening.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n WITHDRAWL\n Code status:\n Height:\n 69 Inch\n Admission weight:\n 60 kg\n Daily weight:\n Allergies/Reactions:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Shellfish\n Hives;\n Precautions:\n PMH: ETOH\n CV-PMH: Hypertension\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:145\n D:95\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 74 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,115 mL\n 24h total out:\n 800 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:40 AM\n Potassium:\n 3.3 mEq/L\n 04:40 AM\n Chloride:\n 106 mEq/L\n 04:40 AM\n CO2:\n 23 mEq/L\n 04:40 AM\n BUN:\n 6 mg/dL\n 04:40 AM\n Creatinine:\n 0.6 mg/dL\n 04:40 AM\n Glucose:\n 80 mg/dL\n 04:40 AM\n Hematocrit:\n 24.9 %\n 04:40 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with: transferred with pt to 11 \n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: 401\n Transferred to: 1175\n Date & time of Transfer: 1020\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 553369,
"text": "38 year-old Female with a history of etoh abuse, vaginal bleeding\n requiring bld transfusion, HSIL s/p loop excision who presents with 14\n day history of vaginal bleeding (approx 6 pads a day), reported chills,\n nausea. Admission to ICU for concern of EtoH withdrawal,pt's last EtoH\n drink was a 1/5th of vodka Saturday night associated with abdominal\n pain\nmenstrual cramping , vomiting and diarrhea.\n Pt did recieve 10 mg of Valium IV in ED\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt has received a total of 15 mg of valium since her arrival here to\n . Pt a&o x3. no auditory or visual hallucinations and no\n diaphoresis. Pt follows simple commands and is appropriate. Pt is\n trmulous at rest and with tongue protrusion she does have brisk tremor\n that does not appear to be fasculations. Ciwa scale < 10 and has not\n required any additional valium. Now tolerating reg heart healthy diet.\n Pt oob to commode with steady gait. Pt normotensive and not\n tachycardic. Amt of vaginal bleeding has slowed down since her admit to\n micu.\n Action:\n Pt\ns neurologial status assessed. Frequnecy of ciwa scale checks has\n dropped. Social w orker consulted to follow pt. maintenance ivf d/c\n since pt taking in adequate amts of liqs. Sc heparin d/c\nd since pt now\n oob.\n Response:\n Pt hemodynamically stable as well as her hct.\n Plan:\n Transfer to medical floor bed. Continue to assess for possible etoh\n withdrawal since pt\ns last drink was . follow continue to assess\n pt\ns neurological status. Will need gyn/ob follow up outpt. Increase pt\ns activity level as pt tolerates. Recheck hct and coags this\n evenening.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n WITHDRAWL\n Code status:\n Height:\n 69 Inch\n Admission weight:\n 60 kg\n Daily weight:\n Allergies/Reactions:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Shellfish\n Hives;\n Precautions:\n PMH: ETOH\n CV-PMH: Hypertension\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:145\n D:95\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 74 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,115 mL\n 24h total out:\n 800 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:40 AM\n Potassium:\n 3.3 mEq/L\n 04:40 AM\n Chloride:\n 106 mEq/L\n 04:40 AM\n CO2:\n 23 mEq/L\n 04:40 AM\n BUN:\n 6 mg/dL\n 04:40 AM\n Creatinine:\n 0.6 mg/dL\n 04:40 AM\n Glucose:\n 80 mg/dL\n 04:40 AM\n Hematocrit:\n 24.9 %\n 04:40 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with: transferred with pt to 11 \n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: 401\n Transferred to: 1175\n Date & time of Transfer: 1020\n"
},
{
"category": "Physician ",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 553353,
"text": "Chief Complaint: EtOH Withdrawl\n Anemia-Secondary to Blood loss\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 Diazepam 5mg x1 overnight\n History obtained from Medical records\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:48 AM\n Heparin Sodium (Prophylaxis) - 07:48 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Gastrointestinal: Abdominal pain\n Flowsheet Data as of 08:43 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: 36.9\nC (98.4\n HR: 59 (58 - 86) bpm\n BP: 115/58(72) {115/58(72) - 150/100(114)} mmHg\n RR: 20 (10 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 69 Inch\n Total In:\n 55 mL\n 1,023 mL\n PO:\n 120 mL\n TF:\n IVF:\n 55 mL\n 902 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 55 mL\n 223 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic, Lingual Tremor with tounge\n protrusion--decreased\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Patient move all extremeties without difficulty. She has\n brisk bilateral reflexes and decreased ankle jerk reflexes. Motor\n strength appears to be in tact. With tounge protrusion patient does\n have brisk tremor and this does not appear to be fasculations\n Labs / Radiology\n 8.4 g/dL\n 127 K/uL\n 80 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 6 mg/dL\n 106 mEq/L\n 142 mEq/L\n 24.9 %\n 3.4 K/uL\n [image002.jpg]\n 04:40 AM\n WBC\n 3.4\n Hct\n 24.9\n Plt\n 127\n Cr\n 0.6\n Glucose\n 80\n Other labs: PT / PTT / INR:16.1/63.4/1.4, ALT / AST:23/124, Alk Phos /\n T Bili:59/1.3, Amylase / Lipase:/73, Differential-Neuts:64.8 %,\n Lymph:26.1 %, Mono:7.1 %, Eos:1.3 %, Albumin:3.8 g/dL, LDH:198 IU/L,\n Ca++:7.8 mg/dL, Mg++:1.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 30 yo female with history of EtOH abuse now admitted with vaginal\n bleeding and concern for EtOH withdrawl. She was seen in ED with\n complaints of vaginal bleeding and in ED she clearly had symptoms of\n agitation responsive to Diazepam and given response to medications\n patient to ICU for further monitoring.\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n -B12/Folate/Thiamine\n -Diazepam as needed\n -Will need continued monitoring on medical floor and follow up\n neurologic examinations\n Vaginal Bleeding-\n -Will need GYN exam\ninitial pelvic exam was without findings in ED\n -Will confirm past evaluation and we do have transfusion and negative\n transvaginal ultrasound in the past.\n -Will need to consider inpatient consult given reason for admission\n Anemia Secondary to Blood Loss\n -FeSO4\n -5pm HCT to follow up\n ICU Care\n Nutrition: PO intake\n Glycemic Control:\n Lines:\n 20 Gauge - 01:02 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 553328,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Since admission last night pt has required 5mg Diazepam x 1.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Shellfish\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:55 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: 37.2\nC (98.9\n HR: 62 (60 - 86) bpm\n BP: 134/86(98) {133/80(93) - 142/100(114)} mmHg\n RR: 13 (13 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 55 mL\n 592 mL\n PO:\n TF:\n IVF:\n 55 mL\n 592 mL\n Blood products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 55 mL\n 42 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\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 127 K/uL\n 8.4 g/dL\n 24.9 %\n 3.4 K/uL\n [image002.jpg]\n 04:40 AM\n WBC\n 3.4\n Hct\n 24.9\n Plt\n 127\n Other labs: PT / PTT / INR:15.7/27.4/1.3, Differential-Neuts:64.8 %,\n Lymph:26.1 %, Mono:7.1 %, Eos:1.3 %\n Assessment and Plan\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n Young adult Female with a history of EtoH abuse w/ seizures, h.o.\n vaginal bld requiring transfusions who presents with sub acute chills,\n nausea, vaginal blding w/ stable Hct and resting tremors in the setting\n of recent excessive EtoH use.\n Plan:\n # EtoH Withdrawal: Pt has a history of EtoH abuse with seizures 10\n years ago. Her current clinical tremulous state is interesting given\n that she has never presented in withdrawal like this, she also is not\n tachycardic and has only mild hypertension. However she does take\n Atenolol which would blunt the adrenergic state of withdrawal, her\n tremors also appeared to improve with Diazepam. Other cause of tremors\n to consider would include infectious state however given her\n unremarkable U/A and lack of clinical findings this is unlikely. Etoh\n level in the ED 16.\n - will continue CIWA scale\n - Will monitor for DTs\n - Will start Banana bag, daily MVI, thiamine, folate\n - Social work/addictions consult\n # DUB: Pt currently on her regular menstrual cycle. She reports an\n increase in length of blding from her usual menses cycle. She does have\n a history () of vaginal blding requiring a 1u PRBC transfusion\n (Hct was 26.3). At the time a transvag U/S was performed and showed\n and unremarkable pelvic son. Currently her Hct is 27.4 which is\n close to her prior baseline of 26-32 over the past year. Currently she\n is hemodynamically stable and her blding is not profuse given that it\n is only 6 pads. Will also check coags as pt may be coagulopathic given\n EtoH history.\n - Trend Hct\n - Will monitor pt's vaginal blding with the number of pads she uses\n - Will consider OB/GYN consult if blding continues for possible D&C\n - Will set up outpatient gynecology follow up\n - Transfuse for Hct < 21\n # Abdominal Pain: Pt's abdominal pain is consistent with her menses\n cramping, now is resolved. Pt was noted to have a mildly elevated\n lipase, given her lack of clinical findings Pancreatitis is very\n unlikely.\n - Continue to follow exam\n # Elevated AST: AST elevated consistent with history of pt\ns EtoH\n abuse, pt does complain of increased bld as mentioned above will add on\n coags.\n # HTN: Will continue pt on home regimen of Atenolol.\n # FEN: Regular diet\n # Access: PIV\n # PPx: Heparin SQ TID, PPI\n # Code: FULL (Presumed)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:02 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 553307,
"text": "38 year-old Female with a history of etoh abuse, vaginal bleeding\n requiring bld transfusion, HSIL s/p loop excision who presents with 14\n day history of vaginal bleeding (approx 6 pads a day), reported chills,\n nausea. Admission to ICU for concern of EtoH withdrawal,pt's last EtoH\n drink was a 1/5th of vodka Saturday night associated with abdominal\n pain\nmenstrual cramping , vomiting and diarrhea.\n Pt did recieve 10 mg of Valium IV in ED\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n New admission from ED,lethargic and tremulous on admission oriented X 3\n last drink was on Saturday night ^th of vodka, ,MAE,denies any pain\n or discomfort,revieved with 2L NC from ED, on RA since admission sats\n 100%.very minimal vaginal bleeding after admission.CIWA scale 7 on\n admission\n Action:\n On CIWA scale, received one dose of PO valium 5mg on admission,started\n on banana bag, can have normal diet in AM\n Response:\n Pt was comfortable CIWA scale 7 on admission then slept after Po\n valium\n Plan:\n Monitor DT,s CIWA scale,PRN Valium ,social work consult,follow up\n crit, transfusion for crit <21, monitor vaginal bleeding and number of\n pads.\n"
},
{
"category": "Nursing",
"chartdate": "2130-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 553294,
"text": "38 year-old Female with a history of etoh abuse, vaginal bleeding\n requiring bld transfusion, HSIL s/p loop excision who presents with 14\n day history of vaginal bleeding (approx 6 pads a day), reported chills,\n nausea. Admission to ICU for concern of EtoH withdrawal,pt's last EtoH\n drink was a 1/5th of vodka Saturday night associated with abdominal\n pain\nmenstrual cramping , vomiting and diarrhea.\n Pt did reciev 10 mg of Valium IV in ED\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n New admission from ED,lethargic and tremulous oriented X 3 last drink\n was on Saturday night ^th of vodka, ,MAE,denies any pain or\n discomfort,revieved with 2L NC from ED on RA since admission sats\n 100%.very minimal vaginal bleeding after admission.CIWA scale 7 on\n admission\n Action:\n On CIWA scale, received one dose of PO valium 5mg on admission,started\n on banana bag, can have normal diet in AM\n Response:\n Pt was comfortable CIWA scale 7 on admission then slept after Po\n valium\n Plan:\n Monitor DT,s CIWA scale,PRN Valium ,social work consult,follow up\n crit, transfusion for crit <21, monitor vaginal bleeding and number of\n pads.\n"
},
{
"category": "Radiology",
"chartdate": "2130-03-06 00:00:00.000",
"description": "PELVIS U.S., TRANSVAGINAL",
"row_id": 1059030,
"text": " 2:49 PM\n PELVIS U.S., TRANSVAGINAL; PELVIS, NON-OBSTETRIC Clip # \n Reason: menorrhagia, eval endometrium\n Admitting Diagnosis: WITHDRAWL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with mennorrhagia\n REASON FOR THIS EXAMINATION:\n menorrhagia, eval endometrium\n ______________________________________________________________________________\n FINAL REPORT\n PELVIC ULTRASOUND:\n\n INDICATION: Menorrhagia.\n\n Transabdominal images demonstrate an anteverted uterus measuring 7.4 cm x 3.8\n cm x 4.8 cm. Transvaginal exam was performed for improved visualization of\n the endometrium and adnexa. The endometrium is normal in thickness, measuring\n 6 mm. The ovaries are normal. There is no free fluid or hydronephrosis.\n\n IMPRESSION: Normal pelvic ultrasound.\n\n\n"
}
] |
16,728 | 181,102 | 1) Coronary artery disease. The patient was transferred to the floor for vigilant monitoring in the CCU, status post his right coronary artery stent. Aspirin was continued. Plavix was started for 30 day course. Aggrastat was continued for 18 hours. Beta blocker and ACE inhibitor therapy were initiated. Lipitor was started 10 mg a day. Nitroglycerin and Morphine were given prn to keep the patient pain free. He remained hemodynamically stable over night. CCU day #2 he had no events overnight, no complaints. The patient was continued on all medications. The patient continued to have an idioventricular rhythm but was hemodynamically stable. This rhythm was believed to be a peri MI event and was monitored in tele. EP was not involved because the patient was not symptomatic. Follow-up echocardiogram revealed an ejection fraction mildly depressed at 45-55%. Also noted was severely depressed right ventricular systolic dysfunction. The right ventricle was moderately dilated and the patient had inferoseptal akinesis. The patient continued to do well and was transferred out of the CCU to the floor. He was monitored there on hospital day #3 where he continued to do well. At that time it was decided to take him back to the cath lab for stenting of his left circumflex lesion which had also been noted on initial cath although it had not been addressed due to his complications in the cath lab. The patient went to the cath lab, had his 90% left circumflex lesion stented with no significant complications. He was transferred back to the floor. At that time he developed a small left groin hematoma approximately 1 cm by 2 cm which remained stable overnight. His hematocrit remained stable, did not significantly drop. He was monitored until the morning following his second cath at which time he was hemodynamically stable and deemed safe for discharge home. He will follow-up with his primary care physician who will arrange for cardiology care for the patient. | Mild (1+) mitral regurgitation isseen. Right ventricular systolic functionappears depressed.AORTA: The aortic root is normal in diameter. Overall left ventricular systolic functionis mildly depressed.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -hypokinetic;RIGHT VENTRICLE: The right ventricular wall thickness is normal. There is mild symmetric left ventricularhypertrophy. NO C/O NAUSEA.GU; AUTODIURESING AFTER POST CATH FLUID. The right ventricularcavity is moderately dilated. Mild (1+) mitralregurgitation is seen.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is mildly dilated. The ascending aorta is mildlydilated.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion.MITRAL VALVE: The mitral valve leaflets are mildly thickened. 7P-7A;NEURO; ALERT, ORIENTED, MOVES ALL EXTREMITIES WELL.RESP; LUNGS CLEAR 02 SAT AND RESP RATES WNL ON 1L/M N/C. CSRU TRANSFER NOTENEURO~A+O X3, OOB T O CHAIR TOL WELL.CARDIAC~REMAINS IN SR HR 70'S SBP~100-130. The rightventricular cavity is moderately dilated. The leftventricular cavity size is normal. NO C/O CHEST PAIN TODAY.RIGHT GROIN ECCYMOTIC. Sinus rhythmInferior infarct, probably recent/acuteSince last ECG, , no significant change The left ventricular cavity size is normal. COLACE THIS AM.A/P~STABLE FOR TRANSFER TO 2. DILT GTT DC'D. Sinus bradycardia - premature ventricular contractionsInferior infarct - probably acuteTransient junctional rhythmSince last ECG, , atrial fibrillation absent O2 2LNP SATS 100%.FINE CRACKLES ON LEFT.GI/GU NO NAUSEA. GOT MSO4 TOTAL 2MG NO FURTHUR RELIEF. PATIENT/TEST INFORMATION:Indication: Myocardial infarction.Height: (in) 70Weight (lb): 195BSA (m2): 2.07 m2BP (mm Hg): 128/65Status: InpatientDate/Time: at 09:04Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The ascending aorta is mildly dilated. LUNGS CLEAR IN UPPER DIMINISHED IN BASES.GI/GU~TOL PO FOOD AND FLUIDS WELL. Right ventricular systolic function appearsseverely depressed. FOOT SL COOL GOOD CSM. FOLEY GOOD CLEAR YELLOW UOP.INTEG. POS PAL PEDAL PULSES IN FOOT, CSM GOOD.RESP~RA SATS:98-100%. Sinus rhythm, rate 62. Themitral valve leaflets are mildly thickened. ARRIVED IN AFIB 120'S. Overall leftventricular systolic function is mildly depressed. RATE REDUCED TO 80'S-90'S STILL IN AFIB. BP REMAINS SLIGHLY ELEVATED AND PT TO START CAPOTEN 37.5MG THIS AM. The aortic valveleaflets (3) appear structurally normal with good leaflet excursion. 160 SYST ON ADMISSION NOW 100-110/SYST. WILL REMAIN IN ICU OVER NIGHT FOR CLOSER OBSERVATION.NEURO~A+O X3,INTACT.RESP~WEANED TO 1L NP TOL WELL. OOB TO COMMODE.RIGHT LEG SHEATH SITE NEG FOR HEMATOMA POS PAL PEDAL PULSE AND GOOD CSM TO EXTREMITY. PER CCU TEAM AMNIODIRONE GTT DC'D AND CAPOTEN DOSE INCREASED. CONSULT PT TO ASSIST W/ AMBULATION. TOL PO H2O WITH PILLS. Since the previous tracing of no changes areseen. AND HAS HAD IT ALL ALONG POST CATH. GOT TOTAL OF 10MG LOPRESSOR IV AND 10MG DILT. BP LOWER. C/O OCC THROAT PAIN WITH COUGHING ONLY. NEURO ALERT AND ORIENTED ANXIOUS AND SL. CCU RESIDENT NOTIFIED. CARDIAC~PT CONT IN AFIB 112~125 SBP 118~ CONVERTED TO SB 55 AFTER STARTING DILTIAZEM GTT, EKG DONE. SKIN INTACT. DENIES ANY C/O SOB.CARDIOVAS; NS NO NOTED ECTOPY. PT HAS HAD NO C/O CHEST PAIN TODAY. Atrial fibrillation with rapid ventricular responseVentricular premature complexIntraventricular conduction defectProbable recent inferior infarct STATES ITS MUCH WORSE WHEN HE TAKES A DEEP BREATH. RESTLESS.CV/RESP ARRIVED FROM CATH LAB S/P STENT TO RCA. IV. LUNGS:INSP/EXP WHEEZES ON RIGHT DIMINISHED ON LEFT.GI/GU~TOL PO FOOD AND FLIUDS WELL.A/P~CONT TO MONITOR IN ICU SETTING OVER NIGHT. INCREASE LOPRESSOR TO 37.5 MG. VSS SEE CAREVIEW FLOWSHEET. RIGHT FEM SHEATH DC'D BY CATH LAB @ 1000 WILL REMAIN FLAT ON BED REST X 10 HRS.POS PAL PEDAL PULSES IN RIGHT FOOT. ADDENDUM TO NPN FOLEY DC'D 2 1900 DTV @ 0300. Resting regional wallmotion abnormalities include inferoseptal akinesis. ALSO ONAMNIODIRONE .5 MG/MIN. FOLEY DC'D VOIDING QS IN URINAL.COMFORT; NO C/O CHEST PAIN.PLAN; TRANSFER TO FLOOR IF REMAINS STABLE AND HOME IN A FEW DAYS.SOCIAL; FAMILY IN TO VISIT WIFE AND CHILDREN. STATES HE'S HAVING CHEST PAIN. STAYED OVERNOC IN WAITING ROOM. NO BM. EGG FOR ANY CHANGES IN RHYTHM. There is no pericardial effusion. STRONG CIGAR ODOR NOTED. CONSULT SOCIAL SERVICES FAMILY HAS FINANCIAL. ISSUES THAT NEED ADDRESSING. | 10 | [
{
"category": "Echo",
"chartdate": "2121-11-13 00:00:00.000",
"description": "Report",
"row_id": 70087,
"text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nHeight: (in) 70\nWeight (lb): 195\nBSA (m2): 2.07 m2\nBP (mm Hg): 128/65\nStatus: Inpatient\nDate/Time: at 09:04\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.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis mildly depressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -\nhypokinetic;\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. The right\nventricular cavity is moderately dilated. Right ventricular systolic function\nappears depressed.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\ndilated.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is mildly depressed. Resting regional wall\nmotion abnormalities include inferoseptal akinesis. The right ventricular\ncavity is moderately dilated. Right ventricular systolic function appears\nseverely depressed. The ascending aorta is mildly dilated. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion. The\nmitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is\nseen. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2121-11-14 00:00:00.000",
"description": "Report",
"row_id": 152571,
"text": "Sinus rhythm, rate 62. Since the previous tracing of no changes are\nseen.\n\n"
},
{
"category": "ECG",
"chartdate": "2121-11-12 00:00:00.000",
"description": "Report",
"row_id": 152572,
"text": "Sinus rhythm\nInferior infarct, probably recent/acute\nSince last ECG, , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2121-11-11 00:00:00.000",
"description": "Report",
"row_id": 152573,
"text": "Sinus bradycardia\n - premature ventricular contractions\nInferior infarct - probably acute\nTransient junctional rhythm\nSince last ECG, , atrial fibrillation absent\n\n"
},
{
"category": "ECG",
"chartdate": "2121-11-11 00:00:00.000",
"description": "Report",
"row_id": 152574,
"text": "Atrial fibrillation with rapid ventricular response\nVentricular premature complex\nIntraventricular conduction defect\nProbable recent inferior infarct\n_\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-11-11 00:00:00.000",
"description": "Report",
"row_id": 1481015,
"text": "CARDIAC~PT CONT IN AFIB 112~125 SBP 118~ CONVERTED TO SB 55 AFTER STARTING DILTIAZEM GTT, EKG DONE. CCU RESIDENT NOTIFIED. ALSO ON\nAMNIODIRONE .5 MG/MIN. DILT GTT DC'D. PER CCU TEAM AMNIODIRONE GTT DC'D AND CAPOTEN DOSE INCREASED. PT HAS HAD NO C/O CHEST PAIN TODAY. C/O OCC THROAT PAIN WITH COUGHING ONLY. RIGHT FEM SHEATH DC'D BY CATH LAB @ 1000 WILL REMAIN FLAT ON BED REST X 10 HRS.\nPOS PAL PEDAL PULSES IN RIGHT FOOT. FOOT SL COOL GOOD CSM. WILL REMAIN IN ICU OVER NIGHT FOR CLOSER OBSERVATION.\nNEURO~A+O X3,INTACT.\nRESP~WEANED TO 1L NP TOL WELL. LUNGS:INSP/EXP WHEEZES ON RIGHT DIMINISHED ON LEFT.\nGI/GU~TOL PO FOOD AND FLIUDS WELL.\nA/P~CONT TO MONITOR IN ICU SETTING OVER NIGHT. EGG FOR ANY CHANGES IN RHYTHM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-11-11 00:00:00.000",
"description": "Report",
"row_id": 1481016,
"text": "ADDENDUM TO NPN \n\nFOLEY DC'D 2 1900 DTV @ 0300. OOB TO COMMODE.\nRIGHT LEG SHEATH SITE NEG FOR HEMATOMA POS PAL PEDAL PULSE AND GOOD CSM TO EXTREMITY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-11-12 00:00:00.000",
"description": "Report",
"row_id": 1481017,
"text": " 7P-7A;\n\nNEURO; ALERT, ORIENTED, MOVES ALL EXTREMITIES WELL.\n\nRESP; LUNGS CLEAR 02 SAT AND RESP RATES WNL ON 1L/M N/C. DENIES ANY C/O SOB.\n\nCARDIOVAS; NS NO NOTED ECTOPY. VSS SEE CAREVIEW FLOWSHEET. BP REMAINS SLIGHLY ELEVATED AND PT TO START CAPOTEN 37.5MG THIS AM. AGGRISTAT DC'D AT 2100 PER ORDERS.\n\nGI; BS PRESENT APPITITE GOOD ATE 100% OF DINNER. NO C/O NAUSEA.\n\nGU; AUTODIURESING AFTER POST CATH FLUID. FOLEY DC'D VOIDING QS IN URINAL.\n\nCOMFORT; NO C/O CHEST PAIN.\n\nPLAN; TRANSFER TO FLOOR IF REMAINS STABLE AND HOME IN A FEW DAYS.\n\nSOCIAL; FAMILY IN TO VISIT WIFE AND CHILDREN. STAYED OVERNOC IN WAITING ROOM.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-11-12 00:00:00.000",
"description": "Report",
"row_id": 1481018,
"text": "CSRU TRANSFER NOTE\n\nNEURO~A+O X3, OOB T O CHAIR TOL WELL.\n\nCARDIAC~REMAINS IN SR HR 70'S SBP~100-130. NO C/O CHEST PAIN TODAY.\nRIGHT GROIN ECCYMOTIC. POS PAL PEDAL PULSES IN FOOT, CSM GOOD.\n\nRESP~RA SATS:98-100%. LUNGS CLEAR IN UPPER DIMINISHED IN BASES.\n\nGI/GU~TOL PO FOOD AND FLUIDS WELL. COLACE THIS AM.\n\nA/P~STABLE FOR TRANSFER TO 2. INCREASE LOPRESSOR TO 37.5 MG. CONSULT PT TO ASSIST W/ AMBULATION. CONSULT SOCIAL SERVICES FAMILY HAS FINANCIAL. ISSUES THAT NEED ADDRESSING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-11-11 00:00:00.000",
"description": "Report",
"row_id": 1481014,
"text": "NEURO ALERT AND ORIENTED ANXIOUS AND SL. RESTLESS.\nCV/RESP ARRIVED FROM CATH LAB S/P STENT TO RCA. STATES HE'S HAVING CHEST PAIN. AND HAS HAD IT ALL ALONG POST CATH. GOT MSO4 TOTAL 2MG NO FURTHUR RELIEF. STATES ITS MUCH WORSE WHEN HE TAKES A DEEP BREATH. ARRIVED IN AFIB 120'S. GOT TOTAL OF 10MG LOPRESSOR IV AND 10MG DILT. IV. RATE REDUCED TO 80'S-90'S STILL IN AFIB. BP LOWER. 160 SYST ON ADMISSION NOW 100-110/SYST. O2 2LNP SATS 100%.FINE CRACKLES ON LEFT.\nGI/GU NO NAUSEA. TOL PO H2O WITH PILLS. NO BM. FOLEY GOOD CLEAR YELLOW UOP.\nINTEG. SKIN INTACT. STRONG CIGAR ODOR NOTED.\n"
}
] |
46,028 | 143,210 | He was admitted status post a left parietal craniotomy for resection of tumor. He was in the recovery room overnight. He was awake, alert, oriented x 3. Face symmetric. Tongue midline. Pupils equal, round and reactive to light. Visual fields full. EOMS intact with no diplopia. His strength was in all muscle groups. He was transferred to the regular floor, was out-of-bed, ambulating, tolerating a regular diet, voiding spontaneously. He was discharged to home on postop day #3 with follow-up with Dr. in the Brain Clinic on . His staples will be removed at that time. | FINDINGS: Within the area of the left posterior parietal lobe where the tumor was previously seen, there is evidence of hyperintensity on FLAIR and T2W images consistent with hemorrhage. The post gadolinium images do not show any area of abnormal enhancement. Minor or major vascular territorial infarcts are not apparent. However, the previous mass showed minimal to no gadolinium enhancement. There is no appreciable change in the left parietal lobe nonenhancing hypointense mass. There is also some dural enhancement over this lesion which is consistent with postoperative changes. No evidence of abnromal gadolinium enhancement around lesion; however, the preoperative mass showed little to no enhancement. No evidence of acute intracranial hemorrhage or new mass lesions. FINDINGS: Comparison is made to the previous MRI of . TECHNIQUE: T1 weighted post contrast high resolution volumetrically acquired images were obtained with a WAND protocol for stereotactic localization. IMPRESSION: Postoperative changes in the left posterior parietal lobe including areas of hemorrhage. The ventricles are not dilated. There is no abnormal intracranial enhancement. TECHNIQUE: Multiplanar T1W, T2W and FLAIR images. IMPRESSION: Protocol for stereotactic localization of the left parietal mass. FINAL REPORT INDICATION: WAND protocol for stereotactic localization of a tumor. Note is made of a soft tissue focus within the left parotid which seems to have hyperintensity on T1W images consistent with fat. No evidence of hydrocephalus or shift of normally midline structures. Post gadolinium as well as diffusion weighted images also obtained. COMPARISONS: . 1:03 AM MR HEAD W & W/O CONTRAST Clip # Reason: evaluate s/p resection of L parietal tumor Admitting Diagnosis: BRAIN /SDA Contrast: MAGNEVIST Amt: 15CC MEDICAL CONDITION: 45 year old man with L parietal tumor REASON FOR THIS EXAMINATION: evaluate s/p resection of L parietal tumor FINAL REPORT INDICATIONS: Left parietal lobe tumor, status post resection. The gyri appear expanded in this location. 6:10 AM MR HEAD W/ CONTRAST Clip # Reason: PRE-SURGERY HEAD SCAN WITH CONTRAST FOR PLACEMENT OF MARKERS Contrast: MAGNEVIST Amt: 15CC MEDICAL CONDITION: 45 year old man with REASON FOR THIS EXAMINATION: PRE-SURGERY HEAD SCAN WITH CONTRAST FOR PLACEMENT OF MARKERS FOR WAND PROTOCOL. | 2 | [
{
"category": "Radiology",
"chartdate": "2154-11-12 00:00:00.000",
"description": "MR HEAD W/ CONTRAST",
"row_id": 804215,
"text": " 6:10 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: PRE-SURGERY HEAD SCAN WITH CONTRAST FOR PLACEMENT OF MARKERS\n Contrast: MAGNEVIST Amt: 15CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with\n REASON FOR THIS EXAMINATION:\n PRE-SURGERY HEAD SCAN WITH CONTRAST FOR PLACEMENT OF MARKERS FOR WAND PROTOCOL.\n SURGERY @ 8AM.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: WAND protocol for stereotactic localization of a tumor.\n\n TECHNIQUE: T1 weighted post contrast high resolution volumetrically acquired\n images were obtained with a WAND protocol for stereotactic localization.\n\n FINDINGS: Comparison is made to the previous MRI of .\n\n There is no appreciable change in the left parietal lobe nonenhancing\n hypointense mass. The gyri appear expanded in this location. There is no\n abnormal intracranial enhancement. The ventricles are not dilated.\n\n IMPRESSION:\n\n Protocol for stereotactic localization of the left parietal mass.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-11-14 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 804416,
"text": " 1:03 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evaluate s/p resection of L parietal tumor\n Admitting Diagnosis: BRAIN /SDA\n Contrast: MAGNEVIST Amt: 15CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with L parietal tumor\n REASON FOR THIS EXAMINATION:\n evaluate s/p resection of L parietal tumor\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Left parietal lobe tumor, status post resection.\n\n COMPARISONS: .\n\n TECHNIQUE: Multiplanar T1W, T2W and FLAIR images. Post gadolinium as well as\n diffusion weighted images also obtained.\n\n FINDINGS: Within the area of the left posterior parietal lobe where the\n tumor was previously seen, there is evidence of hyperintensity on FLAIR and\n T2W images consistent with hemorrhage. The post gadolinium images do not show\n any area of abnormal enhancement. However, the previous mass showed minimal\n to no gadolinium enhancement. There is also some dural enhancement over this\n lesion which is consistent with postoperative changes. No evidence of acute\n intracranial hemorrhage or new mass lesions. Note is made of a soft tissue\n focus within the left parotid which seems to have hyperintensity on T1W images\n consistent with fat. No evidence of hydrocephalus or shift of normally\n midline structures. Minor or major vascular territorial infarcts are not\n apparent.\n\n IMPRESSION: Postoperative changes in the left posterior parietal lobe\n including areas of hemorrhage. No evidence of abnromal gadolinium enhancement\n around lesion; however, the preoperative mass showed little to no enhancement.\n\n\n"
}
] |
76,987 | 109,874 | Admitted same day as surgery and underwent coronary artery bypass graft surgery. Received cefazolin for perioperative antibiotics. See operative report for further details. He was transferred to the intensive care unit for hemodynamic monitoring. In the first twenty four hours he was weaned from sedation, awoke with confusion but has baseline dementia, and was extubated without complications. He remained in the intensive care unit on nitroglycerin drip and management of confusion receiving haldol. With his confusion at times he became aggressive with staff. On post operative day four he was transferred to the floor for the remainder of his care. Physical therapy worked with him on strength and mobility. He continued to progress but remained on haldol due to confusion although no aggressive behavior toward staff. He was confused with environment, getting in and out of bed frequently, forgetting were things were in the room which may be due to the unfamiliar environment. He was ready for discharge home on post operative day seven with services. Sternal incision clean no erythema no drainage Left leg EVH sites no erythema, no drainage Lower extemeties with +1 edema which is progressively decreasing Plan to follow up with Dr on , he has been prescribed haldol for 1mg at bedtime with repeat dose of 0.5mg once if needed, wife has been instructed to call Dr with any concerns about confusion, agitation, and aggression. Spoke with Dr and she will monitor him and manage the haldol dosing, prescription given for only 20 tablets of 0.5mg. Social work meet with Wife Elder services and Alzheimers association were contact on Mr behalf. | Right supraclavicular catheter sheath ends at the thoracic inlet. Mildly dilated ascending aorta. An eccentric, posteriorly directed jet of Mild to moderate(+) mitral regurgitation is seen.There is no pericardial effusion.Dr. Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Normal regional LV systolic function.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus. Sinus rhythmProlonged QT intervalT wave abnormalitiesSince previous tracing of , ST segment elevation in the lateral leadsare less Coronary artery disease (CAD, ischemic heart disease) Assessment: Pt remains orally Intubated. FRONTAL AND LATERAL CHEST: Patient is status post CABG and median sternotomy. Chlorhexidine Gluconate 0.12% Oral Rinse 8. FINDINGS: In comparison with the earlier study of this date, there has been removal of the left chest tube. Simple atheroma indescending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). Consider interval pericarditis. Valvular heart disease.Height: (in) 70Weight (lb): 220BSA (m2): 2.18 m2BP (mm Hg): 140/70HR (bpm): 72Status: InpatientDate/Time: at 09:08Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or theRA/RAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV. Normalaortic arch diameter. The cardiomediastinal silhouette is stable demonstrating moderate cardiomegaly and tortuosity of the aorta. Eccentric MR jet.Mild to moderate (+) MR.TRICUSPID VALVE: Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: No PS. No AR.MITRAL VALVE: Myxomatous mitral valve leaflets. Mildly dilated descending aorta. was notified in person of the results on Mr , P at 8AMbefore incision.Post-Bypass:Preserved biventricular systolic function.Normal LVEF 55%,Intact thoracic aorta.Mild to moderate MR> Patient is status post median sternotomy and CABG. Regional left ventricular wall motionis normal.Right ventricular chamber size and free wall motion are normal.The aortic root is mildly dilated at the sinus level. Demographics Day of intubation: Day of mechanical ventilation: 1 Ideal body weight: 75.3 None Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg Tube Type ETT: Position: cm at teeth Route: Oral Type: Standard Lung sounds RLL Lung Sounds: Diminished RUL Lung Sounds: Ins/Exp Wheeze LUL Lung Sounds: Ins/Exp Wheeze LLL Lung Sounds: Diminished Comments: Ventilation Assessment Level of breathing assistance: Continuous invasive ventilation Visual assessment of breathing pattern: Patient not triggering over the set rate Action: Neosynephrine gtt weaned per protocol. Albuterol-Ipratropium 4. Albuterol-Ipratropium 4. Albuterol-Ipratropium 3. PO2 on ABG 70 Action: Pt weaned to CPAP and extubated per protocol. CTs, wires, leg drain d/c'd, hypoxic->diurese, tx'd 1 UPRBC : 1U PRBC Current medications: 1. CTs, wires, leg drain d/c'd, hypoxic->diurese, tx'd 1 UPRBC : 1U PRBC Current medications: 1. Albuterol 0.083% Neb Soln 6. Albuterol 0.083% Neb Soln 6. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Metoprolol Tartrate 21. Metoprolol Tartrate 21. Phenylephrine 18. Aspirin EC 7. Aspirin EC 7. Fluids: Consults: P.T. Fluids: Consults: P.T. Ipratropium Bromide Neb 19. Ipratropium Bromide Neb 19. Citalopram Hydrobromide 10. Citalopram Hydrobromide 10. Metoclopramide 20. Metoclopramide 20. CefazoLIN 7. Hypotension (not Shock) Assessment: On arrival pt on neosynephrine gtt at 1 mcg/kg/min and propofol gtt at 40 mcg/kg/min. Aspirin EC 5. PA notified and pain meds changed to dilaudid po/iv. Cont diuresis today with lasix . Morphine Sulfate 15. aggressive diuresis and pulm. aggressive diuresis and pulm. Hx COPD. Albuterol Inhaler 4. Clopidogrel 11. Clopidogrel 11. Haldol and PRN. Haldol and PRN. : 0.8 PMHx: HTN, ^lipids, CAD-s/p stent L-PDA and OM, mid LCX , MR, venous insufficiency, GERD, pseudogout R knee, Alzheimer's, Arthritis, OSA, polio, hyperuricemia, s/p MIs : Atenolol 50', Lipitor 80', Citalopram 60 qhs, Plavix 75', Colchicine 0.6', Donepezil 10', Zetia 10', Felodipine 10', Fluticasone 50 mcg 2 sprays each nostril daily, HCTZ 25', Lisinopril 40', Omeprazole 20', ASA 325', SL NTG PRN Current medications: 1. : 0.8 PMHx: HTN, ^lipids, CAD-s/p stent L-PDA and OM, mid LCX , MR, venous insufficiency, GERD, pseudogout R knee, Alzheimer's, Arthritis, OSA, polio, hyperuricemia, s/p MIs : Atenolol 50', Lipitor 80', Citalopram 60 qhs, Plavix 75', Colchicine 0.6', Donepezil 10', Zetia 10', Felodipine 10', Fluticasone 50 mcg 2 sprays each nostril daily, HCTZ 25', Lisinopril 40', Omeprazole 20', ASA 325', SL NTG PRN events: very confused, combative, haldol given. Action: Neosynephrine gtt weaned per protocol. Neo gtt infusing, then titrated off shortly thereafter. Neo gtt infusing, then titrated off shortly thereafter. Neo gtt infusing, then titrated off shortly thereafter. PO2 on ABG 70 Action: Pt weaned to CPAP and extubated per protocol. Hypotension (not Shock) Assessment: On arrival pt on neosynephrine gtt at 1 mcg/kg/min and propofol gtt at 40 mcg/kg/min. Pt with episode of hypertension r/t agitation. Response: pt visibly more comfortable and less agitated Plan: Continue providing decreased stimuli environment, frequent reassurances and monitoring Hypertension, benign Assessment: ABP 130-160mmHg. Deescalated using reassurances, family presence and PRN Haldol 1-2.5mg IV. Pt initially hypotensive from OR. Pt initially hypotensive from OR. Pt initially hypotensive from OR. LSC with dim bases bilaterally throughout shift. PA notified and pain meds changed to dilaudid po/iv. C/o pain after extubation. Volume resuscitated patient with LR (see Metavision for details). Volume resuscitated patient with LR (see Metavision for details). Volume resuscitated patient with LR (see Metavision for details). ao aneurysm, prostate ca (s/p external beam radiation ), GERD (?h/o esophageal stricture), h/o afib/flutter-s/p CV/ablations, diverticular disease, cholelithiasis, s/p appy, herniorraphy, empyema s/p R decortication @2yo, esophageal dilatation Current medications: atenolol 25', MVI', advil pm prn coumadin: 2/ 24 Hour Events: TEMPORARY PACEMAKER WIRES DISCONTINUED - At 01:00 PM DRAIN REMOVED - At 01:00 PM CHEST TUBE REMOVED - At 01:00 PM Post operative day: POD s/p repair of Asc. ao aneurysm, prostate ca (s/p external beam radiation ), GERD (?h/o esophageal stricture), h/o afib/flutter-s/p CV/ablations, diverticular disease, cholelithiasis, s/p appy, herniorraphy, empyema s/p R decortication @2yo, esophageal dilatation Current medications: atenolol 25', MVI', advil pm prn coumadin: 2/ 24 Hour Events: TEMPORARY PACEMAKER WIRES DISCONTINUED - At 01:00 PM DRAIN REMOVED - At 01:00 PM CHEST TUBE REMOVED - At 01:00 PM Post operative day: POD s/p repair of Asc. | 45 | [
{
"category": "Echo",
"chartdate": "2173-02-25 00:00:00.000",
"description": "Report",
"row_id": 62664,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Coronary artery disease. Left ventricular function. Right ventricular function. Valvular heart disease.\nHeight: (in) 70\nWeight (lb): 220\nBSA (m2): 2.18 m2\nBP (mm Hg): 140/70\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 09:08\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. Lipomatous hypertrophy of the interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. Normal\naortic arch diameter. Mildly dilated descending aorta. Simple atheroma in\ndescending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Myxomatous mitral valve leaflets. Mild MVP. Eccentric MR jet.\nMild to moderate (+) MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS. 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. 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:\nPRE-BYPASS:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand global systolic function (LVEF>55%). Regional left ventricular wall motion\nis normal.\nRight ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated at the sinus level. The ascending aorta is\nmildly dilated. The descending thoracic aorta is mildly dilated. There are\nsimple atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis. No aortic regurgitation is seen.\nThe mitral valve leaflets are myxomatous. There is mild mitral valve prolapse\nof the P2 region. An eccentric, posteriorly directed jet of Mild to moderate\n(+) mitral regurgitation is seen.\nThere is no pericardial effusion.\nDr. was notified in person of the results on Mr , P at 8AM\nbefore incision.\n\nPost-Bypass:\n\nPreserved biventricular systolic function.\nNormal LVEF 55%,\nIntact thoracic aorta.\nMild to moderate MR>\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-02-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1058616,
"text": " 7:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulm edema\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with\n REASON FOR THIS EXAMINATION:\n r/o pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post-CABG, to evaluate for pulmonary edema.\n\n FINDINGS: In comparison with the study of , all of the monitoring and\n support devices have been removed except for the left chest tube. No\n pneumothorax. Residual atelectatic change especially at the left base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-03-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1059176,
"text": " 10:40 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with s/p CABG - hx alzeiheimers with confusion please limit\n time in radiology\n REASON FOR THIS EXAMINATION:\n evaluate for effusion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb 12:38 PM\n Left lower lung opacity demonstrates interval improvement which may represent\n atelectasis. Small bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of Alzheimer's with confusion.\n\n COMPARISON: CXR, .\n\n FRONTAL AND LATERAL CHEST: Patient is status post CABG and median sternotomy.\n The cardiomediastinal silhouette appears unchanged. The pulmonary vascularity\n appears stable. Left lower lung opacity, likely representing atelectasis,\n demonstrates mild improvement with small bilateral pleural effusions noted.\n The right lung appears clear and there is no pneumothorax.\n\n IMPRESSION: Improved left lower lung opacity with small bilateral pleural\n effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-03-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1059177,
"text": ", C. CSURG FA6A 10:40 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with s/p CABG - hx alzeiheimers with confusion please limit\n time in radiology\n REASON FOR THIS EXAMINATION:\n evaluate for effusion\n ______________________________________________________________________________\n PFI REPORT\n Left lower lung opacity demonstrates interval improvement which may represent\n atelectasis. Small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-02-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1058352,
"text": " 12:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/hypoxia-r/o effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with\n REASON FOR THIS EXAMINATION:\n s/p CABG w/hypoxia-r/o effusion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc 12:12 PM\n Interval development of moderate bilateral pleural effusions and mild\n congestive heart failure.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 66-year-old male status post recent CABG, now with\n hypoxia. Please evaluate for effusions.\n\n EXAMINATION: Single portable chest radiograph.\n\n COMPARISONS: Comparison to chest radiographs from .\n\n FINDINGS: There has been interval development of bilateral moderate pleural\n effusions and diffuse pulmonary vascular engorgement with prominent\n interstitial markings that is consistent with mild congestive heart failure.\n There is persistent left basilar atelectasis that demonstrates no significant\n interval change from prior examination. The cardiomediastinal silhouette is\n stable demonstrating moderate cardiomegaly and tortuosity of the aorta.\n Patient is status post median sternotomy and CABG. An endotracheal tube, left\n basal chest tube, mediastinal drain, and nasogastric tube are in stable\n standard positions. A Swan-Ganz cancer catheter is seen with tip probable in\n the right ventricular outflow tract or main pulmonary trunk.\n\n IMPRESSION: Interval development of bilateral moderate pleural effusions and\n mild congestive heart failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-02-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1058353,
"text": ", C. CSURG CSRU 12:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/hypoxia-r/o effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with\n REASON FOR THIS EXAMINATION:\n s/p CABG w/hypoxia-r/o effusion\n ______________________________________________________________________________\n PFI REPORT\n Interval development of moderate bilateral pleural effusions and mild\n congestive heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-02-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1058654,
"text": " 1:25 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p ct d/c. r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with\n REASON FOR THIS EXAMINATION:\n s/p ct d/c. r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n removal of the left chest tube. No convincing evidence of pneumothorax. When\n compared to the previous study, there are even lower lung volumes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-02-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1058795,
"text": " 11:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with resp distress\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:52 A.M. \n\n HISTORY: Respiratory distress. Rule out pneumothorax.\n\n IMPRESSION: AP chest compared to through 24:\n\n Left lower lobe collapse has been present without appreciable change since at\n least . Small left pleural effusion, however, is increasing, while\n top normal heart size and mediastinal vascular engorgement are stable.\n Heterogeneous opacification in the right mid lung could represent a small\n region of pneumonia, alternatively atelectasis. Right supraclavicular\n catheter sheath ends at the thoracic inlet. No pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2173-03-02 00:00:00.000",
"description": "Report",
"row_id": 116926,
"text": "Sinus rhythm\nProlonged QT interval\nT wave abnormalities\nSince previous tracing of , ST segment elevation in the lateral leads\nare less\n\n"
},
{
"category": "ECG",
"chartdate": "2173-02-25 00:00:00.000",
"description": "Report",
"row_id": 116927,
"text": "Normal sinus rhythm, rate 81. Q-T interval prolongation. Subtle lateral\nST segment elevation consistent with lateral current of injury. Compared to\nthe previous tracing of ST segment elevation laterally is more\npronounced and PR segment depression in leads I, II and V4-V6 with\nPR segment elevation in lead aVR is new. Consider interval pericarditis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-02-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1058640,
"text": " 11:34 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ct to water seal, r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with\n REASON FOR THIS EXAMINATION:\n ct to water seal, r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube on waterseal, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with previous study, there is no interval change.\n Left chest tube remains in place, and there is no convincing evidence of\n pneumothorax. Basilar atelectatic changes are again seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-02-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1058268,
"text": " 1:08 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with CAD s/p CABG. Please at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male with coronary artery disease, post-CABG.\n\n COMPARISON: Preoperative chest x-ray from and CT chest from\n .\n\n The endotracheal tube, Swan-Ganz catheter, nasogastric tube, mediastinal\n drains, and left chest drain are in standard position. The median sternotomy\n wires and mediastinal clips are consistent with recent CABG. There are low\n lung volumes with increased interstitial lung markings and several Kerley B\n lines consistent with mild new pulmonary edema. There is mild left basilar\n atelectasis. There is no pleural effusion or pneumothorax.\n\n\n"
},
{
"category": "Respiratory ",
"chartdate": "2173-02-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 656214,
"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 Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Patient not triggering over the\n set rate\n"
},
{
"category": "Nursing",
"chartdate": "2173-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656258,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt remains orally Intubated. Neo on/off overnight for low sbp into\n 80\ns. Svo2 dropped to to 52 with turning and repositioning. CI>2.\n Insulin drip remains for elevated blood sugars per cvicu protocol.\n Chest tubes to sx draining serosang drainage. Tele noted sr with bbb\n new, Pa aware. mae\ns pupils equal/reactive.\n Action:\n Sbp dropped to 80\ns, propofol changed to 45mcg/neo at 1mcg. Svo2\n droppef to 56 per mixed venous lr given per Pa . Lytes repleted.\n A-paced for bp support.\n Response:\n Svo2\ns 60% now, and ci>2, sbp 120\ns with a-pacing. See flowsheet\n Plan:\n Wean neo for bp support, wean insulin drip, extubate.\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n Pt remains orally Intubated. Propofol for sedation. Simv 8 peep, 70%\n fio2. Hx of copd and sleep apnea according to hx and refuses to wear\n cpap at night.\n Action:\n Attempted numerous times overnight to drop fio2 to 60% see flowsheet.\n Sx for thick white secretions.\n Response:\n Sats decreased to 92% with fio2 change and pao2 decreased to 60.\n Rechecked abg pa02 70 now.\n Plan:\n Continue to wean vent as pt tolerates.\n"
},
{
"category": "Physician ",
"chartdate": "2173-02-26 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656273,
"text": "CVICU\n HPI:\n HD2\n POD 1\n 66M s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n EF: 55% Wt.: 97.9 kg Cr.: 0.8\n PMHx: HTN, ^lipids, CAD-s/p stent L-PDA and OM, mid LCX , MR,\n venous insufficiency, GERD, pseudogout R knee, Alzheimer's, Arthritis,\n OSA, polio, hyperuricemia, s/p MIs\n : Atenolol 50', Lipitor 80', Citalopram 60 qhs, Plavix 75',\n Colchicine 0.6', Donepezil 10', Zetia 10', Felodipine 10', Fluticasone\n 50 mcg 2 sprays each nostril daily, HCTZ 25', Lisinopril 40',\n Omeprazole 20', ASA 325', SL NTG PRN\n Current medications:\n 1. Acetaminophen 2. Albuterol-Ipratropium 3. Albuterol Inhaler 4.\n Aspirin EC\n 5. Aspirin 6. CefazoLIN 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium 9. Docusate Sodium (Liquid) 10. Insulin 11.\n Magnesium Sulfate 12. Glycopyrrolate 13. Milk of Magnesia 14. Morphine\n Sulfate\n 15. Neostigmine 16. Oxycodone-Acetaminophen 17. Phenylephrine 18.\n Potassium Chloride 19. Propofol 20. Ranitidine 21. Sodium Chloride 0.9%\n Flush 22. Lipitor 23. Lasix 24.Plavix 25. 250 of 5% dextrose\n 24 Hour Events:\n NASAL SWAB - At 12:53 PM\n OR RECEIVED - At 12:53 PM\n INVASIVE VENTILATION - START 12:53 PM\n ARTERIAL LINE - START 01:30 PM\n CCO PAC - START 01:31 PM\n CORDIS/INTRODUCER - START 01:31 PM\n EKG - At 02:37 PM\n -> Lasix 10 mg\n -> sputum C/S\n Allergies:\n Naproxen\n Diarrhea; Abdom\n Last dose of Antibiotics:\n Cefazolin - 02:04 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Ranitidine (Prophylaxis) - 05:33 PM\n Insulin - Regular - 06:05 PM\n Morphine Sulfate - 11:43 PM\n Other medications:\n Flowsheet Data as of 08:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n HR: 78 (74 - 89) bpm\n BP: 106/61(75) {86/54(63) - 148/92(112)} mmHg\n RR: 14 (9 - 17) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 93.6 kg\n Height: 70 Inch\n CVP: 12 (7 - 21) mmHg\n PAP: (38 mmHg) / (22 mmHg)\n CO/CI (Fick): (5.3 L/min) / (2.5 L/min/m2)\n CO/CI (CCO): (4.8 L/min) / (2.4 L/min/m2)\n SvO2: 61%\n Mixed Venous O2% sat: 58 - 76\n Total In:\n 6,776 mL\n 517 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,716 mL\n 517 mL\n Blood products:\n Total out:\n 2,606 mL\n 560 mL\n Urine:\n 2,155 mL\n 315 mL\n NG:\n Stool:\n Drains:\n 20 mL\n 15 mL\n Balance:\n 4,170 mL\n -43 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: SIMV/PSV/AutoFlow\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 708 (0 - 721) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%, No Spon Resp\n PIP: 15 cmH2O\n Plateau: 14 cmH2O\n Compliance: 108.3 cmH2O/mL\n SPO2: 97%\n ABG: 7.39/41/76./25/0\n Ve: 9 L/min\n PaO2 / FiO2: 127\n Physical Examination\n General Appearance: No acute distress, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: CTA bilateral : , Diminished: Lt infra-axillary),\n (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 184 K/uL\n 10.4 g/dL\n 123\n 0.8 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 10 mg/dL\n 110 mEq/L\n 140 mEq/L\n 28.4 %\n 12.6 K/uL\n [image002.jpg]\n 05:29 PM\n 08:52 PM\n 12:06 AM\n 01:07 AM\n 01:55 AM\n 02:14 AM\n 03:00 AM\n 04:17 AM\n 06:02 AM\n 07:00 AM\n WBC\n 12.6\n Hct\n 28.4\n Plt\n 184\n Creatinine\n 0.8\n TCO2\n 27\n 25\n 25\n 25\n 26\n 26\n Glucose\n 120\n 111\n 104\n 118\n 107\n 98\n 123\n Other labs: PT / PTT / INR:18.8/56.4/1.7, Fibrinogen:52.5 mg/dL, Lactic\n Acid:2.4 mmol/L, Mg:2.0 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION, CORONARY ARTERY DISEASE\n (CAD, ISCHEMIC HEART DISEASE), .H/O CHRONIC OBSTRUCTIVE PULMONARY\n DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr\n Cardiovascular: Aspirin, to start plavix and lipitor. Continue on same\n dose of Neo, Give Lasix to reduce chest congestion, withhold on beta\n blockers, keep pacing wires connected with back up mode on\n Pulmonary: Cont ETT, SIMV with PSV to keep SpO2 >92%, plan to wean by\n the end of the day and extubate\n Gastrointestinal / Abdomen: continue same\n Nutrition: NPO\n Renal: Foley, Lasix 10 mg to diurese to keep UO > 50 ml/hr with a\n target of litres of negative by the end of the day\n Hematology: Stable anemia, continue watching Hct\n Endocrine: Insulin drip to keep BS < 150 mg/dl\n Infectious Disease: follow cultures, send sputum C/S because of H/O\n COPD with emphysematous blebs\n Lines / Tubes / Drains: Foley, OGT, ETT, Chest tube - pleural , Chest\n tube - mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: CT surgery\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:30 PM\n CCO PAC - 01:31 PM\n Cordis/Introducer - 01:31 PM\n 16 Gauge - 01:33 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2173-02-26 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656279,
"text": "CVICU\n HPI:\n HD2\n POD 1\n 66M s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n EF: 55% Wt.: 97.9 kg Cr.: 0.8\n PMHx: HTN, ^lipids, CAD-s/p stent L-PDA and OM, mid LCX , MR,\n venous insufficiency, GERD, pseudogout R knee, Alzheimer's, Arthritis,\n OSA, polio, hyperuricemia, s/p MIs\n : Atenolol 50', Lipitor 80', Citalopram 60 qhs, Plavix 75',\n Colchicine 0.6', Donepezil 10', Zetia 10', Felodipine 10', Fluticasone\n 50 mcg 2 sprays each nostril daily, HCTZ 25', Lisinopril 40',\n Omeprazole 20', ASA 325', SL NTG PRN\n Current medications:\n 1. Acetaminophen 2. Albuterol-Ipratropium 3. Albuterol Inhaler 4.\n Aspirin EC\n 5. Aspirin 6. CefazoLIN 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium 9. Docusate Sodium (Liquid) 10. Insulin 11.\n Magnesium Sulfate 12. Glycopyrrolate 13. Milk of Magnesia 14. Morphine\n Sulfate\n 15. Neostigmine 16. Oxycodone-Acetaminophen 17. Phenylephrine 18.\n Potassium Chloride 19. Propofol 20. Ranitidine 21. Sodium Chloride 0.9%\n Flush 22. Lipitor 23. Lasix 24.Plavix 25. 250 of 5% dextrose\n 24 Hour Events:\n NASAL SWAB - At 12:53 PM\n OR RECEIVED - At 12:53 PM\n INVASIVE VENTILATION - START 12:53 PM\n ARTERIAL LINE - START 01:30 PM\n CCO PAC - START 01:31 PM\n CORDIS/INTRODUCER - START 01:31 PM\n EKG - At 02:37 PM\n -> Lasix 10 mg\n -> sputum C/S\n Allergies:\n Naproxen\n Diarrhea; Abdom\n Last dose of Antibiotics:\n Cefazolin - 02:04 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Ranitidine (Prophylaxis) - 05:33 PM\n Insulin - Regular - 06:05 PM\n Morphine Sulfate - 11:43 PM\n Other medications:\n Flowsheet Data as of 08:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n HR: 78 (74 - 89) bpm\n BP: 106/61(75) {86/54(63) - 148/92(112)} mmHg\n RR: 14 (9 - 17) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 93.6 kg\n Height: 70 Inch\n CVP: 12 (7 - 21) mmHg\n PAP: (38 mmHg) / (22 mmHg)\n CO/CI (Fick): (5.3 L/min) / (2.5 L/min/m2)\n CO/CI (CCO): (4.8 L/min) / (2.4 L/min/m2)\n SvO2: 61%\n Mixed Venous O2% sat: 58 - 76\n Total In:\n 6,776 mL\n 517 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,716 mL\n 517 mL\n Blood products:\n Total out:\n 2,606 mL\n 560 mL\n Urine:\n 2,155 mL\n 315 mL\n NG:\n Stool:\n Drains:\n 20 mL\n 15 mL\n Balance:\n 4,170 mL\n -43 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: SIMV/PSV/AutoFlow\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 708 (0 - 721) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 1\n PEEP: 8 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%, No Spon Resp\n PIP: 15 cmH2O\n Plateau: 14 cmH2O\n Compliance: 108.3 cmH2O/mL\n SPO2: 97%\n ABG: 7.39/41/76./25/0\n Ve: 9 L/min\n PaO2 / FiO2: 127\n Physical Examination\n General Appearance: No acute distress, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: Lt infra-axillary), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender; Positive BS\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 184 K/uL\n 10.4 g/dL\n 123\n 0.8 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 10 mg/dL\n 110 mEq/L\n 140 mEq/L\n 28.4 %\n 12.6 K/uL\n [image002.jpg]\n 05:29 PM\n 08:52 PM\n 12:06 AM\n 01:07 AM\n 01:55 AM\n 02:14 AM\n 03:00 AM\n 04:17 AM\n 06:02 AM\n 07:00 AM\n WBC\n 12.6\n Hct\n 28.4\n Plt\n 184\n Creatinine\n 0.8\n TCO2\n 27\n 25\n 25\n 25\n 26\n 26\n Glucose\n 120\n 111\n 104\n 118\n 107\n 98\n 123\n Other labs: PT / PTT / INR:18.8/56.4/1.7, Fibrinogen:52.5 mg/dL, Lactic\n Acid:2.4 mmol/L, Mg:2.0 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD,\n BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION, CORONARY ARTERY DISEASE\n (CAD, ISCHEMIC HEART DISEASE), .H/O CHRONIC OBSTRUCTIVE PULMONARY\n DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr; Morphine PRN\n Cardiovascular: Aspirin, to start plavix and lipitor. Post-op\n Hypotension\n Wean Neo gtt for MAP > 60, Hold on beta blockers, keep\n pacing wires connected with back up mode on\n Pulmonary: Change to CPAP/PSV and wean FiO2 to keep SpO2 >92%, plan to\n extubate today if able to wean vent and pass SBT; Start Diuresis with\n Lasix for pulmonary edema\n Gastrointestinal / Abdomen: Bowel Regimen\n Nutrition: NPO\n Renal: Foley, Lasix 10 mg to diurese to keep UO > 50 ml/hr with a\n target of 1 liter negative by the end of the day\n Hematology: Stable anemia, continue follow Hct\n Endocrine: Insulin drip to keep BS < 150 mg/dl\n Infectious Disease: send sputum C/S\n Lines / Tubes / Drains: Foley, OGT, ETT, Chest tube - pleural , Chest\n tube - mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: CT surgery\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 01:30 PM\n CCO PAC - 01:31 PM\n Cordis/Introducer - 01:31 PM\n 16 Gauge - 01:33 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Time : 36 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2173-02-26 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 656286,
"text": "Ht: 70\n Wt (admit): 93.6kg*\n Wt (current): 97kg\n 124% IBW/ BMI = 29.5*\n Diet: NPO\n Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Pt screened ICU policy. s/p CABG x 4 . Pt remains\n intubated/sedated w/ plan to extubate today. NPO x ~2 days. Pt\n presents at 124% IBW, no weight loss noted per H+P.\n Will follow up to check plan/extubation. Page if ?s *\n"
},
{
"category": "Physician ",
"chartdate": "2173-02-27 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656382,
"text": "CVICU\n HPI:\n POD 2\n 66M s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n EF: 55% Wt.: 97.9 kg Cr.: 0.8\n PMHx: HTN, ^lipids, CAD-s/p stent L-PDA and OM, mid LCX , MR,\n venous insufficiency, GERD, pseudogout R knee, Alzheimer's, Arthritis,\n OSA, polio, hyperuricemia, s/p MIs\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen , Albuterol-Ipratropium , Albuterol Inhaler, Aspirin EC ,\n Atorvastatin , Calcium Gluconate ,Captopril Citalopram Hydrobromide ,\n Clopidogrel , Dextrose 50% , Docusate Sodium , Ezetimibe , Furosemide,\n HYDROmorphone (Dilaudid) , Haloperidol , HydrALAzine, Insulin ,\n Ipratropium Bromide Neb, Magnesium Sulfate, Metoclopramide ,\n Metoprolol Tartrate, Milk of Magnesia , Nitroglycerin\n ,Oxycodone-Acetaminophen , Phenylephrine, Potassium Chloride ,\n Ranitidine ,Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:44 AM\n CCO PAC - STOP 12:18 PM\n Post operative day:\n POD 2 CABG\n Allergies:\n Naproxen\n Diarrhea; Abdom\n Last dose of Antibiotics:\n Cefazolin - 05:53 PM\n Infusions:\n Nitroglycerin - 1 mcg/Kg/min\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:00 PM\n Furosemide (Lasix) - 03:32 AM\n Metoprolol - 08:00 AM\n Haloperidol (Haldol) - 08:34 AM\n Other medications:\n Flowsheet Data as of 10:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.1\nC (98.8\n HR: 92 (80 - 115) bpm\n BP: 131/54(72) {100/51(67) - 192/84(115)} mmHg\n RR: 28 (18 - 29) insp/min\n SPO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 97 kg (admission): 93.6 kg\n Height: 70 Inch\n CVP: 4 (3 - 5) mmHg\n PAP: (34 mmHg) / (14 mmHg)\n CO/CI (CCO): (6.6 L/min) / (3.1 L/min/m2)\n SvO2: 60%\n Total In:\n 1,059 mL\n 491 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 939 mL\n 491 mL\n Blood products:\n Total out:\n 2,130 mL\n 1,175 mL\n Urine:\n 1,545 mL\n 985 mL\n NG:\n Stool:\n Drains:\n 15 mL\n 20 mL\n Balance:\n -1,071 mL\n -684 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n PEEP: 5 cmH2O\n FiO2: 100%\n SPO2: 90%\n ABG: 7.50/30/61/26/0\n PaO2 / FiO2: 61\n Physical Examination\n General Appearance: Anxious\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 1), Moves all extremities,\n Very confused, intermittently combative\n Labs / Radiology\n 153 K/uL\n 8.6 g/dL\n 113 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.2 mEq/L\n 13 mg/dL\n 108 mEq/L\n 140 mEq/L\n 24.3 %\n 13.0 K/uL\n [image002.jpg]\n 09:27 AM\n 10:00 AM\n 11:08 AM\n 12:59 PM\n 03:12 PM\n 05:23 PM\n 01:18 AM\n 02:28 AM\n 02:39 AM\n 06:09 AM\n WBC\n 13.0\n Hct\n 24.3\n Plt\n 153\n Creatinine\n 0.7\n TCO2\n 26\n 25\n 25\n 22\n 27\n 27\n 24\n Glucose\n 107\n 121\n 106\n 107\n 115\n 123\n 132\n 113\n Other labs: PT / PTT / INR:18.8/56.4/1.7, ALT / AST:15/28, Alk-Phos / T\n bili:35/0.5, Fibrinogen:52.5 mg/dL, Lactic Acid:4.1 mmol/L, LDH:269\n IU/L, Mg:2.0 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR: increased vascular markings, no ptx\n Microbiology: all neg\n Assessment and Plan\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT), HYPOTENSION (NOT\n SHOCK), CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION, CORONARY ARTERY DISEASE (CAD,\n ISCHEMIC HEART DISEASE), .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan: Pt. remains very confused and intermittently\n combative. Haldol and PRN. Will leave CT in today, no air leak.\n Cont. aggressive diuresis and pulm. rx.\n Neurologic: Neuro checks Q: 4 hr\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley\n Hematology:\n Endocrine: RISS\n Infectious Disease: all neg\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), Chest\n tube - pleural , Chest tube - mediastinal, Pacing wires, D/C leg drain\n today.\n Wounds: Dry dressings\n Imaging: CXR today, Will check CXR on water seal today.\n Fluids:\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:30 PM\n Cordis/Introducer - 01:31 PM\n 16 Gauge - 01:33 PM\n Prophylaxis:\n DVT: 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"
},
{
"category": "Nursing",
"chartdate": "2173-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656300,
"text": ".H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt with history of dementia, alert and oriented x 2 at baseline.\n Unable to follow command on low dose propofol, but very agitated off\n propofol. Medicated with morphine for agitation with good effect.\n Action:\n Pt extubated per protocol. Oriented to person only. C/o pain after\n extubation. PA notified and pain meds changed to dilaudid\n po/iv. OOB to chair with chair alarm in place.\n Response:\n Pt slept in chair and pain level improved. Family at bedside.\n Plan:\n Monitor mental status, provide adequate pain relief. Provide\n reassurance and reorientation as needed.\n Hypotension (not Shock)\n Assessment:\n On arrival pt on neosynephrine gtt at 1 mcg/kg/min and propofol gtt at\n 40 mcg/kg/min.\n Action:\n Neosynephrine gtt weaned per protocol.\n Response:\n Pt SBP remains > 90, MAP > 60. Lopressor po started.\n Plan:\n Monitor SBP and continue with po lopressor.\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n Pt orally intubated on full mechanical ventilation. PO2 on ABG 70\n Action:\n Pt weaned to CPAP and extubated per protocol. OOB to chair, tolerating\n well. Cough and deep breathing encouraged, pt with some difficulty\n comprehending.\n Response:\n O2 sat 93-95% on 6l nc when oob to chair. Lungs clear, diminished.\n Plan:\n Monitor respiratory status and pulmonary toilet as tolerates.\n"
},
{
"category": "Nursing",
"chartdate": "2173-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656252,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt remains orally Intubated. Neo on/off overnight for low sbp into\n 80\ns. Svo2 dropped to to 52 with turning and repositioning. CI>2.\n Insulin drip remains for elevated blood sugars per cvicu protocol.\n Chest tubes to sx draining serosang drainage. Tele noted sr with bbb\n new, Pa aware.\n Action:\n Sbp dropped to 80\ns, propofol changed to 45mcg/neo at 1mcg. Svo2\n droppef to 56 per mixed venous lr given per Pa . Lytes repleted.\n A-paced for bp support.\n Response:\n Svo2\ns 60% now, and ci>2, sbp 120\ns with a-pacing. See flowsheet\n Plan:\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n Pt remains orally Intubated. Propofol for sedation. Simv 8 peep, 70%\n fio2. Hx of copd and sleep apnea according to hx and refuses to wear\n cpap at night.\n Action:\n Attempted numerous times overnight to drop fio2 to 60% see flowsheet.\n Sx for thick white secretions.\n Response:\n Sats decreased to 92% with fio2 change and pao2 decreased to 60.\n Changed back to fio2 70%, ? change to 5\n Plan:\n Continue to wean vent as pt tolerates.\n"
},
{
"category": "Physician ",
"chartdate": "2173-02-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 656376,
"text": "Intensivist Note:\n Patient remains with respiratory insufficiency post-op with significant\n O2 requirement. Cont diuresis today with lasix . Will also change\n CT\ns to water seal and check CXR in 6 hours to assess for pneumothorax\n given positive air leak yesterday. Will cont Haldol prn agitation with\n dilaudid prn pain and avoid benzo\ns in this patient with dementia.\n"
},
{
"category": "Nursing",
"chartdate": "2173-03-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656562,
"text": ".H/O dementia (including Alzheimer's, Multi Infarct) NEURO PT\n REMAINS ALERT 0X2 AGITATED AND COFUSED AT TIMES WITH BASLINE DEMENTIA\n CHRONIC WIFE STATES PT IN SAME NEURO STATUS SLEEPS SHORT PERIODS\n WALKS ON COMMAND TURNS SELF IN BED WIFE AT BEDSIDE FOR SUPPORT HELPS\n WITH PT PERIODS OF AGITATION\n HEART S1S2 NSR PR .14 QRS .08 PULSES POS 2 THRU OUT\n DIS HEART TONES M NEG NVD OR HJR\n RESP RESOVING O2 NEED PLEASE SEE ABG FOR DETAILS RESP\n ALK MIX SCANT SPUTUM PRODUCTION STRONG COUGH\n SUPPORTIVE SURROUNDINGS FAMILY AT BEDSIDE THRU STAY FOR HELP\n AND FOCUS OF PT\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2173-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656553,
"text": ".H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Baseline confusion\n Action:\n Pt\ns family staying at bedside 24 hours a day\n Response:\n Pt does well with family in room. Oriented to person, confused to\n place.\n Plan:\n Continue with family in room\n Hypertension, benign\n Assessment:\n Pt hypertensive at times\n Action:\n PRN Hydralazine\n Response:\n Decrease in BP\n Plan:\n Treat SBP to keep <160\n Anemia, other\n Assessment:\n HCT 24.7 this am\n Action:\n 1 Unit PRBC given\n Response:\n Repeat HCT 29.4\n Plan:\n Draw am labs\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n Morning ABG pa O2 55. Hx COPD.\n Action:\n Pt on 4L NC with neb tx and inhalers\n Response:\n Pt with PaO2 60 at noon ABG\n Plan:\n Monitor ABG\ns PRN\n"
},
{
"category": "Nursing",
"chartdate": "2173-03-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 656657,
"text": "66YO male POD4 CABG X 4 \n Off gtts, chest tubes out, wires out.\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt oriented to self and place in AM. Does not know DOB, has trouble\n focusing on questions being asked by staff\n Action:\n Speak slowly and talk about one issue at a time. Keep stimuli to a\n minimum in the room. Wife stays in the room all the time\n Response:\n Pt responds well to one on one interaction with RN. Consistency with\n staff helps. Wife to stay throughout day, pt responds well to her when\n he get worked up and aggravated with staff.\n Plan:\n Transfer to 6 private room\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reports back pain when back in bed.\n Action:\n Given 2mg Dilaudid PO, repositioned back to chair, back rub\n Response:\n Reports improvement with back pain\n Plan:\n Assess pain level and ask specific questions regarding pain and types.\n Does better answering specific questions.\n Foley out at 1000. voided ~150cc @ 1330.\n Introducer out this AM, 20gauge IV in left hand.\n Chair pad ordered and used for pt. prefers to be in chair.\n Walked in AM around unit with RN and wife. PT came as well\n to evaluate, and got pt to chair\n No appetite today, ate small amount of fruit in AM\n"
},
{
"category": "Physician ",
"chartdate": "2173-03-01 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656614,
"text": "CVICU\n HPI:\n HD5\n POD 4\n 66M s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n EF: 55% Wt.: 97.9 kg Cr.: 0.8\n PMHx: HTN, ^lipids, CAD-s/p stent L-PDA and OM, mid LCX , MR,\n venous insufficiency, GERD, pseudogout R knee, Alzheimer's, Arthritis,\n OSA, polio, hyperuricemia, s/p MIs\n : Atenolol 50', Lipitor 80', Citalopram 60 qhs, Plavix 75',\n Colchicine 0.6', Donepezil 10', Zetia 10', Felodipine 10', Fluticasone\n 50 mcg 2 sprays each nostril daily, HCTZ 25', Lisinopril 40',\n Omeprazole 20', ASA 325', SL NTG PRN\n events: very confused, combative, haldol given. CTs, wires, leg\n drain d/c'd, hypoxic->diurese, tx'd 1 UPRBC\n : 1U PRBC\n Current medications:\n 1. 250 mL D5W 2. Acetaminophen 3. Albuterol-Ipratropium 4. Albuterol\n Inhaler 5. Albuterol 0.083% Neb Soln 6. Aspirin EC 7. Atorvastatin 8.\n Captopril 9. Citalopram Hydrobromide 10. Clopidogrel 11. Docusate\n Sodium 12. Ezetimibe 13. Furosemide 14. HYDROmorphone (Dilaudid) 15.\n Haloperidol 16. Heparin 17. HydrALAzine 18. Ipratropium Bromide Neb 19.\n Metoclopramide 20. Metoprolol Tartrate 21. Milk of Magnesia 22.\n Ranitidine 23. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n - PaO2 on ABG has improved from 50-60s to 131\n - Delirious and agitated sometimes, responded to haloperidol, needs\n support from family members\n - good diuresis on 40 mg of lasix.\n - CT, pacing wires and leg drains discontinued.\n - 1 Unit of PRBC transfused, Hct increased to 29.8.\n Allergies:\n Naproxen\n Diarrhea; Abdom\n Last dose of Antibiotics:\n Cefazolin - 05:53 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 03:33 PM\n Furosemide (Lasix) - 05:58 PM\n Other medications:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 36.7\nC (98\n HR: 85 (71 - 111) bpm\n BP: 110/65(81) {110/65(0) - 128/68(0)} mmHg\n RR: 20 (18 - 26) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 93.6 kg\n Height: 70 Inch\n Total In:\n 800 mL\n 50 mL\n PO:\n 200 mL\n Tube feeding:\n IV Fluid:\n 250 mL\n 50 mL\n Blood products:\n 350 mL\n Total out:\n 2,460 mL\n 1,775 mL\n Urine:\n 2,460 mL\n 1,775 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,660 mL\n -1,725 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: 7.52/24/131/21/0\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 : ), (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 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 212 K/uL\n 10.8 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 112 mEq/L\n 142 mEq/L\n 29.8 %\n 11.8 K/uL\n [image002.jpg]\n 02:39 AM\n 06:09 AM\n 12:54 PM\n 02:55 PM\n 11:45 PM\n 12:00 AM\n 01:32 PM\n 01:40 PM\n 12:01 AM\n 12:14 AM\n WBC\n 10.1\n 11.8\n Hct\n 24.7\n 29.4\n 29.8\n Plt\n 112\n 212\n Creatinine\n 0.7\n 0.8\n TCO2\n 27\n 24\n 28\n 25\n 18\n 20\n Glucose\n 113\n 109\n 107\n 103\n Other labs: PT / PTT / INR:14.0/32.4/1.2, ALT / AST:21/30, Alk-Phos / T\n bili:41/1.6, Fibrinogen:52.5 mg/dL, Lactic Acid:1.6 mmol/L, LDH:269\n IU/L, Ca:8.0 mg/dL, Mg:2.6 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT), HYPERTENSION,\n BENIGN, ANEMIA, OTHER, .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION, CHRONIC\n OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE\n EXACERBATION, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr\n Cardiovascular: Aspirin, Beta-blocker, Statins, will reduce Lasix from\n 40 mg/d to 20 mg/d\n Pulmonary: IS, reduce O2 to 2 L/min\n Gastrointestinal / Abdomen: Standard diet\n Nutrition: Advance diet as tolerated\n Renal: Foley\n Hematology: continue same\n Endocrine: RISS to keep BS < 150 mg/dl\n Infectious Disease: none\n Lines / Tubes / Drains: Foley, Pull out the cordis before transfer to\n the floor\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: CT surgery\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 01:31 PM\n 20 Gauge - 05:12 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2173-02-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 656236,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 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: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated):\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated, Adjust Min. ventilation to control\n pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Hemodynimic instability, Underlying\n illness not resolved\n Notes: lower po2 with abgs, titrating fio2 accordingly.\n"
},
{
"category": "Nursing",
"chartdate": "2173-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656353,
"text": ".H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n O2 sats dipping to 81-82% on finger and 90% on forehead. Abg returned\n with PO@ of 48 on 70% aerosol mask and 5l NP. pt would become agitated\n at times refusing to cough , taking O2 on and off. Breath sounds were\n clear throughout but diminished in bases\n Action:\n Pt placed on High flow 100% and 5l NP, Albuterol and Atrovent changed\n to neb treatments 2^nd to pt unable to follow direction with confusion.\n HOB elevated 30-45 degrees, attempting to get pt to cough and deep\n breath and CPT when pt calm. Pt oob to chair. HO aware of events Lasix\n 20mg IV ordered.\n Response:\n PO@ increased to 50\ns on high flow with O2 sat of 89-91% correlating\n with ABG.\n Plan:\n Continue aggressive Pulmonary toilet when pt allows. Keep pt calm\n agitation decreases saturation.\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt only oriented to person, does not know where he is or why and does\n not recall even when explained to pt. Pt attempts to get oob\n intermittently and will then fall to sleep within minutes of attempting\n to get up. Brief periods of aggitation hitting out at people, refusing\n things despite explainations. Pt does not hear what you say to him\n correctly. Pt becomes very agitated when having pain\n Action:\n Restarted on Celexa, medicated with dilaudid po every 4hours as\n needed for pain. Reoriented pt frequently. Bed alarm activated when in\n bed and chair alarm placed on pt when ooB\n Response:\n Pt remains confused but cooperative when not in pain.\n Plan:\n Continue to assess pt for pain and discomfort and reoriented frequetly\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n HR 90-130\ns sinus depending on agitation level. SBP 120\ns too 190\ns on\n nitro 1.5mcg\n Action:\n Nitro titrated , pt given Lopressor 10mg IV last evening then started\n on 25mg po at 2300. Captopril also started.\n Response:\n Pt remains on nitro with SBP in the 120\ns but increasing to 180\ns when\n agitated.\n Plan:\n Increase antihypertensive as ordered. Wean nitro as tolerated\n"
},
{
"category": "Physician ",
"chartdate": "2173-03-01 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656623,
"text": "CVICU\n HPI:\n 66M s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n Chief complaint:\n PMHx:\n HTN, ^lipids, CAD-s/p stent L-PDA and OM, mid LCX , MR, venous\n insufficiency, GERD, pseudogout R knee, Alzheimer's, Arthritis, OSA,\n polio, hyperuricemia, s/p MIs\n Current medications:\n Atenolol 50', Lipitor 80', Citalopram 60 qhs, Plavix 75', Colchicine\n 0.6', Donepezil 10', Zetia 10', Felodipine 10', Fluticasone 50 mcg 2\n sprays each nostril daily, HCTZ 25', Lisinopril 40', Omeprazole 20',\n ASA 325', SL NTG PRN\n 24 Hour Events:\n TEMPORARY PACEMAKER WIRES DISCONTINUED - At 01:00 PM\n DRAIN REMOVED - At 01:00 PM\n CHEST TUBE REMOVED - At 01:00 PM\n Post operative day:\n POD 3\n 66M s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n Allergies:\n Naproxen\n Diarrhea; Abdom\n Last dose of Antibiotics:\n Cefazolin - 05:53 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:30 AM\n Haloperidol (Haldol) - 11:30 AM\n Hydromorphone (Dilaudid) - 01:00 PM\n Hydralazine - 05:30 PM\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: 37.7\nC (99.8\n T current: 36.2\nC (97.2\n HR: 91 (77 - 108) bpm\n BP: 150/64(89) {123/55(74) - 742/75(103)} mmHg\n RR: 21 (18 - 32) insp/min\n SPO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 93.6 kg\n Height: 70 Inch\n Total In:\n 1,068 mL\n 50 mL\n PO:\n Tube feeding:\n IV Fluid:\n 718 mL\n 50 mL\n Blood products:\n 350 mL\n Total out:\n 2,910 mL\n 1,250 mL\n Urine:\n 2,540 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n 70 mL\n Balance:\n -1,842 mL\n -1,200 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 89%\n ABG: 7.51/30/55/22/1\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, hypoactive\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: No(t) Absent, Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands\n Labs / Radiology\n 112 K/uL\n 9.2 g/dL\n 107 mg/dL\n 0.7 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 15 mg/dL\n 109 mEq/L\n 141 mEq/L\n 24.7 %\n 10.1 K/uL\n [image002.jpg]\n 03:12 PM\n 05:23 PM\n 01:18 AM\n 02:28 AM\n 02:39 AM\n 06:09 AM\n 12:54 PM\n 02:55 PM\n 11:45 PM\n 12:00 AM\n WBC\n 13.0\n 10.1\n Hct\n 24.3\n 24.7\n Plt\n 153\n 112\n Creatinine\n 0.7\n 0.7\n TCO2\n 22\n 27\n 27\n 24\n 28\n 25\n Glucose\n 115\n 123\n 132\n 113\n 109\n 107\n Other labs: PT / PTT / INR:14.8/36.0/1.3, ALT / AST:18/32, Alk-Phos / T\n bili:37/1.2, Fibrinogen:52.5 mg/dL, Lactic Acid:1.6 mmol/L, LDH:269\n IU/L, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT), HYPERTENSION,\n BENIGN, ANEMIA, OTHER, .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION, CHRONIC\n OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE\n EXACERBATION, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS, wean FIO2\n pulmonary toilet\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet\n Renal: Foley\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:30 PM\n Cordis/Introducer - 01:31 PM\n 20 Gauge - 05:12 AM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status:\n Disposition: ICU\n ------ Protected Section ------\n Agree with above note by Soti .\n ------ Protected Section Addendum Entered By: , MD\n on: 07:51 ------\n"
},
{
"category": "Physician ",
"chartdate": "2173-03-01 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656624,
"text": "CVICU\n HPI:\n POD 2\n 66M s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n EF: 55% Wt.: 97.9 kg Cr.: 0.8\n PMHx: HTN, ^lipids, CAD-s/p stent L-PDA and OM, mid LCX , MR,\n venous insufficiency, GERD, pseudogout R knee, Alzheimer's, Arthritis,\n OSA, polio, hyperuricemia, s/p MIs\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen , Albuterol-Ipratropium , Albuterol Inhaler, Aspirin EC ,\n Atorvastatin , Calcium Gluconate ,Captopril Citalopram Hydrobromide ,\n Clopidogrel , Dextrose 50% , Docusate Sodium , Ezetimibe , Furosemide,\n HYDROmorphone (Dilaudid) , Haloperidol , HydrALAzine, Insulin ,\n Ipratropium Bromide Neb, Magnesium Sulfate, Metoclopramide ,\n Metoprolol Tartrate, Milk of Magnesia , Nitroglycerin\n ,Oxycodone-Acetaminophen , Phenylephrine, Potassium Chloride ,\n Ranitidine ,Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:44 AM\n CCO PAC - STOP 12:18 PM\n Post operative day:\n POD 2 CABG\n Allergies:\n Naproxen\n Diarrhea; Abdom\n Last dose of Antibiotics:\n Cefazolin - 05:53 PM\n Infusions:\n Nitroglycerin - 1 mcg/Kg/min\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:00 PM\n Furosemide (Lasix) - 03:32 AM\n Metoprolol - 08:00 AM\n Haloperidol (Haldol) - 08:34 AM\n Other medications:\n Flowsheet Data as of 10:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.1\nC (98.8\n HR: 92 (80 - 115) bpm\n BP: 131/54(72) {100/51(67) - 192/84(115)} mmHg\n RR: 28 (18 - 29) insp/min\n SPO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 97 kg (admission): 93.6 kg\n Height: 70 Inch\n CVP: 4 (3 - 5) mmHg\n PAP: (34 mmHg) / (14 mmHg)\n CO/CI (CCO): (6.6 L/min) / (3.1 L/min/m2)\n SvO2: 60%\n Total In:\n 1,059 mL\n 491 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 939 mL\n 491 mL\n Blood products:\n Total out:\n 2,130 mL\n 1,175 mL\n Urine:\n 1,545 mL\n 985 mL\n NG:\n Stool:\n Drains:\n 15 mL\n 20 mL\n Balance:\n -1,071 mL\n -684 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n PEEP: 5 cmH2O\n FiO2: 100%\n SPO2: 90%\n ABG: 7.50/30/61/26/0\n PaO2 / FiO2: 61\n Physical Examination\n General Appearance: Anxious\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 1), Moves all extremities,\n Very confused, intermittently combative\n Labs / Radiology\n 153 K/uL\n 8.6 g/dL\n 113 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.2 mEq/L\n 13 mg/dL\n 108 mEq/L\n 140 mEq/L\n 24.3 %\n 13.0 K/uL\n [image002.jpg]\n 09:27 AM\n 10:00 AM\n 11:08 AM\n 12:59 PM\n 03:12 PM\n 05:23 PM\n 01:18 AM\n 02:28 AM\n 02:39 AM\n 06:09 AM\n WBC\n 13.0\n Hct\n 24.3\n Plt\n 153\n Creatinine\n 0.7\n TCO2\n 26\n 25\n 25\n 22\n 27\n 27\n 24\n Glucose\n 107\n 121\n 106\n 107\n 115\n 123\n 132\n 113\n Other labs: PT / PTT / INR:18.8/56.4/1.7, ALT / AST:15/28, Alk-Phos / T\n bili:35/0.5, Fibrinogen:52.5 mg/dL, Lactic Acid:4.1 mmol/L, LDH:269\n IU/L, Mg:2.0 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR: increased vascular markings, no ptx\n Microbiology: all neg\n Assessment and Plan\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT), HYPOTENSION (NOT\n SHOCK), CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION, CORONARY ARTERY DISEASE (CAD,\n ISCHEMIC HEART DISEASE), .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan: Pt. remains very confused and intermittently\n combative. Haldol and PRN. Will leave CT in today, no air leak.\n Cont. aggressive diuresis and pulm. rx.\n Neurologic: Neuro checks Q: 4 hr\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley\n Hematology:\n Endocrine: RISS\n Infectious Disease: all neg\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), Chest\n tube - pleural , Chest tube - mediastinal, Pacing wires, D/C leg drain\n today.\n Wounds: Dry dressings\n Imaging: CXR today, Will check CXR on water seal today.\n Fluids:\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:30 PM\n Cordis/Introducer - 01:31 PM\n 16 Gauge - 01:33 PM\n Prophylaxis:\n DVT: 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 ------ Protected Section ------\n Agree with above note by .\n ------ Protected Section Addendum Entered By: , MD\n on: 07:52 ------\n"
},
{
"category": "Physician ",
"chartdate": "2173-03-01 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656629,
"text": "CVICU\n HPI:\n HD5\n POD 4\n 66M s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n EF: 55% Wt.: 97.9 kg Cr.: 0.8\n PMHx: HTN, ^lipids, CAD-s/p stent L-PDA and OM, mid LCX , MR,\n venous insufficiency, GERD, pseudogout R knee, Alzheimer's, Arthritis,\n OSA, polio, hyperuricemia, s/p MIs\n : Atenolol 50', Lipitor 80', Citalopram 60 qhs, Plavix 75',\n Colchicine 0.6', Donepezil 10', Zetia 10', Felodipine 10', Fluticasone\n 50 mcg 2 sprays each nostril daily, HCTZ 25', Lisinopril 40',\n Omeprazole 20', ASA 325', SL NTG PRN\n events: very confused, combative, haldol given. CTs, wires, leg\n drain d/c'd, hypoxic->diurese, tx'd 1 UPRBC\n : 1U PRBC\n Current medications:\n 1. 250 mL D5W 2. Acetaminophen 3. Albuterol-Ipratropium 4. Albuterol\n Inhaler 5. Albuterol 0.083% Neb Soln 6. Aspirin EC 7. Atorvastatin 8.\n Captopril 9. Citalopram Hydrobromide 10. Clopidogrel 11. Docusate\n Sodium 12. Ezetimibe 13. Furosemide 14. HYDROmorphone (Dilaudid) 15.\n Haloperidol 16. Heparin 17. HydrALAzine 18. Ipratropium Bromide Neb 19.\n Metoclopramide 20. Metoprolol Tartrate 21. Milk of Magnesia 22.\n Ranitidine 23. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n - PaO2 on ABG has improved from 50-60s to 131\n - Delirious and agitated sometimes, responded to haloperidol, needs\n support from family members\n - good diuresis on 40 mg of lasix.\n - CT, pacing wires and leg drains discontinued.\n - 1 Unit of PRBC transfused, Hct increased to 29.8.\n Allergies:\n Naproxen\n Diarrhea; Abdom\n Last dose of Antibiotics:\n Cefazolin - 05:53 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 03:33 PM\n Furosemide (Lasix) - 05:58 PM\n Other medications:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 36.7\nC (98\n HR: 85 (71 - 111) bpm\n BP: 110/65(81) {110/65(0) - 128/68(0)} mmHg\n RR: 20 (18 - 26) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 93.6 kg\n Height: 70 Inch\n Total In:\n 800 mL\n 50 mL\n PO:\n 200 mL\n Tube feeding:\n IV Fluid:\n 250 mL\n 50 mL\n Blood products:\n 350 mL\n Total out:\n 2,460 mL\n 1,775 mL\n Urine:\n 2,460 mL\n 1,775 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,660 mL\n -1,725 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: 7.52/24/131/21/0\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 : ), (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 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 212 K/uL\n 10.8 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 112 mEq/L\n 142 mEq/L\n 29.8 %\n 11.8 K/uL\n [image002.jpg]\n 02:39 AM\n 06:09 AM\n 12:54 PM\n 02:55 PM\n 11:45 PM\n 12:00 AM\n 01:32 PM\n 01:40 PM\n 12:01 AM\n 12:14 AM\n WBC\n 10.1\n 11.8\n Hct\n 24.7\n 29.4\n 29.8\n Plt\n 112\n 212\n Creatinine\n 0.7\n 0.8\n TCO2\n 27\n 24\n 28\n 25\n 18\n 20\n Glucose\n 113\n 109\n 107\n 103\n Other labs: PT / PTT / INR:14.0/32.4/1.2, ALT / AST:21/30, Alk-Phos / T\n bili:41/1.6, Fibrinogen:52.5 mg/dL, Lactic Acid:1.6 mmol/L, LDH:269\n IU/L, Ca:8.0 mg/dL, Mg:2.6 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT), HYPERTENSION,\n BENIGN, ANEMIA, OTHER, .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATIOdN, CHRONIC\n OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE\n EXACERBATION, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr\n Cardiovascular: Aspirin, Beta-blocker, Statins, will reduce Lasix from\n 40 mg/d to 20 mg/d, Plavix\n Pulmonary: IS, reduce O2 to 2 L/min\n Gastrointestinal / Abdomen: Standard diet\n Nutrition: Advance diet as tolerated\n Renal: Foley\n Hematology: continue same\n Endocrine: RISS to keep BS < 150 mg/dl\n Infectious Disease: none\n Lines / Tubes / Drains: Foley, Pull out the cordis before transfer to\n the floor\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: CT surgery\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 01:31 PM\n 20 Gauge - 05:12 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2173-03-01 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656632,
"text": "CVICU\n HPI:\n POD 4\n 66M s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n EF: 55% Wt.: 97.9 kg Cr.: 0.8\n PMHx:\n PMHx: HTN, ^lipids, CAD-s/p stent L-PDA and OM, mid LCX , MR,\n venous insufficiency, GERD, pseudogout R knee, Alzheimer's, Arthritis,\n OSA, polio, hyperuricemia, s/p MIs\n Current medications:\n : Atenolol 50', Lipitor 80', Citalopram 60 qhs, Plavix 75',\n Colchicine 0.6', Donepezil 10', Zetia 10', Felodipine 10', Fluticasone\n 50 mcg 2 sprays each nostril daily, HCTZ 25', Lisinopril 40',\n Omeprazole 20', ASA 325', SL NTG PRN\n 4 Hour Events:\n events: very confused, combative, haldol given. CTs, wires, leg\n drain d/c'd, hypoxic->diurese, tx'd 1 UPRBC\n : 1U PRBC\n Post operative day:\n s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n Allergies:\n Naproxen\n Diarrhea; Abdom\n Last dose of Antibiotics:\n Cefazolin - 05:53 PM\n Other ICU medications:\n Hydralazine - 03:33 PM\n Furosemide (Lasix) - 05:58 PM\n Flowsheet Data as of 09:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.9\nC (98.4\n HR: 84 (71 - 111) bpm\n BP: 141/77(92) {110/65(89) - 141/77(92)} mmHg\n RR: 19 (18 - 26) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 93.6 kg\n Height: 70 Inch\n Total In:\n 800 mL\n 50 mL\n PO:\n 200 mL\n Tube feeding:\n IV Fluid:\n 250 mL\n 50 mL\n Blood products:\n 350 mL\n Total out:\n 2,460 mL\n 1,975 mL\n Urine:\n 2,460 mL\n 1,975 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,660 mL\n -1,925 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: 7.52/24/131/21/0\n Physical Examination\n General Appearance: No acute distress, sitting in chair\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: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities, Hx dementia. Calm\n when family members present\n / Radiology\n 212 K/uL\n 10.8 g/dL\n 103 mg/dL\n 0.8 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 20 mg/dL\n 112 mEq/L\n 142 mEq/L\n 29.8 %\n 11.8 K/uL\n [image002.jpg]\n 02:39 AM\n 06:09 AM\n 12:54 PM\n 02:55 PM\n 11:45 PM\n 12:00 AM\n 01:32 PM\n 01:40 PM\n 12:01 AM\n 12:14 AM\n WBC\n 10.1\n 11.8\n Hct\n 24.7\n 29.4\n 29.8\n Plt\n 112\n 212\n Creatinine\n 0.7\n 0.8\n TCO2\n 27\n 24\n 28\n 25\n 18\n 20\n Glucose\n 113\n 109\n 107\n 103\n Other : PT / PTT / INR:14.0/32.4/1.2, ALT / AST:21/30, Alk-Phos / T\n bili:41/1.6, Fibrinogen:52.5 mg/dL, Lactic Acid:1.6 mmol/L, LDH:269\n IU/L, Ca:8.0 mg/dL, Mg:2.6 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT), HYPERTENSION,\n BENIGN, ANEMIA, OTHER, .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION, CHRONIC\n OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE\n EXACERBATION, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 66yoM s/p CAbg. Hemodynamically stable. Remained\n in ICU for pulmonary toilet\n Neurologic: Pain controlled, tylenol, dilaudid, celexa, haldol\n Cardiovascular: Aspirin, Beta-blocker, Statins, plavix, ace, zetia\n Pulmonary: IS, chest PT, OOB ambulate\n Gastrointestinal / Abdomen: ADAT\n Nutrition: Advance diet as tolerated\n Renal: Foley, decrease lasix. goal 1-1.5 liters negative\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: no new data. Afebrile, normal wbc\n Lines / Tubes / Drains: Foley, Cordis\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n ICU Care\n Nutrition: ADAT\n Glycemic Control: Regular insulin sliding scale\n Lines: Cordis/Introducer - 01:31 PM\n 20 Gauge - 05:12 AM\n Prophylaxis: DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: full\n Disposition: Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2173-02-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656432,
"text": ".H/O dementia (including Alzheimer's, Multi Infarct) NEURO PT\n REMAINS AGITATED AT TIMES 0X2 TRIES TO BUT DOES NOT UNDERSTANDS CARE\n GIVEN PAIN AND PROCEDURES WIFE AT BEDSIDE TO HELP WITH CARE GIVEN\n POSITIVE EFFECT MORE RELAXED PT SELF IN BED OOB TO CHAIR\n AND WALK DID WELL SLEPT SHORT PERIODS MEDICATED FOR PAIN WELL PT\n TRIES TO HAVE SELF CONTROL FIGHTS WITH HIS IMPULSIVENESS\n RESP DIM AT BASES POOR PO2 LEVELS MD \n PRESENT PLAN OF CARE PT CHRONIC RESP FAILURE / COPD 02 4 L NP SAO2\n 96 CPT WELL T/P HELPS WITH SAO2 THICK SPUTUM NOTED HEART\n S1S2 NSR PR .16 QRS .08 PULSES POS 3 THRU OUT VSS NO TEMP\n PLAN HELP PT TO UNDERSTAND PROGRESSIVE CARE CPT\n T/P S/S FOR HELP WIR E WHAT IS NEEDED A HOME\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2173-02-28 00:00:00.000",
"description": "Intensivist Note",
"row_id": 656487,
"text": "Intensivist Note:\n Doing well post-op, however remains significantly hypoxic. I believe\n his volume status and lung pathology explain his hypoxia at this\n point. Cont OB with IS and diuresis with lasix. Wean FiO2 as\n tolerated. Encourage PO intake.\n"
},
{
"category": "Physician ",
"chartdate": "2173-02-28 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656495,
"text": "CVICU\n HPI:\n 66M s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n Chief complaint:\n PMHx:\n HTN, ^lipids, CAD-s/p stent L-PDA and OM, mid LCX , MR, venous\n insufficiency, GERD, pseudogout R knee, Alzheimer's, Arthritis, OSA,\n polio, hyperuricemia, s/p MIs\n Current medications:\n Atenolol 50', Lipitor 80', Citalopram 60 qhs, Plavix 75', Colchicine\n 0.6', Donepezil 10', Zetia 10', Felodipine 10', Fluticasone 50 mcg 2\n sprays each nostril daily, HCTZ 25', Lisinopril 40', Omeprazole 20',\n ASA 325', SL NTG PRN\n 24 Hour Events:\n TEMPORARY PACEMAKER WIRES DISCONTINUED - At 01:00 PM\n DRAIN REMOVED - At 01:00 PM\n CHEST TUBE REMOVED - At 01:00 PM\n Post operative day:\n POD 3\n 66M s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n Allergies:\n Naproxen\n Diarrhea; Abdom\n Last dose of Antibiotics:\n Cefazolin - 05:53 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:30 AM\n Haloperidol (Haldol) - 11:30 AM\n Hydromorphone (Dilaudid) - 01:00 PM\n Hydralazine - 05:30 PM\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: 37.7\nC (99.8\n T current: 36.2\nC (97.2\n HR: 91 (77 - 108) bpm\n BP: 150/64(89) {123/55(74) - 742/75(103)} mmHg\n RR: 21 (18 - 32) insp/min\n SPO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 93.6 kg\n Height: 70 Inch\n Total In:\n 1,068 mL\n 50 mL\n PO:\n Tube feeding:\n IV Fluid:\n 718 mL\n 50 mL\n Blood products:\n 350 mL\n Total out:\n 2,910 mL\n 1,250 mL\n Urine:\n 2,540 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n 70 mL\n Balance:\n -1,842 mL\n -1,200 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 89%\n ABG: 7.51/30/55/22/1\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, hypoactive\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: No(t) Absent, Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands\n Labs / Radiology\n 112 K/uL\n 9.2 g/dL\n 107 mg/dL\n 0.7 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 15 mg/dL\n 109 mEq/L\n 141 mEq/L\n 24.7 %\n 10.1 K/uL\n [image002.jpg]\n 03:12 PM\n 05:23 PM\n 01:18 AM\n 02:28 AM\n 02:39 AM\n 06:09 AM\n 12:54 PM\n 02:55 PM\n 11:45 PM\n 12:00 AM\n WBC\n 13.0\n 10.1\n Hct\n 24.3\n 24.7\n Plt\n 153\n 112\n Creatinine\n 0.7\n 0.7\n TCO2\n 22\n 27\n 27\n 24\n 28\n 25\n Glucose\n 115\n 123\n 132\n 113\n 109\n 107\n Other labs: PT / PTT / INR:14.8/36.0/1.3, ALT / AST:18/32, Alk-Phos / T\n bili:37/1.2, Fibrinogen:52.5 mg/dL, Lactic Acid:1.6 mmol/L, LDH:269\n IU/L, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT), HYPERTENSION,\n BENIGN, ANEMIA, OTHER, .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION, CHRONIC\n OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE\n EXACERBATION, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Pain controlled\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS, wean FIO2\n pulmonary toilet\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet\n Renal: Foley\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:30 PM\n Cordis/Introducer - 01:31 PM\n 20 Gauge - 05:12 AM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status:\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2173-02-28 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656496,
"text": "CVICU\n HPI:\n 86M s/p repair of Asc. Aortic Aneurysm (28 mm dacron) AVR (tissue 21mm\n CE)/ circ arrest , chest closed \n Chief complaint:\n PMHx:\n 9cm asc. ao aneurysm, prostate ca (s/p external beam radiation ),\n GERD (?h/o esophageal stricture), h/o afib/flutter-s/p CV/ablations,\n diverticular disease, cholelithiasis, s/p appy, herniorraphy, empyema\n s/p R decortication @2yo, esophageal dilatation\n Current medications:\n atenolol 25', MVI', advil pm prn\n coumadin: 2/\n 24 Hour Events:\n TEMPORARY PACEMAKER WIRES DISCONTINUED - At 01:00 PM\n DRAIN REMOVED - At 01:00 PM\n CHEST TUBE REMOVED - At 01:00 PM\n Post operative day:\n POD \n s/p repair of Asc. Aortic Aneurysm (28 mm dacron) AVR (tissue 21mm\n CE)/ circ arrest , chest closed \n Allergies:\n Naproxen\n Diarrhea; Abdom\n Last dose of Antibiotics:\n Cefazolin - 05:53 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:30 AM\n Haloperidol (Haldol) - 11:30 AM\n Hydromorphone (Dilaudid) - 01:00 PM\n Hydralazine - 05:30 PM\n Other medications:\n Flowsheet Data as of 09:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 36.2\nC (97.2\n HR: 91 (77 - 108) bpm\n BP: 150/64(89) {123/55(74) - 742/75(103)} mmHg\n RR: 21 (18 - 32) insp/min\n SPO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 93.6 kg\n Height: 70 Inch\n Total In:\n 1,068 mL\n 50 mL\n PO:\n Tube feeding:\n IV Fluid:\n 718 mL\n 50 mL\n Blood products:\n 350 mL\n Total out:\n 2,910 mL\n 1,250 mL\n Urine:\n 2,540 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n 70 mL\n Balance:\n -1,842 mL\n -1,200 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 89%\n ABG: 7.51/30/55/22/1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: b bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 112 K/uL\n 9.2 g/dL\n 107 mg/dL\n 0.7 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 15 mg/dL\n 109 mEq/L\n 141 mEq/L\n 24.7 %\n 10.1 K/uL\n [image002.jpg]\n 03:12 PM\n 05:23 PM\n 01:18 AM\n 02:28 AM\n 02:39 AM\n 06:09 AM\n 12:54 PM\n 02:55 PM\n 11:45 PM\n 12:00 AM\n WBC\n 13.0\n 10.1\n Hct\n 24.3\n 24.7\n Plt\n 153\n 112\n Creatinine\n 0.7\n 0.7\n TCO2\n 22\n 27\n 27\n 24\n 28\n 25\n Glucose\n 115\n 123\n 132\n 113\n 109\n 107\n Other labs: PT / PTT / INR:14.8/36.0/1.3, ALT / AST:18/32, Alk-Phos / T\n bili:37/1.2, Fibrinogen:52.5 mg/dL, Lactic Acid:1.6 mmol/L, LDH:269\n IU/L, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT), HYPERTENSION,\n BENIGN, ANEMIA, OTHER, .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION, CHRONIC\n OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE\n EXACERBATION, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Pain controlled\n Cardiovascular: po amiodarone per EP\n v wires tested currently working per EP\n PPM possibly Tuesday\n Pulmonary: cont CPAP/PS\n try to extubate in AM\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal: Foley\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: EP dept\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:30 PM\n Cordis/Introducer - 01:31 PM\n 20 Gauge - 05:12 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments: hold coumadin for possible PPM placement Tuesday\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status:\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2173-02-28 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656497,
"text": "CVICU\n HPI:\n 86M s/p repair of Asc. Aortic Aneurysm (28 mm dacron) AVR (tissue 21mm\n CE)/ circ arrest , chest closed \n Chief complaint:\n PMHx:\n 9cm asc. ao aneurysm, prostate ca (s/p external beam radiation ),\n GERD (?h/o esophageal stricture), h/o afib/flutter-s/p CV/ablations,\n diverticular disease, cholelithiasis, s/p appy, herniorraphy, empyema\n s/p R decortication @2yo, esophageal dilatation\n Current medications:\n atenolol 25', MVI', advil pm prn\n coumadin: 2/\n 24 Hour Events:\n TEMPORARY PACEMAKER WIRES DISCONTINUED - At 01:00 PM\n DRAIN REMOVED - At 01:00 PM\n CHEST TUBE REMOVED - At 01:00 PM\n Post operative day:\n POD \n s/p repair of Asc. Aortic Aneurysm (28 mm dacron) AVR (tissue 21mm\n CE)/ circ arrest , chest closed \n Allergies:\n Naproxen\n Diarrhea; Abdom\n Last dose of Antibiotics:\n Cefazolin - 05:53 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:30 AM\n Haloperidol (Haldol) - 11:30 AM\n Hydromorphone (Dilaudid) - 01:00 PM\n Hydralazine - 05:30 PM\n Other medications:\n Flowsheet Data as of 09:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 36.2\nC (97.2\n HR: 91 (77 - 108) bpm\n BP: 150/64(89) {123/55(74) - 742/75(103)} mmHg\n RR: 21 (18 - 32) insp/min\n SPO2: 89%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 93.6 kg\n Height: 70 Inch\n Total In:\n 1,068 mL\n 50 mL\n PO:\n Tube feeding:\n IV Fluid:\n 718 mL\n 50 mL\n Blood products:\n 350 mL\n Total out:\n 2,910 mL\n 1,250 mL\n Urine:\n 2,540 mL\n 1,250 mL\n NG:\n Stool:\n Drains:\n 70 mL\n Balance:\n -1,842 mL\n -1,200 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 89%\n ABG: 7.51/30/55/22/1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: b bases), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 112 K/uL\n 9.2 g/dL\n 107 mg/dL\n 0.7 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 15 mg/dL\n 109 mEq/L\n 141 mEq/L\n 24.7 %\n 10.1 K/uL\n [image002.jpg]\n 03:12 PM\n 05:23 PM\n 01:18 AM\n 02:28 AM\n 02:39 AM\n 06:09 AM\n 12:54 PM\n 02:55 PM\n 11:45 PM\n 12:00 AM\n WBC\n 13.0\n 10.1\n Hct\n 24.3\n 24.7\n Plt\n 153\n 112\n Creatinine\n 0.7\n 0.7\n TCO2\n 22\n 27\n 27\n 24\n 28\n 25\n Glucose\n 115\n 123\n 132\n 113\n 109\n 107\n Other labs: PT / PTT / INR:14.8/36.0/1.3, ALT / AST:18/32, Alk-Phos / T\n bili:37/1.2, Fibrinogen:52.5 mg/dL, Lactic Acid:1.6 mmol/L, LDH:269\n IU/L, Ca:8.0 mg/dL, Mg:2.3 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT), HYPERTENSION,\n BENIGN, ANEMIA, OTHER, .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION, CHRONIC\n OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE\n EXACERBATION, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Pain controlled\n Cardiovascular: po amiodarone per EP\n v wires tested currently working per EP\n PPM possibly Tuesday\n Pulmonary: cont CPAP/PS\n try to extubate in AM\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal: Foley\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: EP dept\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:30 PM\n Cordis/Introducer - 01:31 PM\n 20 Gauge - 05:12 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments: hold coumadin for possible PPM placement Tuesday\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status:\n Disposition: ICU\n ------ Protected Section------\n Error in this note. Please disregard\n ------ Protected Section Error Entered By: , MD\n on: 09:39 ------\n"
},
{
"category": "Physician ",
"chartdate": "2173-02-28 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656499,
"text": "HPI:\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n Post operative day:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Respiratory support\n Physical Examination\n Labs / Radiology\n [image002.jpg]\n WBC\n Hct\n Plt\n Creatinine\n Troponin T\n TCO2\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\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 Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2173-03-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 656674,
"text": "66YO male POD4 CABG X 4 \n Off gtts, chest tubes out, wires out.\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt oriented to self and place in AM. Does not know DOB, has trouble\n focusing on questions being asked by staff\n Action:\n Speak slowly and talk about one issue at a time. Keep stimuli to a\n minimum in the room. Wife stays in the room all the time\n Response:\n Pt responds well to one on one interaction with RN. Consistency with\n staff helps. Wife to stay throughout day, pt responds well to her when\n he get worked up and aggravated with staff.\n Plan:\n Transfer to 6 private room\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reports back pain when back in bed.\n Action:\n Given 2mg Dilaudid PO, repositioned back to chair, back rub\n Response:\n Reports improvement with back pain\n Plan:\n Assess pain level and ask specific questions regarding pain and types.\n Does better answering specific questions.\n Foley out at 1000. voided ~150cc @ 1330.\n Introducer out this AM, 20gauge IV in left hand.\n Chair pad ordered and used for pt. prefers to be in chair.\n Walked in AM around unit with RN and wife. PT came as well\n to evaluate, and got pt to chair\n No appetite today, ate small amount of fruit in AM\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Height:\n 70 Inch\n Admission weight:\n 93.6 kg\n Daily weight:\n 97 kg\n Allergies/Reactions:\n Naproxen\n Diarrhea; Abdom\n Precautions:\n PMH:\n CV-PMH:\n Additional history: htn,dyslipidemia,alzheimer's, severe osa-has\n refused cpap in the past,mod-severe copd-s/p spont. ptx in the\n past,gout,depression,known cad-s/p silent mi->stents. cath->mvd,ef\n 55-60%, + mr.\n Surgery / Procedure and date: c x 4 lima->lad,vg->om1,2,diag.\n uneventful o.r. post tee->preserved bivent. fcn,mr +\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:145\n D:70\n Temperature:\n 97.2\n Arterial BP:\n S:136\n D:73\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 86 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 170 mL\n 24h total out:\n 2,275 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 12:01 AM\n Potassium:\n 3.9 mEq/L\n 09:29 AM\n Chloride:\n 112 mEq/L\n 12:01 AM\n CO2:\n 21 mEq/L\n 12:01 AM\n BUN:\n 20 mg/dL\n 12:01 AM\n Creatinine:\n 0.8 mg/dL\n 12:01 AM\n Glucose:\n 96 mg/dL\n 09:29 AM\n Hematocrit:\n 29.8 %\n 12:01 AM\n Finger Stick Glucose:\n 117\n 03:40 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables: bag of clothing. service respomce called/\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash Amount: none\n Credit Cards: n one\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: \n Transferred to: 6\n Date & time of Transfer: \n 17:00\n"
},
{
"category": "Nursing",
"chartdate": "2173-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656224,
"text": "66yo Male same-day admit for CABG x 4 (lima->lad, svg->om1,2,diag).\n Uneventful o.r. post tee->preserved bivent. Function,,mr +.\n Pt initially hypotensive from OR. Neo gtt infusing, then titrated off\n shortly thereafter. Volume resuscitated patient with LR (see\n Metavision for details). Filling pressures showed good response to\n volume. Hemodynamically stable. Pt\ns pO2 remains low relative to\n level of FiO2. Titrated down FiO2 to 60% and increase in PEEP with\n marginal PO2 on ABG.\n Pt auto-diuresed well. Chest tube output with sanguineous to\n serosanguineous drainage WNL. HCT remained stable throughout shift\n despite the large volume of IVF infused.\n Family updated via phone.\n"
},
{
"category": "Physician ",
"chartdate": "2173-02-26 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656316,
"text": "CVICU\n HPI:\n POD 1\n 66M s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n EF: 55% Wt.: 97.9 kg Cr.: 0.8\n PMHx: HTN, ^lipids, CAD-s/p stent L-PDA and OM, mid LCX , MR,\n venous insufficiency, GERD, pseudogout R knee, Alzheimer's, Arthritis,\n OSA, polio, hyperuricemia, s/p MIs\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen, Albuterol-Ipratropium , Albuterol Inhaler , Aspirin EC\n , Calcium Gluconate , CefazoLIN , Dextrose 50% , Docusate Sodium ,\n Furosemide , HYDROmorphone (Dilaudid) , Insulin , Magnesium Sulfate\n ,Metoclopramide , Metoprolol Tartrate, Milk of Magnesia , Morphine\n Sulfate , Nitroglycerin, Oxycodone-Acetaminophen , Phenylephrine ,\n Potassium Chloride , Ranitidine , Sodium Chloride 0.9% Flush\n 24 Hour Events:\n NASAL SWAB - At 12:53 PM\n OR RECEIVED - At 12:53 PM\n INVASIVE VENTILATION - START 12:53 PM\n ARTERIAL LINE - START 01:30 PM\n CCO PAC - START 01:31 PM\n CORDIS/INTRODUCER - START 01:31 PM\n EKG - At 02:37 PM\n Post operative day:\n POD 1 CABG\n Allergies:\n Naproxen\n Diarrhea; Abdom\n Last dose of Antibiotics:\n Cefazolin - 09:54 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 05:33 PM\n Insulin - Regular - 06:05 PM\n Morphine Sulfate - 09:00 AM\n Other medications:\n Flowsheet Data as of 03:34 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 101.1 ( )\n T current: 100.8 ( )\n HR: 95 (74 - 95) bpm\n BP: 163/70(96) {86/53(63) - 163/76(97)} mmHg\n RR: 23 (9 - 26) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 93.6 kg\n Height: 70 Inch\n CVP: 4 (3 - 21) mmHg\n PAP: (34 mmHg) / (14 mmHg)\n CO/CI (Fick): (5.4 L/min) / (2.6 L/min/m2)\n CO/CI (CCO): (6.6 L/min) / (3.1 L/min/m2)\n SvO2: 60%\n Mixed Venous O2% sat: 58 - 65\n Total In:\n 6,776 mL\n 741 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,716 mL\n 741 mL\n Blood products:\n Total out:\n 2,606 mL\n 1,260 mL\n Urine:\n 2,155 mL\n 855 mL\n NG:\n Stool:\n Drains:\n 20 mL\n 15 mL\n Balance:\n 4,170 mL\n -519 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 708 (584 - 721) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%, No Spon Resp\n PIP: 15 cmH2O\n Plateau: 14 cmH2O\n Compliance: 108.3 cmH2O/mL\n SPO2: 94%\n ABG: 7.38/40/66/25/0\n Ve: 9 L/min\n PaO2 / FiO2: 132\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\n Pt.'s baseline MS is A+Ox2. Does not follow commands at this point.\n Labs / Radiology\n 184 K/uL\n 10.4 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 10 mg/dL\n 110 mEq/L\n 140 mEq/L\n 28.4 %\n 12.6 K/uL\n [image002.jpg]\n 02:14 AM\n 03:00 AM\n 04:17 AM\n 06:02 AM\n 07:00 AM\n 08:00 AM\n 09:27 AM\n 10:00 AM\n 11:08 AM\n 12:59 PM\n TCO2\n 26\n 26\n 26\n 25\n 25\n Glucose\n 104\n 118\n 107\n 98\n 123\n 128\n 107\n 121\n 106\n 107\n Other labs: PT / PTT / INR:18.8/56.4/1.7, Fibrinogen:52.5 mg/dL, Lactic\n Acid:3.0 mmol/L, Mg:2.0 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR; sm bilat. effusions\n Microbiology: all neg\n Assessment and Plan\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT), HYPOTENSION (NOT\n SHOCK), CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION, CORONARY ARTERY DISEASE (CAD,\n ISCHEMIC HEART DISEASE), .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan: Pt. doing fairly well post op. Extubated this AM,\n extremely confused. Needs aggressive pulm. rx. Has +air leak in CT.\n Lopressor and Lasix started.\n Neurologic: Neuro checks Q: 1 hr\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS, Extubate today\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley\n Hematology:\n Endocrine: RISS\n Infectious Disease: all neg\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:30 PM\n Cordis/Introducer - 01:31 PM\n 16 Gauge - 01:33 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 ------ Protected Section ------\n Agree with above note by .\n ------ Protected Section Addendum Entered By: , MD\n on: 17:32 ------\n"
},
{
"category": "Nursing",
"chartdate": "2173-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656222,
"text": "66yo Male same-day admit for CABG x 4 (lima->lad, svg->om1,2,diag).\n Uneventful o.r. post tee->preserved bivent. Function,,mr +.\n Pt initially hypotensive from OR. Neo gtt infusing, then titrated off\n shortly thereafter. Volume resuscitated patient with LR (see\n Metavision for details). Filling pressures showed good response to\n volume, but SvO2 and CO/CI decreased. Pt\ns pO2 low with high levels\n of FiO2. Titrated down FiO2 to 70% with marginal PO2 on ABG.\n Pt auto-diuresed well. Chest tube output with sanguineous to\n serosanguineous drainage WNL. HCT remained stable throughout shift\n despite the large volume of IVF infused.\n"
},
{
"category": "Nursing",
"chartdate": "2173-02-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656223,
"text": "66yo Male same-day admit for CABG x 4 (lima->lad, svg->om1,2,diag).\n Uneventful o.r. post tee->preserved bivent. Function,,mr +.\n Pt initially hypotensive from OR. Neo gtt infusing, then titrated off\n shortly thereafter. Volume resuscitated patient with LR (see\n Metavision for details). Filling pressures showed good response to\n volume, but SvO2 and CO/CI decreased. Pt\ns pO2 remains low relative\n to level of FiO2. Titrated down FiO2 to 70% with marginal PO2 on ABG.\n Pt auto-diuresed well. Chest tube output with sanguineous to\n serosanguineous drainage WNL. HCT remained stable throughout shift\n despite the large volume of IVF infused.\n"
},
{
"category": "Nursing",
"chartdate": "2173-02-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656417,
"text": "66y/o M with significant history of 5yr dementia Alzheimer\ns type and\n COPD with OSA. CABGx4 uneventful on . POD#2.\n Alert and confused. Restless,agitated and combative at times.\n Deescalated using reassurances, family presence and PRN Haldol 1-2.5mg\n IV. MAE\ns with good ROM. Afebrile this shift. LSC with dim bases\n bilaterally throughout shift. Requiring frequent reminders about CDB;\n but limited attempts made due to dementia and agitation. SAT O2 85-90on\n 10L HF NC. ABG PO 55- . 60\ns.ST 90-110 this shift. ABP\n 130-160mmHg with Lopressor IV, Hydralazine PRN . Captopril PO,\n Lopressor PO increased to 50mg. NTG off this afternoon. Palpable PP\n bilaterally. CT\ns, wires and L-groin JP D/C\nd per PA at 1300hr.\n CXR OK. Good diuresis with Lasix 40mg TID as of today; Diamox started\n as well. U/O 50cc/hr otherwise. C/O Incisional pain unable to rate,\n following grimace and change in vitals scale. IV dilaudid PRN with good\n analgesic response. Family in this afternoon, pt visibly more\n comfortable and less agitated. Spouse and children providing positive\n reassurances and participating with nursing care. HCT 24\n1Unit PRBC\n this AM, recheck HCT on .\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Restless,agitated and combative at times\n Action:\n Deescalated using reassurances, family presence and PRN Haldol 1-2.5mg\n IV.\n Response:\n pt visibly more comfortable and less agitated\n Plan:\n Continue providing decreased stimuli environment, frequent reassurances\n and monitoring\n Hypertension, benign\n Assessment:\n ABP 130-160mmHg. Higher numbers with agitation\n Action:\n Lopressor IV, Hydralazine PRN . Captopril PO, Lopressor PO increased\n to 50mg. NTG off this afternoon.\n Response:\n Good response SBP 120\n Plan:\n Continue monitoring\n Anemia, other\n Assessment:\n HCT 24\n Action:\n PRBC\ns x1 this AM\n Response:\n No HCT check per PA\n Plan:\n Recheck am HCT\n Pain control (acute pain, chronic pain)\n Assessment:\n C/O Incisional pain unable to rate, following grimace and change in\n vitals scale\n Action:\n IV dilaudid PRN\n Response:\n good analgesic response. Pt appears calm and is able to rest\n Plan:\n Continue monitoring for pain and document pain intervention accordingly\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n SAT O2 85-90on 10L HF NC\n Action:\n Requiring frequent reminders about CDB; but limited attempts made due\n to dementia and agitation\n Response:\n Improved O2 sats when pt settled, calm and family presence\n Plan:\n Continue encouraging CDB. Continue to monitor Oxygenation and signs of\n respiratory distress.\n"
},
{
"category": "Physician ",
"chartdate": "2173-02-26 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 656302,
"text": "CVICU\n HPI:\n POD 1\n 66M s/p CABGx4(LIMA->LAD, Diag, OM1, OM2) \n EF: 55% Wt.: 97.9 kg Cr.: 0.8\n PMHx: HTN, ^lipids, CAD-s/p stent L-PDA and OM, mid LCX , MR,\n venous insufficiency, GERD, pseudogout R knee, Alzheimer's, Arthritis,\n OSA, polio, hyperuricemia, s/p MIs\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen, Albuterol-Ipratropium , Albuterol Inhaler , Aspirin EC\n , Calcium Gluconate , CefazoLIN , Dextrose 50% , Docusate Sodium ,\n Furosemide , HYDROmorphone (Dilaudid) , Insulin , Magnesium Sulfate\n ,Metoclopramide , Metoprolol Tartrate, Milk of Magnesia , Morphine\n Sulfate , Nitroglycerin, Oxycodone-Acetaminophen , Phenylephrine ,\n Potassium Chloride , Ranitidine , Sodium Chloride 0.9% Flush\n 24 Hour Events:\n NASAL SWAB - At 12:53 PM\n OR RECEIVED - At 12:53 PM\n INVASIVE VENTILATION - START 12:53 PM\n ARTERIAL LINE - START 01:30 PM\n CCO PAC - START 01:31 PM\n CORDIS/INTRODUCER - START 01:31 PM\n EKG - At 02:37 PM\n Post operative day:\n POD 1 CABG\n Allergies:\n Naproxen\n Diarrhea; Abdom\n Last dose of Antibiotics:\n Cefazolin - 09:54 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Ranitidine (Prophylaxis) - 05:33 PM\n Insulin - Regular - 06:05 PM\n Morphine Sulfate - 09:00 AM\n Other medications:\n Flowsheet Data as of 03:34 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 101.1 ( )\n T current: 100.8 ( )\n HR: 95 (74 - 95) bpm\n BP: 163/70(96) {86/53(63) - 163/76(97)} mmHg\n RR: 23 (9 - 26) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97 kg (admission): 93.6 kg\n Height: 70 Inch\n CVP: 4 (3 - 21) mmHg\n PAP: (34 mmHg) / (14 mmHg)\n CO/CI (Fick): (5.4 L/min) / (2.6 L/min/m2)\n CO/CI (CCO): (6.6 L/min) / (3.1 L/min/m2)\n SvO2: 60%\n Mixed Venous O2% sat: 58 - 65\n Total In:\n 6,776 mL\n 741 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,716 mL\n 741 mL\n Blood products:\n Total out:\n 2,606 mL\n 1,260 mL\n Urine:\n 2,155 mL\n 855 mL\n NG:\n Stool:\n Drains:\n 20 mL\n 15 mL\n Balance:\n 4,170 mL\n -519 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 708 (584 - 721) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%, No Spon Resp\n PIP: 15 cmH2O\n Plateau: 14 cmH2O\n Compliance: 108.3 cmH2O/mL\n SPO2: 94%\n ABG: 7.38/40/66/25/0\n Ve: 9 L/min\n PaO2 / FiO2: 132\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), Moves all extremities,\n Pt.'s baseline MS is A+Ox2. Does not follow commands at this point.\n Labs / Radiology\n 184 K/uL\n 10.4 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 10 mg/dL\n 110 mEq/L\n 140 mEq/L\n 28.4 %\n 12.6 K/uL\n [image002.jpg]\n 02:14 AM\n 03:00 AM\n 04:17 AM\n 06:02 AM\n 07:00 AM\n 08:00 AM\n 09:27 AM\n 10:00 AM\n 11:08 AM\n 12:59 PM\n TCO2\n 26\n 26\n 26\n 25\n 25\n Glucose\n 104\n 118\n 107\n 98\n 123\n 128\n 107\n 121\n 106\n 107\n Other labs: PT / PTT / INR:18.8/56.4/1.7, Fibrinogen:52.5 mg/dL, Lactic\n Acid:3.0 mmol/L, Mg:2.0 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR; sm bilat. effusions\n Microbiology: all neg\n Assessment and Plan\n .H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT), HYPOTENSION (NOT\n SHOCK), CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION, CORONARY ARTERY DISEASE (CAD,\n ISCHEMIC HEART DISEASE), .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE\n (COPD, BRONCHITIS, EMPHYSEMA) WITH ACUTE EXACERBATION\n Assessment and Plan: Pt. doing fairly well post op. Extubated this AM,\n extremely confused. Needs aggressive pulm. rx. Has +air leak in CT.\n Lopressor and Lasix started.\n Neurologic: Neuro checks Q: 1 hr\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS, Extubate today\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley\n Hematology:\n Endocrine: RISS\n Infectious Disease: all neg\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:30 PM\n Cordis/Introducer - 01:31 PM\n 16 Gauge - 01:33 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"
},
{
"category": "Nursing",
"chartdate": "2173-02-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 656323,
"text": ".H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt with history of dementia, alert and oriented x 2 at baseline.\n Unable to follow command on low dose propofol, but very agitated off\n propofol. Medicated with morphine for agitation with good effect.\n Action:\n Pt extubated per protocol. Oriented to person only. C/o pain after\n extubation. PA notified and pain meds changed to dilaudid\n po/iv. OOB to chair with chair alarm in place.\n Response:\n Pt slept in chair and pain level improved. Family at bedside.\n Plan:\n Monitor mental status, provide adequate pain relief. Provide\n reassurance and reorientation as needed.\n Hypotension (not Shock)\n Assessment:\n On arrival pt on neosynephrine gtt at 1 mcg/kg/min and propofol gtt at\n 40 mcg/kg/min.\n Action:\n Neosynephrine gtt weaned per protocol.\n Response:\n Pt SBP remains > 90, MAP > 60. Lopressor po started.\n Plan:\n Monitor SBP and continue with po lopressor.\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n Pt orally intubated on full mechanical ventilation. PO2 on ABG 70\n Action:\n Pt weaned to CPAP and extubated per protocol. OOB to chair, tolerating\n well. Cough and deep breathing encouraged, pt with some difficulty\n comprehending.\n Response:\n O2 sat 93-95% on 6l nc when oob to chair. Lungs clear, diminished.\n Plan:\n Monitor respiratory status and pulmonary toilet as tolerates.\n Pt with episode of hypertension r/t agitation. Medicated with haldol\n iv for agitation and lopressor and hydralazine for bp control. Family\n at bedside. Oral antihypertensive and anxiety meds ordered,\n unable to take po meds at this time. Goal SBp < 150. Appears more\n comfortable with periods of sleeping. Will monitor and provide safe\n environment.\n Lactic acid rising to 4.1, LFTs sent and PA aware Will recheck\n levels throughout evening.\n"
}
] |
32,034 | 176,981 | On HD 1 () the pt was admitted with the history and exam as above. He was s/p fiberoptic intubation at the OSH for airway protection after he was found to have multiple thyroid cartilage fractures. The otolaryngology service was consulted, and the pt underwent operative fixation of the fractures on HD2. The pt tolerated the procedure well, and returned intubated to the trauma icu post-operatively. On HD3 the pt remained intubated due to airway edema and R sided laryngeal hematoma s/p his ORIF. The pt also had a post-op fever to 102.2, the fever evaluation was negative, and the temperature trended down over 24 hours to normal. On (HD 4), the pt had a good cuff leak and was extubated with no complications. The drain in his neck was also pulled by the ENT service on HD 4. On HD 5 the pt remained stable without airway concerns or stridor and was sent to the floor from the ICU. On HD 6, meeting all goals prior to d/c, the patient was discharged in good condition. | intact, given ativan and diludid prior to extubation for pain/anxiety. Pt fiberoptically intubated and transferred to . LS clear bilaterally throughout.GI: abd soft. Pt remains full code and on universal precautions.ROS:RESP: R nare intubation, pt on CPAP & PS, peep 5, PS 3, FiO2 30%, SpO2 95-100%, RR 13-18. Foley patent, draining adequate amts of c/y/u- uop 80-450cc/hr. SC heparin & venodynes for DVT prophylaxis.NEURO: Alert & cooperative. given Dilaudid and Ativan PRN. remains nasally intubated, positive cuff leak. LS clear with diminished bases esp to LLL. Receiving prn ativan & dilaudid for anxiety and comfort while nasal ett remains in place. LS clear bilat, diminished in lower lobes, CXR complete today. HR 84-130, NIBP 120/63-137/79, Tmax 102.2. Propofol gtt.Cardio: NSR-sinus tach. Ween propofol as tolerated. NOETT SECURE AND PATENT. Nursing NoteSee FlowsheetNeuro: Propofol d'cd today. sent on ,Tylenol given PRN.Resp: Pt. status, encourage IS, CDB, ambulation? Pt remains hemodynamically stable.ROS:RESP: Pt remains on CPAP+ PS, peep 5, PS 3, FiO2 30%. place OGT if pt cont to remain intubated. Hct stable. VAP care performed per protocol.CVS: NSR to ST, no ectopy noted. Na 141, K 3.8, BUn 18, creatinine 0.8, Ca 9.3, Mg 1.8, Phos 3.0. H2B for GI prophylaxis. HR 80-100s, SBP 110-130s, Tmax 100.2. adequate u/o Qhr this shift.IV: LR @100. IVF KVO'd. Plan to extubate today.CVS: NSR to ST, no ectopy noted. Bld cultures sent and pnding, tylenol PR given. CDB, IS encouraged.GI/GU: pt. Plan to have foley placed by anesthesia while pt is in OR. Vent settings are as followed- CPAP + PS, PS 3, peep 5, FiO2 30%, RR 13-21, SpO2 93-100%, RSBI 50 this am. IMPRESSION: Persistent left hilar opacity which again could represent atelectasis or aspiration. Bld cultures pnding. extubated, JP drain pulled todayNeuro: Pt. c/o heartburn this am, Pepcid given. Pt c/o continual ha and neck tenderness, receiving prn ativan and dilaudid ivp for light sedation & adequate pain control.GI/GU: Abd soft, NT, ND, + BS, no BM, remains NPO, FS wnl, no insulin required per RISS. VT 400'S AND RR 118-20. + productive cough noted. + productive cough noted. + productive cough noted. Penrose drain in place, draining scant to small amt of sanguinous output. BBS clear. LS clear bilaterally. LS clear bilaterally. CHEST, AP: Cardiac, mediastinal, and hilar contours are stable. C/O nausea, Zofran given.CV: HR 80-100's, BP WNL, afebrile today, blood cultures pending.Resp: Pt. Sagittal and coronal reformatted images were then obtained. Neuro exam intact. Pt moves all extremities and follows commands appropriately.GI: Abd soft, NT, hypoactive BS, currently NPO in preparation for OR procedure today. BUN 8, creatinine 0.9, Na 140, K 4.0, Ca 8.8, Phos 3.8, and Mg 2. CT revealing swelling around airway with only ETT visible. The mediastinal contours are within normal limits. RESP CARE NOTEPT REMAINED ON PSV 3/5/30% WITH A
TC ON. HR 88-115, NIBP 120-150/65-85, pt spiked temp to 102.5. place OGT & start TF if pt remains intubated, begin SC heparin this am, request bowel regimen, cont to provide pt and family with emotional support. Venodynes for DVT prophylaxis.NEURO: Pt mouths words and able to write out requests to make needs known. Hct 42.9, WBC 12.3, INR 1.1. wakens to voice, follows all commands, mouths and writes.CV: HR 80-100, BP WNL, T-max 101.3 today. Nursing NoteSee FlowsheetSignificant Events: Pt. Pt back at 0830- intubated. EXTUBATION. LS clear in upper lobes, coarse in lower lobes bilat. alcohol withdrawl symptoms, pt follows all commands, MAE's, does not demonstrate any neurolicial dysfunction at this present time.CV: St to NSR with minimal ectopy noted, adequate blp with MAP's > 60 mmHg, palp pedal pulses, warm extremities, SC heprin, pneumoboots at rest, 20 g PIV for access, afebrile.Resp: Weaned cool aerosol Fio2 to 35% this shift, remains on humidified oxygen to keep oropharynx mosit while pt is NPO, moderate cough with the ability to expectorate thick white sputum, remains coarse to auscultate lung lobes, oxygen saturations in mid to high 90's, shallow resp volumes with rest, clears incentive spirometer, independent cough and deep breathing with reinforcement.GI: NPO, soft abdomen with active bowel sounds, ordered to ice chips as tol, c/c nausea in earlier shifts after hydromorphone administration.GU: Foley remains, plan to d/c by morning, am labd drawn, will repleat lytes as ordered.Endo: RISS with coverage provided.Skin: C/D/I.MS: Independent bed mobility.Plan: Prepare for transfer to floor when able, wean supplemental o2 requirements, pain and anxiety mgmt, monitor and assess as ordered. Await CT results. revealing gram positive cocci. Start SC heparin this am, venodynes for DVT prophylaxis.NEURO: Pt sedated on 60 mcg/kg/min of propofol for comfort while NT tube remains in place. The visualized portion of the lung apices appear normal. Pt and family told about procedures and plan of care.Plan: Ween vent as tolerated. Resp CarePt remains on vent. Mild mucosal thickening of both maxillary sinuses and ethmoid sinuses are noted. Blood cx. Suctioned for mod amt of white secretions. DR. Pt. Pt. Pt. Pt. Pt. Pt. received one dose Dilaudid 1 mg post extubation. wean off ventilator, hemodynamics & I/Os, bld cultures pnding, have anesthesia place additional IV access & foley, plan for fixation of thyroid cardiladge fx at 0600 by ENT, cont to assess pts level of comfort, replete lytes as necessary, cont to provide pt and family with emotional support. Bulb drain in neck draining small amount of sanguinous fluid.GI/GU: NPO, abd. having nausea after Dilaudid, Zofran, Reglan and Haldol given per HO. BREATH SOUNDS ESSSENT CLE EAR. Nursing Progress Note, 1900-0730Please refer to careview for specifics.No significant events noted this shift.ROS:RESP: Nasal tracheal intubation, remains on vent for resp support while pt remains lightly sedated on propofol. PIV x1. SBP- 100-150 DBP-60-90's. LR @ 100cc/hr.INTEG: Two incisions to medial/R side of neck- pt s/p fixation of thyroid cartiladge fx. Pt a+ox3, appropriate affect, pleasant. continues with moderate amount of thick yellow secretions, sputum sent for cx. | 15 | [
{
"category": "Radiology",
"chartdate": "2187-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1004390,
"text": " 10:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: NECK HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man with fevers s/p thyroid carti repair (fractured after hockey\n stick injury), extubated today\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 36-year-old man with fever status post thyroid cartilage repair.\n\n COMPARISON: .\n\n CHEST, AP: Cardiac, mediastinal, and hilar contours are stable. The opacity\n overlying the left hilus is more prominent on today's exam which could be\n secondary to extubation and lower lung volumes on this exam. No other\n opacities are identified. There are no pleural effusions. Osseous and soft\n tissue structures are unremarkable.\n\n IMPRESSION: Persistent left hilar opacity which again could represent\n atelectasis or aspiration. Continued followup is recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-01-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1004219,
"text": " 12:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n Admitting Diagnosis: NECK HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man with intubated s/p thyroid sx\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Intubated patient S/P thyroid surgery.\n\n Comparison is made with prior study .\n\n ET tube remains in standard position. New opacity in the left perihilar\n region could be due to atelectasis or aspiration in the superior segment of\n the left lower lobe; otherwise the lungs are clear. There is no pneumothorax\n or sizeable pleural effusion. Cardiac size is normal.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2187-01-29 00:00:00.000",
"description": "TRAUMA #3 (PORT CHEST ONLY)",
"row_id": 1003887,
"text": " 9:13 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: ?Aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man with Thyroid Cartilage Hematoma\n REASON FOR THIS EXAMINATION:\n ?Aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Thyroid cartilage hematoma. Question aspiration.\n\n FINDINGS: AP bedside upright portable chest radiograph is reviewed without\n comparison and demonstrate thin-caliber endotracheal tube terminating only 2.8\n cm above the carina. The mediastinal contours are within normal limits. The\n heart is normal size. The pulmonary vasculature is normal, allowing for low\n lung volumes. The lungs are grossly clear.\n\n IMPRESSION: Low-lying ETT, terminating 2.8 cm above the carina. ETT can be\n partially withdrawn for more optimal placement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-01-30 00:00:00.000",
"description": "CT NECK W/CONTRAST (EG:PAROTIDS)",
"row_id": 1004036,
"text": " 2:32 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: thyroid cartilage injury f/u\n Admitting Diagnosis: NECK HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man with fracture thyroid cartilage\n REASON FOR THIS EXAMINATION:\n thyroid cartilage injury f/u\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Thyroid cartilage injury followup in a 36-year-old male.\n\n No comparisons available.\n\n TECHNIQUE: Axial MDCT images were obtained from thoracic inlet to skull base\n after administration of Optiray intravenously. No oral contrast was used.\n Sagittal and coronal reformatted images were then obtained.\n\n FINDINGS: The patient is status post plate and screw placement of the right\n side of thyroid cartilage. Two discontinuities are noted within the right\n side of the thyroid cartilage, one anteriorly and one posteriorly. The\n posterior contour of the thyroid cartilage is mildly protruding medially. No\n definite pneumomediastinum or subcutaneous emphysema is noted. Penrose\n drainage tube is overlying the thyroid cartilage. The patient is status post\n - tracheal intubation with the tip of tracheal tube in proper position.\n\n The soft tissue windows demonstrate multiple non-pathologically enlarged lymph\n nodes within the neck stations. Mild mucosal thickening of both maxillary\n sinuses and ethmoid sinuses are noted. The mastoid air cells are clear.\n\n BONE WINDOWS: No concerning lytic or sclerotic lesion is identified. The\n visualized portion of the lung apices appear normal.\n\n IMPRESSION: Status post placement of lateral plate and screws over the\n anterior and posterior fracture of the right thyroid cartilage, with no\n complication including no pneumomediastinum or subcutaneous emphysema.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-01-31 00:00:00.000",
"description": "Report",
"row_id": 1668696,
"text": "Nursing Note\nSee Flowsheet\n\nNeuro: Propofol d'cd today. Pt. given Dilaudid and Ativan PRN. Pt. having nausea after Dilaudid, Zofran, Reglan and Haldol given per HO. Pt. wakens to voice, follows all commands, mouths and writes.\n\nCV: HR 80-100, BP WNL, T-max 101.3 today. Blood cx. sent on ,Tylenol given PRN.\n\nResp: Pt. remains nasally intubated, positive cuff leak. CT revealing swelling around airway with only ETT visible. Pt. continues with moderate amount of thick yellow secretions, sputum sent for cx. on . LS clear bilat, diminished in lower lobes, CXR complete today. Bulb drain in neck draining small amount of sanguinous fluid.\n\nGI/GU: NPO, abd. benign, pt. c/o heartburn this am, Pepcid given. Foley continues to drain adequate amount of clear yellow urine. IVF KVO, Lasix 20mg given.\n\nEndo: Insulin given per RISS.\n\nSocial: Family in to visit this afternoon, appropriately concerned and worried, updated to plan of care.\n\nPlan:\n Decrease swelling: fluid balance (slightly negative),maintain HOB 45 degrees\n?Possible extubation\nPt. and family support\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-01-31 00:00:00.000",
"description": "Report",
"row_id": 1668697,
"text": "Respiratory Care\nPatient remains nasally intubated and on mechanical ventilatory support, breath sounds bilaterally diminished, suctioned intermittently for moderate amounts of thick yellow secretions, follow commands, no ABGs done nor vent changed made, spiked a fever, sputum sample sent to lab yesterday still pending, still has some swelling in the oropharynx, will continue to be followed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-02-01 00:00:00.000",
"description": "Report",
"row_id": 1668698,
"text": "Resp Care\nPt remains on vent. Suctioned for mod amt of white secretions. No changes made. Rsbi 32. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-02-01 00:00:00.000",
"description": "Report",
"row_id": 1668699,
"text": "Nursing Progress Note, 1900-0730\nPlease refer to careview for details.\n\nNo significant events this shift. Pt remains hemodynamically stable.\n\nROS:\n\nRESP: Pt remains on CPAP+ PS, peep 5, PS 3, FiO2 30%. LS clear with diminished bases esp to LLL. Sxned for thick yellow secretions. + productive cough noted. Sputum culture sent yesterday results pnding. Plan to extubate today.\n\nCVS: NSR to ST, no ectopy noted. HR 80-100s, SBP 110-130s, Tmax 100.2. Bld cultures pnding. Hct stable. PIV x2 for access. SC heparin & venodynes for DVT prophylaxis.\n\nNEURO: Alert & cooperative. Slept comfortably majority of night. Neuro exam intact. Pt c/o continual ha and neck tenderness, receiving prn ativan and dilaudid ivp for light sedation & adequate pain control.\n\nGI/GU: Abd soft, NT, ND, + BS, no BM, remains NPO, FS wnl, no insulin required per RISS. Foley patent, draining adequate amts of amber clear urine. IVF KVO'd. K repleted with 10 mEq KCL.\n\nSOCIAL: Family and friends into visit last night, updated as to POC and status. Father and mother will call in am for update.\n\nPOC: Plan to extubate if cuff leak present and swelling to neck has decreased, hemodynamics, f/u with pnding bld/urine/sputum cultures, temperature, cont pain mgmt, start bowel regimen, ? start form of diet/nutrition depending on if pt is extubated, cont to provide family and pt with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-01-30 00:00:00.000",
"description": "Report",
"row_id": 1668691,
"text": "Admission & Nursing Progress Note, 1900-0730\n36 y.o.m. s/p injury to neck via hockey stick 2 days ago. Pt presented to yesterday with c/o neck discomfort and swelling, CT scan revealed thyroid cartiladge fx w/ a hematoma and partial airway compromise. Pt fiberoptically intubated and transferred to . Pt currently being followed by ENT & is scheduled for fixation of thyroid fx today at 0600. Pt does not have a significant PMH, surgeries include R knee surgery. Denies med allergies. Pt remains full code and on universal precautions.\n\nROS:\n\nRESP: R nare intubation, pt on CPAP & PS, peep 5, PS 3, FiO2 30%, SpO2 95-100%, RR 13-18. LS clear bilaterally. + productive cough noted. Pt sats well off vent with face tent, however Dr. adamant that pt remains on ventilator for further resp support.\n\nCVS: NSR to ST, no ectopy noted. HR 84-130, NIBP 120/63-137/79, Tmax 102.2. Bld cultures sent and pnding, tylenol PR given. Hct 42.9, WBC 12.3, INR 1.1. PIV x1. + pedal pulses. Cap refill <3 sec. Venodynes for DVT prophylaxis.\n\nNEURO: Pt mouths words and able to write out requests to make needs known. Pt a+ox3, appropriate affect, pleasant. Receiving prn ativan & dilaudid for anxiety and comfort while nasal ett remains in place. Pt moves all extremities and follows commands appropriately.\n\nGI: Abd soft, NT, hypoactive BS, currently NPO in preparation for OR procedure today. FS 110, no insulin required per RISS.\n\nGU: Voided 50cc after pt arrived to ICU, otherwise pt denies having urge to urinate. Plan to have foley placed by anesthesia while pt is in OR. LR at 100cc/hr for IVF. Na 141, K 3.8, BUn 18, creatinine 0.8, Ca 9.3, Mg 1.8, Phos 3.0. Mg and K repleted as ordered.\n\nSOCIAL: Father into visit with pt last night and returned this am at 0500 to be with pt before he goes to OR.\n\nPOC: Wean vent settings as appropriate, ? wean off ventilator, hemodynamics & I/Os, bld cultures pnding, have anesthesia place additional IV access & foley, plan for fixation of thyroid cardiladge fx at 0600 by ENT, cont to assess pts level of comfort, replete lytes as necessary, cont to provide pt and family with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-01-30 00:00:00.000",
"description": "Report",
"row_id": 1668692,
"text": "Respiratory Care: Pt remains nasally intubated on CPAP+PS 3/5 30% ATC 3%, tolerated well overnight. BBS clear. Plan to go to OR for repair of thyroid cartilage and possible extubation in OR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-01-30 00:00:00.000",
"description": "Report",
"row_id": 1668693,
"text": "nursing 0700- present\nEvents: Pt to OR for repair of thyroid fracture- screws and plates placed and JP drain. Pt back at 0830- intubated. Tried to ween throughout the day to CPAP +PS but unable to due to pt having apneic periods. Pt on CMV. Down to CT to reassess hematoma on right side of thyroid- results pending.\n\nSkin: Pt has incision to Medial/Right side of neck uta incision due to post op dressing still in place. No drainage noted. JP drain in place- only drained 20cc of sanguinous this shift.\n\nNeuro: Pt Mouths words and can nod yes or no when asked questions. Pt can write some words on piece of paper. Follows commands and MAE's independently. Propofol gtt.\n\nCardio: NSR-sinus tach. HR- 70-100's. SBP- 100-150 DBP-60-90's. P boots. heparin SC to be started tomorrow am. LR @100 propofol @50mcg/kg/min\n\nResp: Pt intubation- Right nare #7.0. Pt unable to be weened to CPAP and on CMV FiO2-30%- 50%, Peep of 5,RR 16 TV 500 Sats- 96-100%. Pt suctioned for scant tan-moderate thick yellow sputum. LS clear bilaterally throughout.\n\nGI: abd soft. +BS in all 4 quadrants. NPO.\n\nEndo: RISS- no insulin needed this shift last FS 97\n\nGU: foley patent and draining yellow urine. adequate u/o Qhr this shift.\n\nIV: LR @100. PIV X2. Left hand and left lower anterior forearm.\n\nPain: pt can nod yes or no that he is in pain. IVP fentanyl ordered and given with good effect.\n\nSocial: Mother and sister very emotional today and crying at times also father here and emotional also. Social worker up here to talk to the family. I also encouraged them to talk to him and showed him that he is able to respond to questions and commands. Pt and family told about procedures and plan of care.\n\nPlan: Ween vent as tolerated. Ween propofol as tolerated. Monitor vitals and labs. Await CT results. Continue to provide emotional support for family. Monitor drainage at site\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-01-31 00:00:00.000",
"description": "Report",
"row_id": 1668694,
"text": "Nursing Progress Note, 1900-0730\nPlease refer to careview for specifics.\n\nNo significant events noted this shift.\n\nROS:\n\nRESP: Nasal tracheal intubation, remains on vent for resp support while pt remains lightly sedated on propofol. Vent settings are as followed- CPAP + PS, PS 3, peep 5, FiO2 30%, RR 13-21, SpO2 93-100%, RSBI 50 this am. Yesterdays neck CT revealed increased swelling, ? attempt to extubate today vs. tomorrow. LS clear bilaterally. Increase in secretions noted, pt sxned for thick yellow secretions. + productive cough noted. VAP care performed per protocol.\n\nCVS: NSR to ST, no ectopy noted. HR 88-115, NIBP 120-150/65-85, pt spiked temp to 102.5. Blood cultures from last night pnding, PR tylenol given to help lower temperature. ? send sputum/urine cultures next time pt spikes. WBC 13.2, Hct 42.2. PIV x2 for access. + pedal pulses. Start SC heparin this am, venodynes for DVT prophylaxis.\n\nNEURO: Pt sedated on 60 mcg/kg/min of propofol for comfort while NT tube remains in place. However pt is easily arousable, opens eyes spontanesouly, able to communicate to staff effectively with non-verbal cues and writes on clip board. Follows commands appropriately, moves all extremities with equal strength. Pt c/o ha and discomfort to neck. Pt receiving 25-50mcg prn fentanyl ivp for adequate pain control.\n\nGI/GU: Abd soft, NT, ND, + BS, no BM, NPO, ? place OGT if pt cont to remain intubated. FS 126-136, no insulin required per RISS. H2B for GI prophylaxis. Foley patent, draining adequate amts of c/y/u- uop 80-450cc/hr. BUN 8, creatinine 0.9, Na 140, K 4.0, Ca 8.8, Phos 3.8, and Mg 2. LR @ 100cc/hr.\n\nINTEG: Two incisions to medial/R side of neck- pt s/p fixation of thyroid cartiladge fx. Penrose drain in place, draining scant to small amt of sanguinous output. Otherwise, skin intact.\n\nSOCIAL: Immediate family into visit with pt last night. Father mentioned last night that pts friends and -workers may come by to visit with him later today.\n\nPOC: Wean vent settings as appropriate, ? extubate if swelling to neck has decreased, hemodynamics, follow pnding blood cultures, if pt spikes again ? send sputum and urine cultures, titrate propofol to appropriate level to allow comfort, cont pain mgmt, ? place OGT & start TF if pt remains intubated, begin SC heparin this am, request bowel regimen, cont to provide pt and family with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-01-31 00:00:00.000",
"description": "Report",
"row_id": 1668695,
"text": "RESP CARE NOTE\nPT REMAINED ON PSV 3/5/30% WITH A\rTC ON. VT 400'S AND RR 118-20. BREATH SOUNDS ESSSENT CLE EAR. SUCTIONING MOD TO LG AMTS OF THICK YELLOW SECRETIONS. NECK STILL WITH A LOT OF SWELLING ? EXTUBATION. RSBI 49. NOETT SECURE AND PATENT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-02-01 00:00:00.000",
"description": "Report",
"row_id": 1668700,
"text": "Nursing Note\nSee Flowsheet\n\nSignificant Events: Pt. extubated, JP drain pulled today\n\nNeuro: Pt. intact, given ativan and diludid prior to extubation for pain/anxiety. Pt. received one dose Dilaudid 1 mg post extubation. C/O nausea, Zofran given.\n\nCV: HR 80-100's, BP WNL, afebrile today, blood cultures pending.\n\nResp: Pt. extubated today, currently on .5 FiO2 via face tent. O2 sats >93%. LS clear in upper lobes, coarse in lower lobes bilat. Pt. expectorating thick yellow sputum, Sputum cx. revealing gram positive cocci. CDB, IS encouraged.\n\nGI/GU: pt. NPO, ice chips only. Abd. benign. Foley draining clear yellow urine, 20mg Lasix given.\n\nSkin: JP drain pulled today by ENT, DSD applied\n\nEndo: Insulin giver per RISS\n\nSocial: Family at bedside, revealing today that pt. was actually kicked in throat during a bar fight that he was apparentlly trying to break up. Family remains supportive and appropriately concerned.\n\nPlan:\nContinue to monitor resp. status, encourage IS, CDB, ambulation\n? Transfer to floor tomorrow\nPt. and family support\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-02-02 00:00:00.000",
"description": "Report",
"row_id": 1668701,
"text": "7p-7a NPN\n\nN: Requesting sleep aid early in shift, responded well to lorazepam (2mg), sleeping for 2 hrs then woke up in a confused state, easy to re-orient, given dilaudid 2mg at a time for pain control and mild headache, ? alcohol withdrawl symptoms, pt follows all commands, MAE's, does not demonstrate any neurolicial dysfunction at this present time.\n\nCV: St to NSR with minimal ectopy noted, adequate blp with MAP's > 60 mmHg, palp pedal pulses, warm extremities, SC heprin, pneumoboots at rest, 20 g PIV for access, afebrile.\n\nResp: Weaned cool aerosol Fio2 to 35% this shift, remains on humidified oxygen to keep oropharynx mosit while pt is NPO, moderate cough with the ability to expectorate thick white sputum, remains coarse to auscultate lung lobes, oxygen saturations in mid to high 90's, shallow resp volumes with rest, clears incentive spirometer, independent cough and deep breathing with reinforcement.\n\nGI: NPO, soft abdomen with active bowel sounds, ordered to ice chips as tol, c/c nausea in earlier shifts after hydromorphone administration.\n\nGU: Foley remains, plan to d/c by morning, am labd drawn, will repleat lytes as ordered.\n\nEndo: RISS with coverage provided.\n\nSkin: C/D/I.\n\nMS: Independent bed mobility.\n\nPlan: Prepare for transfer to floor when able, wean supplemental o2 requirements, pain and anxiety mgmt, monitor and assess as ordered.\n"
}
] |
21,355 | 184,413 | The patient is a 73 year old male with noninsulin dependent diabetes, CAD, status post PTCA in to the RCA who presents with chest pain, post cath revealing three vessel disease and LV dysfunction. 1. CV/CAD. The patient was continued on aspirin, Lipitor, metoprolol and was started on an ACE inhibitor. He was taken back for a second catheterization on which showed LMCA 60 percent ostial lesion with diffuse disease, LAD with 40 to 50 percent stenosis proximally and left circumflex with moderate diffuse disease. A DES was placed in the left main. The patient's cardiac enzymes continued to trend down after catheterization. He was continued on aspirin, Plavix, Lipitor, lisinopril, carvedilol, Imdur. 2. Pump. EF of 25 percent. The patient was maintained on a 2 gm sodium diet and his daily weight was followed as well as ins and outs. For heart failure he was continued on carvedilol, lisinopril, Imdur. 3. Rhythm. The patient had no concerning abnormalities during admission. 4. Renal. The patient's creatinine climbed to 2.1 during this admission, thought to be secondary to catheterization dye. He was hydrated after catheterization and his creatinine trended down and was at his baseline at the time of discharge. 5. Endocrine. The patient was maintained on his diabetic medications and was discharged on his admission medications. 6. Hematologic. The patient was transfused a total of three units of packed red blood cells for low hematocrit thought to be secondary to hydration during his stay. Hematocrit was stable at the time of discharge. | Mildtricuspid [1+] regurgitation is seen. Mild(1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary arterysystolic hypertension.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.Conclusions:The left atrium is mildly dilated. The leftventricular inflow pattern suggests impaired relaxation.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets are mildlythickened. Left ventricular function.Height: (in) 68Weight (lb): 230BSA (m2): 2.17 m2BP (mm Hg): 134/57Status: InpatientDate/Time: at 17:04Test: TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in theright atrium and/or right ventricle.LEFT VENTRICLE: The left ventricular cavity is mildly dilated.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: mid anterior - akinetic; basal anteroseptal -akinetic; mid anteroseptal - akinetic; anterior apex - akinetic; septal apex-akinetic; inferior apex - akinetic; lateral apex - akinetic;RIGHT VENTRICLE: Right ventricular chamber size is normal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened. Left atrial enlargement. There is stable left ventricular enlargement and slight upper zone redistribution. Prior inferior myocardial infarction.Left bundle-branch block. There is mildmitral annular calcification. HR- 57-70'S SR, MINIMAL VEA.BP- 116/50-134/56. T waveabnormalities in the precordial leads. ASSYMPTOMATIC, REMAINS ON TNG GTT. Inferior myocardial infarction of indeterminate age. AP SUPINE CHEST: Compared with , the right central venous catheter is no longer present and there is a new left transfemoral Swan catheter tip located in the left main pulmonary artery. Compared to the previous tracing of nodiagnostic interim change. Sinus rhythmLeft axis deviationConduction defect of LBBB typePossible inferior infarct - age undetermined There is moderate pulmonary artery systolic hypertension. No aorticregurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. The left ventricular cavity is mildly dilated. HTNP: Aggressive diuresis. CCU NSG PROGRESS NOTE 7P-7A/ R/O MI; RCA OCCS- SEE FLOWSHEET FOR OBJECTIVE DATA PT REMAINS HEMODYNAMICALLY STABLE S/P CATH- CPK'S (-), TROPININ (+). IMPRESSION: Improved cardiac failure and appearance of the pulmonary vessels. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythmIntraventricular conduction delay of left bundle branch block typeClinical correlation is suggestedNo previous tracing AP UPRIGHT CHEST: Compared to , there is significant improvement in the bilateral interstitial infiltrates and perihilar haziness. Clinical correlation issuggested.TRACING #1 Denies CP.ID: T 97.7 WBC from OSH 15.9CV: HR 69-73 NSR with LBBB. There isan anterior space which most likely represents a fat pad, though a loculatedanterior pericardial effusion cannot be excluded. Nitro drip cont at 1.05mcg/kg/min. Arrived to CCU with #6Fr Arterial sheath and #8fr venous sheath on Nitro drip at 1.05mcg/kg/min and 4L NC. Since the previous tracing of theleft bundle-branch block pattern has resolved. PT STATES BREATHING IS "MORE COMFORTABLE" - O2 4 L NP- SATS >MID 90'S. The transfemoral Swan-Ganz catheter has been removed. Cont Nitro. Sent from OSH to for diagnostic cath; transferred to CCU for HF management. HF exacerbation. IMPRESSION: Allowing for differences in position, there is slight worsening of the right middle lobe infiltrate and pulmonary vascular congestion, which could represent mild cardiac failure. There is left lower lobe collapse/consolidation and a new illdefined right middle zone infiltrate. "O: A+O x3 very pleasant 74y.o. Abd obese, soft, +BS.ENDO: q6h SSC- PM labs pending.GU: Clear yellow urine via foley catheter. PT GIVEN 1 U PRBC THIS SHIFT FOR HCT- 27.TOLERATED TRANSFUSION WITHOUT PROBLEMAM PENDING.NO SIGN BLEEDING. The aortic valve leaflets are mildly thickened. Right ventricular chamber size is normal and functionappears preserved. The mediastinum is less prominent. A small atrial septal defect cannot beexlcuded. Improved pulmonary redistribution. RT GROIN WITH PA LINE IN PLACE- ALINE D/C.NO HEMATOMA, (+)DOPPLER PULSES, LEG IMMOBILIZER IN PLACE.MUCH ISSUE WITH BACK PAIN WITH IMMOBILITY IN BAD UNCOMFORTABLE BED.REPOSITIONED OFTEN . Since the previous tracing of no significant change.TRACING #2 PT ON STRICT BEDREST- LEFT AKA AND RT LEG IMMOBILE FROM GROIN SITE.PLEASANT, COOPERATIVE.VERY UMCOOFORTABLE D/T BED AND BEDREST AND LIMITED MOBILITY.NOT MUCH SLEEP AT ALL.ASKING TO GET LINES OUT OF GROIN TODAYA/ PT ADMITTED TO CCU S/P CATH- TO RCA - DIURESING TO LASIX AND NATRECOR,CONTINUE CURRENT MEDS AS ORDERED- START CAPTOPRIL THIS AM, CONTINUE B BLOCKERS.LASIX AS ORDERED .CHECK AM FOR LYTES AND CBC.ENCOURAGE PO INTAKE- CONTINUE SS REG INSULIN AS NEEDED FOR COVERAGE.KEEP PT AWARE OF PLAN OF CARE.D/C PA LINE TODAY ONCE MEDICALLY APPROPRIATE ESP TO HELP PT COMFORT.WATCH I/O FOR DIUIRESIS EFFECTS. Left ventricularsystolic function is severely depressed. Persistent cardiomegaly. The mitral valve leaflets are mildly thickened. NOT SLEEPING MUCH AT ALL.PA- 50'S /20'S. Since the previous tracing of no change in previouslydescribed abnormalities. Arterial sheath removed at 1830, site with dressinf C/D/I. Pt rcvd 80mg Lasix, followed by 120mg Lasix. BP 144-160/56-62. Resting regional wall motionabnormalities include anteroseptal, anterior and apical akinesis withhypokinesis elsewhere. CCU Admission NPN: Alt in CVS: "Can I have a drink of water? NO STOOL, GROIN SITE STABLE. I/O (-)1100CC AS OF 12AM. PAP 42-43/13-15. Son aware he is in hospital.A: MMP. No ectopy noted. PATIENT/TEST INFORMATION:Indication: Congestive heart failure. No new focal infiltrates or pneumothorax. K+ 4.2 Mg 1.9 PM labs pending.RESP: RR 13-21 O2 sat 95-97% on 4L NCGI: Cardiac diet ordered. No pneumothorax. GIVEN 40 LASIX 12A- WITH PRBC- DIURESING TO THAT DOSE AS WELL.CRACKLES REMAIN AT BASES.SEE ABOVE FOR PA VALUES.ID- AFEBRILEGU- GOOD UO- SENT UA THIS AM.STARTED ON NATRECOR 0.01 MCG AFTER 2 MCG/KG BOLUS.TOLERATING WITHOUT ISSUES.GI- DECLINING DINNER OR ANY SNACKS- TAKING BLACK SANKA ONLY.BS- 120-89., NO SS REG INSULIN THIS SHIFT. Changes in R wave progression may be related to leadpositioning. I+O: -1.1 LOS/24h.SOC: Three children. No aorticregurgitation is seen. 8:54 AM CHEST (PORTABLE AP) Clip # Reason: evaluate CHF Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH MEDICAL CONDITION: 73 year old man with REASON FOR THIS EXAMINATION: evaluate CHF FINAL REPORT HISTORY: Congestive heart failure. | 11 | [
{
"category": "Nursing/other",
"chartdate": "2118-03-15 00:00:00.000",
"description": "Report",
"row_id": 1542667,
"text": "CCU Admission NPN: Alt in CV\nS: \"Can I have a drink of water?\"\n\nO: A+O x3 very pleasant 74y.o. male with multiple medical problems, dials 911 today for SOB and diaphoresis. Sent from OSH to for diagnostic cath; transferred to CCU for HF management. Arrived to CCU with #6Fr Arterial sheath and #8fr venous sheath on Nitro drip at 1.05mcg/kg/min and 4L NC. Denies CP.\n\nID: T 97.7 WBC from OSH 15.9\n\nCV: HR 69-73 NSR with LBBB. No ectopy noted. BP 144-160/56-62. Nitro drip cont at 1.05mcg/kg/min. Arterial sheath removed at 1830, site with dressinf C/D/I. PAP 42-43/13-15. K+ 4.2 Mg 1.9 PM labs pending.\n\nRESP: RR 13-21 O2 sat 95-97% on 4L NC\n\nGI: Cardiac diet ordered. Abd obese, soft, +BS.\n\nENDO: q6h SSC- PM labs pending.\n\nGU: Clear yellow urine via foley catheter. Pt rcvd 80mg Lasix, followed by 120mg Lasix. I+O: -1.1 LOS/24h.\n\nSOC: Three children. Son aware he is in hospital.\n\nA: MMP. HF exacerbation. HTN\n\nP: Aggressive diuresis. Cont Nitro.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-03-16 00:00:00.000",
"description": "Report",
"row_id": 1542668,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ R/O MI; RCA OCC\n\n\nS- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE S/P CATH- CPK'S (-), TROPININ (+). ASSYMPTOMATIC, REMAINS ON TNG GTT. HR- 57-70'S SR, MINIMAL VEA.\nBP- 116/50-134/56. RT GROIN WITH PA LINE IN PLACE- ALINE D/C.\nNO HEMATOMA, (+)DOPPLER PULSES, LEG IMMOBILIZER IN PLACE.\nMUCH ISSUE WITH BACK PAIN WITH IMMOBILITY IN BAD UNCOMFORTABLE BED.\nREPOSITIONED OFTEN . NOT SLEEPING MUCH AT ALL.\nPA- 50'S /20'S.\n\n PT STATES BREATHING IS \"MORE COMFORTABLE\" - O2 4 L NP- SATS >MID 90'S. I/O (-)1100CC AS OF 12AM. GIVEN 40 LASIX 12A- WITH PRBC- DIURESING TO THAT DOSE AS WELL.\nCRACKLES REMAIN AT BASES.\nSEE ABOVE FOR PA VALUES.\n\nID- AFEBRILE\n\nGU- GOOD UO- SENT UA THIS AM.\nSTARTED ON NATRECOR 0.01 MCG AFTER 2 MCG/KG BOLUS.\nTOLERATING WITHOUT ISSUES.\n\nGI- DECLINING DINNER OR ANY SNACKS- TAKING BLACK SANKA ONLY.\nBS- 120-89., NO SS REG INSULIN THIS SHIFT.\n\n PT GIVEN 1 U PRBC THIS SHIFT FOR HCT- 27.\nTOLERATED TRANSFUSION WITHOUT PROBLEM\nAM PENDING.\nNO SIGN BLEEDING. NO STOOL, GROIN SITE STABLE.\n\n PT ON STRICT BEDREST- LEFT AKA AND RT LEG IMMOBILE FROM GROIN SITE.\nPLEASANT, COOPERATIVE.\nVERY UMCOOFORTABLE D/T BED AND BEDREST AND LIMITED MOBILITY.\nNOT MUCH SLEEP AT ALL.\nASKING TO GET LINES OUT OF GROIN TODAY\n\nA/ PT ADMITTED TO CCU S/P CATH- TO RCA\n - DIURESING TO LASIX AND NATRECOR,\n\n\nCONTINUE CURRENT MEDS AS ORDERED- START CAPTOPRIL THIS AM, CONTINUE B BLOCKERS.\nLASIX AS ORDERED .\nCHECK AM FOR LYTES AND CBC.\nENCOURAGE PO INTAKE- CONTINUE SS REG INSULIN AS NEEDED FOR COVERAGE.\nKEEP PT AWARE OF PLAN OF CARE.\nD/C PA LINE TODAY ONCE MEDICALLY APPROPRIATE ESP TO HELP PT COMFORT.\nWATCH I/O FOR DIUIRESIS EFFECTS.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-03-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 815561,
"text": " 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate CHF\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n evaluate CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Congestive heart failure.\n\n AP SUPINE CHEST: Compared with , the right central venous\n catheter is no longer present and there is a new left transfemoral Swan\n catheter tip located in the left main pulmonary artery. There is left lower\n lobe collapse/consolidation and a new illdefined right middle zone infiltrate.\n There is stable left ventricular enlargement and slight upper zone\n redistribution. No pneumothorax.\n\n IMPRESSION: Allowing for differences in position, there is slight worsening of\n the right middle lobe infiltrate and pulmonary vascular congestion, which\n could represent mild cardiac failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-03-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 816233,
"text": " 8:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate CHF\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n\n REASON FOR THIS EXAMINATION:\n evaluate CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Congestive heart failure.\n\n AP UPRIGHT CHEST: Compared to , there is significant\n improvement in the bilateral interstitial infiltrates and perihilar haziness.\n Improved pulmonary redistribution. The mediastinum is less prominent.\n Persistent cardiomegaly. The transfemoral Swan-Ganz catheter has been\n removed. No new focal infiltrates or pneumothorax.\n\n IMPRESSION: Improved cardiac failure and appearance of the pulmonary vessels.\n\n"
},
{
"category": "Echo",
"chartdate": "2118-03-15 00:00:00.000",
"description": "Report",
"row_id": 67181,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nHeight: (in) 68\nWeight (lb): 230\nBSA (m2): 2.17 m2\nBP (mm Hg): 134/57\nStatus: Inpatient\nDate/Time: at 17:04\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: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nLEFT VENTRICLE: The left ventricular cavity is mildly dilated.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: mid anterior - akinetic; basal anteroseptal -\nakinetic; mid anteroseptal - akinetic; anterior apex - akinetic; septal apex-\nakinetic; inferior apex - akinetic; lateral apex - akinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Mild (1+) mitral regurgitation is seen. The left\nventricular inflow pattern suggests impaired relaxation.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Mild\ntricuspid [1+] regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is mildly dilated. A small atrial septal defect cannot be\nexlcuded. The left ventricular cavity is mildly dilated. Left ventricular\nsystolic function is severely depressed. Resting regional wall motion\nabnormalities include anteroseptal, anterior and apical akinesis with\nhypokinesis elsewhere. Right ventricular chamber size is normal and function\nappears preserved. The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is moderate pulmonary artery systolic hypertension. There is\nan anterior space which most likely represents a fat pad, though a loculated\nanterior pericardial effusion cannot be excluded.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2118-03-23 00:00:00.000",
"description": "Report",
"row_id": 143548,
"text": "Sinus rhythm. Since the previous tracing of no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2118-03-22 00:00:00.000",
"description": "Report",
"row_id": 143549,
"text": "Sinus rhythm. Inferior myocardial infarction of indeterminate age. T wave\nabnormalities in the precordial leads. Since the previous tracing of the\nleft bundle-branch block pattern has resolved. Clinical correlation is\nsuggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2118-03-19 00:00:00.000",
"description": "Report",
"row_id": 143550,
"text": "Sinus rhythm. Left atrial enlargement. Prior inferior myocardial infarction.\nLeft bundle-branch block. Compared to the previous tracing of no\ndiagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2118-03-18 00:00:00.000",
"description": "Report",
"row_id": 143551,
"text": "Sinus rhythm\nLeft axis deviation\nConduction defect of LBBB type\nPossible inferior infarct - age undetermined\n\n"
},
{
"category": "ECG",
"chartdate": "2118-03-17 00:00:00.000",
"description": "Report",
"row_id": 143552,
"text": "Sinus rhythm. Since the previous tracing of no change in previously\ndescribed abnormalities. Changes in R wave progression may be related to lead\npositioning.\n\n"
},
{
"category": "ECG",
"chartdate": "2118-03-16 00:00:00.000",
"description": "Report",
"row_id": 143553,
"text": "Sinus rhythm\nIntraventricular conduction delay of left bundle branch block type\nClinical correlation is suggested\nNo previous tracing\n\n"
}
] |
4,740 | 155,165 | The patient was admitted to the Medical Intensive Care Unit. He had two large bore intravenous placed. He was typed and crossed for two units of packed red blood cells. Serial hematocrits were followed q 4 to 6 hours and the patient underwent angiography by interventional radiology who started him on vasopressin GTT into the inferior mesenteric artery the left colic branch. The patient remained hemodynamically stable with a heart rate in the 80s, blood pressure 112 to 160/53 to 88. His hematocrit dropped to 27.4 by 1:00 p.m. after being 39 on admission. Gastroenterology was consulted and recommended that the patient will need follow up for full colonoscopy since his last colonoscopy was incomplete. On hospital day one the patient was doing well with no complaints. He had no further bright red blood per rectum. His hematocrit was 28.0. The previously hematocrits were 28.0, 26.1 and 27.4. His electrolytes were within normal limits. His PT was 16.6, PTT 28.4, INR was 1.8. He is continued on inferior mesenteric artery vasopressin infusion. Because his hematocrit dropped from 39 to 26 he was transfused one unit of packed red blood cells. The vasopressin infusion was discontinued at 11:00 a.m. on and serial hematocrits remained stable on . His hematocrit was 29.4 at 12:00 a.m. and 28.3 at 5:30 a.m. On the patient continued to do well with no complaints. He was hemodynamically stable off the vasopressin infusion and was transferred to the floor at this time. His hematocrit was 28.3, INR 1.6, electrolytes were within normal limits with the exception of a potassium of 3.3, which was repleted with po K-Dur 40 milliequivalents. Diet was advanced to clears at this time. His Foley catheter was discontinued. He was encouraged to ambulate ad lib. His diet was advanced to regular and his hematocrits were followed. On the patient was doing well with no complaints. His T max was 100.5. His vital signs were stable. His examination was unremarkable. His hematocrit was 27.8 and 27.7. He passed one formed stool, which was hemocult positive, but not grossly bloody. On the patient was doing well with no complaints. He reported he would like to be discharged to home. He was afebrile with stable vital signs. His examination was unremarkable. Follow up hematocrit was 30.7. He is discharged to home in stable condition. He is instructed to avoid non-steroidal anti-inflammatory agents and aspirin. He is instructed to follow up with his primary care physician . this week and to follow up with GI as an outpatient for a full colonoscopy. | BLEED MESENTERIC PR INTERVENTIONAL MD. cont to be cdi- no hematoma. Subsequently, the superior mesenteric artery was then selectively catheterized, and a superior mesenteric arteriogram was obtained, which showed no contrast extravasation. positive palp dp/pt right lower ext. POS PALP DP/PT RIGHT LOWER EXT. IVF changed for dextrose source. Following vasopressin infusion, obvious diffuse vasoconstriction of the inferior mesenteric vessels is demonstrated. NPN: SEE ICU FLOWSHEETNEURO: INTACTCV: VSS. TO SICU AS MICU OVERFLOW POST ANGIO WITH SHEATH AND VASOPRESSINN GTT CONT. NPN/Transfer Note: See ICU flowsheetNEURO: Intact, A/Ox3CV: VSS. The superior mesenteric vein appears patent. /nkg , M.D. (dictated) , M.D. PIV x 2 to R arm. Normal ECG. 7:52 AM MESENTERIC Clip # Reason: GI BLEED Contrast: OPTIRAY Amt: 200 ML ********************************* CPT Codes ******************************** * TRANSCATHETER INFUSION NOT LYS EA 1ST ORDER ABD/PEL/LOWER EXT * * -51 MULTI-PROCEDURE SAME DAY EA 1ST ORDER ABD/PEL/LOWER EXT * * -59 DISTINCT PROCEDURAL SERVICE TRANSCATHETER INFUSION * * F/U STATUS INFUSION/EMBO VISERAL SEL/SUPERSEL A-GRAM * * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * NON-IONIC 200 CC SUPPLY * **************************************************************************** FINAL REPORT INDICATION: A 51-year-old male with bright red blood per rectum and history of diverticular disease. Since the previous tracing of nosignificant change. IVF of D5NS at 100 cc/hr. Approved: 3:59 PM RADLINE ; A radiology consult service. IMPRESSION: GI bleed present at splenic flexure. Abd sl.firm and rounded with + BS x 4. LINE PLACED AND VASOPRESSIN GTT STARTED VIA SHEATH AT .10U/MIN. FINDINGS: The inferior mesenteric arteriogram demonstrates a focal small area of contrast extravasation in the proximal descending colon (near the splenic flexura), within the colonic segment that is perfused by both ascending and (Over) 7:52 AM MESENTERIC Clip # Reason: GI BLEED Contrast: OPTIRAY Amt: 200 ML FINAL REPORT (Cont) descending branches of the left colic artery, consistent with a source of bleeding and correlates well with the nuclear scan findings. The inferior mesenteric artery was selectively catheterized, and an inferior mesenteric arteriogram was obtained, which demonstrated a focal contrast extravasation in the region of the proximal descending colon. The inferior mesenteric artery was again selectively catheterized, with the distal tip of the SOS Omni catheter in the proximal portion of the inferior mesenteric artery. The inferior mesenteric vasculature overall appeared significantly vasoconstricted compared with the pre- vasopressin arteriogram. R CATH SITE WNL BUT NO TRACEABLE WAVE WHEN TRANSDUCED.IVF DECREASED FROM 150 TO 60 CC HR WHEN B/P STARTED TO SLOWLY CLIMB.GI/GU: NPO EXCEPT MEDS. R sheath site WNL; no eccymosis, swelling, drainage and bandaid dry and intact and PPP. ON LOW DOSE VASOPRESSIN TO CONTROL MESENTERIC BLEED. RECEIVED ONE UNIT PRBC. The response to intraarterial() vasopressin(0.2 u/min) was excellent. 18 piv x2. FROM ER SENT TO ANGIO TO LOCATE BLEED. HAS PMH HTN- CAPOTEN 25 TID STARTED. SITE CDI. DENIES ABD PAIN. C/O BACK PAIN WHICH HE STATES HAS "ALWAYS HAD" RX PERCOCETT. Vasopressin D/C'd last shift.RESP: WNL, LCTA. A+O. The rate of vasopressin infusion was then decreased to 0.1 units/minute. c/o back pain- rx with po percocett with relief. no c/o abd pain. 0.9 60/hr. The superior mesenteric arteriogram is unremarkable. Access was gained into the arterial system via the right common femoral artery using a 19g single wall needle. uo via foley 100-400/hr. FINAL REPORT HISTORY: H/o diverticulosis, positive bleeding scan in the past, now with active bleeding, identify site of hemorrhage. nsg progress notevasopressin gtt dc 11 am and right sheath dc at 3 pm by interventional md. Delayed blood pool images show tracer accumulation in the left upper quadrant, which moves distally along the expected course of the descending and sigmoid colon, and retrograde along the expected course of the transverse colon. | 8 | [
{
"category": "Nursing/other",
"chartdate": "2155-09-18 00:00:00.000",
"description": "Report",
"row_id": 1677679,
"text": "NSG ADMIT NOTE\n50 YO MALE WITH RECENT HX POSITIVE BLOODY STOOLS- WENT TO PRIMARY CARE MD - TO ER FROM MD OFFICE FOR GI BLEED. FROM ER SENT TO ANGIO TO LOCATE BLEED. BLEED MESENTERIC PR INTERVENTIONAL MD. LINE PLACED AND VASOPRESSIN GTT STARTED VIA SHEATH AT .10U/MIN. TO SICU AS MICU OVERFLOW POST ANGIO WITH SHEATH AND VASOPRESSINN GTT CONT. HAS PMH HTN- CAPOTEN 25 TID STARTED. TO START IV PROTONIX 40 MG IV Q12. CONT PASSING DARK \"JELLY\" COLORED STOOL- NON BRIGHT RED. HCT AT NOON 29. REPEAT AT 6 PM 26.1 MD AWARE. PT HAS 2 UNITS PRBC IN BLOOD BANK. DENIES ABD PAIN. C/O BACK PAIN WHICH HE STATES HAS \"ALWAYS HAD\" RX PERCOCETT. NKA. A+O. POS PALP DP/PT RIGHT LOWER EXT. SITE CDI. NO HEMATOMA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-09-19 00:00:00.000",
"description": "Report",
"row_id": 1677680,
"text": "NPN: SEE ICU FLOWSHEET\nNEURO: INTACT\n\nCV: VSS. ON LOW DOSE VASOPRESSIN TO CONTROL MESENTERIC BLEED. R CATH SITE WNL BUT NO TRACEABLE WAVE WHEN TRANSDUCED.IVF DECREASED FROM 150 TO 60 CC HR WHEN B/P STARTED TO SLOWLY CLIMB.\n\nGI/GU: NPO EXCEPT MEDS. NO STOOLS THIS SHIFT. MEDICATED FOR BACK PAIN X 2 WITH PERCOCET WITH GOOD RELIEF OBTAINED. RECEIVED ONE UNIT PRBC. FOLEY PATENT OF CLEAR YELLOW URINE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-09-19 00:00:00.000",
"description": "Report",
"row_id": 1677681,
"text": "nsg progress note\nvasopressin gtt dc 11 am and right sheath dc at 3 pm by interventional md. cont to be cdi- no hematoma. positive palp dp/pt right lower ext. noon hct 29.5. repeat 18 pm hct pending. am inr 1.6. inr repeated 1800 pm. no c/o abd pain. no bloody stools. uo via foley 100-400/hr. c/o back pain- rx with po percocett with relief. 18 piv x2. 0.9 60/hr. npo. stable for transfer to floor 8 pm-4 hrs post dc sheath. pt has nka.\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-09-19 00:00:00.000",
"description": "Report",
"row_id": 1677682,
"text": "NPN/Transfer Note: See ICU flowsheet\nNEURO: Intact, A/Ox3\n\nCV: VSS. PIV x 2 to R arm. R sheath site WNL; no eccymosis, swelling, drainage and bandaid dry and intact and PPP. Extremities cool but unchanged. IVF of D5NS at 100 cc/hr. Vasopressin D/C'd last shift.\n\nRESP: WNL, LCTA. Does drop sats to low 90's while asleep.\n\nGI/GU: No more stooling. Abd sl.firm and rounded with + BS x 4. NPO. IVF changed for dextrose source. Foley patent of clear yellow urine in large amounts.\n\nSKIN: Intact.\n\nPAIN: Medicated with prn Percocet x 2 at for c/o level 5 aching to back. Reports pain as 2 at this time.\n\nPSYCH/SOC/SPIRITUAL: Wife called for condition report and notified of transfer to floor. No spiritual needs identified.\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2155-09-18 00:00:00.000",
"description": "Report",
"row_id": 283369,
"text": "Normal sinus rhythm. Normal ECG. Since the previous tracing of no\nsignificant change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-09-18 00:00:00.000",
"description": "GI BLEEDING STUDY",
"row_id": 744351,
"text": "GI BLEEDING STUDY Clip # \n Reason: H/O DIVERTICULOSIS, POSITIVE BLEEDING SCAN IN THE PAST, NOW WITH ACTIVE BLEEDING, IDENTIFY SITE OF HEMORRHAGE.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: H/o diverticulosis, positive bleeding scan in the past, now with\n active bleeding, identify site of hemorrhage.\n\n INTERPRETATION: Following intravenous injection of autologous red blood cells\n labeled with Tc-m, blood flow and delayed images of the abdomen for 90 minutes\n were obtained.\n\n Delayed blood pool images show tracer accumulation in the left upper quadrant,\n which moves distally along the expected course of the descending and sigmoid\n colon, and retrograde along the expected course of the transverse colon. This\n is indicative of bleeding at the splenic flexure of the colon.\n\n IMPRESSION: GI bleed present at splenic flexure. /nkg\n\n\n , M.D.(dictated)\n , M.D. Approved: 3:59 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2155-09-18 00:00:00.000",
"description": "EA 1ST ORDER ABD/PEL/LOWER EXT A-GRAM",
"row_id": 744363,
"text": " 7:52 AM\n MESENTERIC Clip # \n Reason: GI BLEED\n Contrast: OPTIRAY Amt: 200 ML\n ********************************* CPT Codes ********************************\n * TRANSCATHETER INFUSION NOT LYS EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -51 MULTI-PROCEDURE SAME DAY EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATHETER INFUSION *\n * F/U STATUS INFUSION/EMBO VISERAL SEL/SUPERSEL A-GRAM *\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * NON-IONIC 200 CC SUPPLY *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 51-year-old male with bright red blood per rectum and history of\n diverticular disease. The patient had a similar episode in and\n was treated with vasopressin infusion for a bleeding from the transverse\n colon. A tagged red blood cell scintigram completed at 6:00 AM on \n demonstrates increased radiotracer uptake in the region of the splenic\n flexure.\n\n RADIOLOGISTS: Drs. and . Dr. , staff\n radiologist, was present throughout the procedure. Dr. reviewed the\n case.\n\n CONTRAST/MEDICATIONS: 200 ml of Optiray 320 at 60%; 1 mg of Versed and 50\n micrograms of Fentanyl intravenously under continued hemodynamic monitoring.\n\n PROCEDURE/TECHNIQUE: The procedure was described to the patient and informed\n consent obtained. Access was gained into the arterial system via the right\n common femoral artery using a 19g single wall needle. A 4 French sheath was\n placed, and a 4 French SOS Omni catheter was advanced into the abdominal aorta\n over a guidewire. The inferior mesenteric artery was selectively\n catheterized, and an inferior mesenteric arteriogram was obtained, which\n demonstrated a focal contrast extravasation in the region of the proximal\n descending colon. Subsequently, the superior mesenteric artery was then\n selectively catheterized, and a superior mesenteric arteriogram was obtained,\n which showed no contrast extravasation.\n\n The inferior mesenteric artery was again selectively catheterized, with the\n distal tip of the SOS Omni catheter in the proximal portion of the inferior\n mesenteric artery. 0.2 units/minute of vasopressin was then infused for 20\n minutes, and a repeat inferior mesenteric arteriogram was performed, which\n demonstrated no evidence for extravasation. The inferior mesenteric\n vasculature overall appeared significantly vasoconstricted compared with the\n pre- vasopressin arteriogram. The rate of vasopressin infusion was then\n decreased to 0.1 units/minute. The 4 French sheath was secured to the\n patient's skin using 0 Prolene suture material, and normal saline was infused\n through the side arm of the vascular sheath.\n\n FINDINGS: The inferior mesenteric arteriogram demonstrates a focal small area\n of contrast extravasation in the proximal descending colon (near the splenic\n flexura), within the colonic segment that is perfused by both ascending and\n (Over)\n\n 7:52 AM\n MESENTERIC Clip # \n Reason: GI BLEED\n Contrast: OPTIRAY Amt: 200 ML\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n descending branches of the left colic artery, consistent with a source of\n bleeding and correlates well with the nuclear scan findings. No other areas\n of contrast extravasation are noted. Following vasopressin infusion, obvious\n diffuse vasoconstriction of the inferior mesenteric vessels is demonstrated.\n There was no contrast extravasation during vasopressin infusion. The superior\n mesenteric arteriogram is unremarkable. The superior mesenteric vein appears\n patent.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Angiographic evidence of colonic active bleeding in the proximal\n descending colon. The response to intraarterial() vasopressin(0.2 u/min)\n was excellent. The infusion rate was decreased to 0.1 units/minute for\n overnight continues infusion, mainly because of vasospasm on the control\n angiogram. The patient's clinical condition will be assessed for the next 24\n hours and the rate of vasopressin infusion adjusted or stopped accordingly.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-09-18 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 744364,
"text": " 8:08 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with GI bleed likely going to OR\n REASON FOR THIS EXAMINATION:\n pre-op chest x-ray\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS, PA AND LATERAL\n\n HISTORY: Pre-op GI bleed.\n\n The heart size is normal. No evidence of CHF. The lungs are clear and the\n pulmonary vasculature is unremarkable. The costophrenic sulci are clear.\n\n IMPRESSION: No significant abnormality.\n\n"
}
] |
70,518 | 177,172 | The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: 1. This is a 74 year old male with PMH significant for HTN, CAD, diastolic dysfunction, moderate pulmonary hypertension with an estimated PASP of 41 mm Hg on last ECHO in , OA, hyperlipidemia, DM2, who was admitted to the MICU post-operatively while still intubated and sedated for hemodynamic monitoring following a left THA revision complicated by a large amount of blood loss and hemodynamic instability requiring two pressors. 2. course: The patient had extensive blood loss requiring 12 units of pRBCs, 14 units of FFP, and a 6 pack of platelets. He was also on Levophed and phenylephrine to maintain his blood pressures. There was concern for CVA or neurogenic shock as his blood pressures have varied widely from 80s-180s systolic, he is bradycardic, however CTA head was negative. Central line was placed and levophed continued for low pressures. He received another 1 unit of PRBC and 1 unit of platelets. He was also noted to have ST elevations on EKG likely in setting of demand ischemia related to hypotension and blood loss in setting of CAD. Patient was extubated POD2. Aspirin and held, coumadin was started on POD 3 for DVT ppx. Ancef was continued until removal of JP drains on POD3. 3. POD 4 - Hct 26.9 -> Transfused 1 unit PRBCs Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is PARTIAL (50%) weight bearing on the operative extremity at all times with posterior/trochanter off precautions. Mr. is discharged to rehab in stable condition. | INDICATION: Left total hip arthroplasty revision. There is a left custom total hip arthroplasty. Sinus rhythm with one ventricular premature beat. There are moderate degenerative changes of the right hip. FINDINGS: The single AP view of the right hip demonstrates joint space narrowing. COMPARISON: Intraoperative left femoral radiographs from at 11:56. Compared to the previous tracing of the QRS duration is shorter and ST-T wave changes are no longer present.TRACING #1 FINDINGS: In comparison with study of , there has been removal of the femoral component of the total hip arthroplasty on the left. Compared to the previous tracingof arm lead reversal is now present and the rate is slower.Ventricular ectopy is now present. LEFT HIP, AP, TWO VIEWS: There has been interval total left hip arthroplasty, with acetabular cup, femoral shaft, cerclage wires, and lateral fixation plate and screws. COMPARISON: Radiograph dated and . Status post left total hip revision arthroplasty and ORIF of the left femur. There are non-diagnosticQ waves in the inferior leads. There are non-diagnosticQ waves in the inferior leads. PROGRESS AND HARDWARE Admitting Diagnosis: FAILED TOTAL HIP LEFT/SDA FINAL REPORT HISTORY: Intraoperative study to evaluate hardware. Separation of the greater trochanter is seen. Non-specific ST-T wave changes. Right and left arm leadreversal. FINAL REPORT INDICATION: Mental status changes, recent left hip surgery. Postoperative changes are seen. Delayed R wave progression. Sinus rhythm. 9:41 AM HIP UNILAT MIN 2 VIEWS LEFT Clip # Reason: LTHA Admitting Diagnosis: FAILED TOTAL HIP LEFT/SDA FINAL REPORT HISTORY: Left THA. IMPRESSION: Total left hip arthroplasty, without complications. Sinus bradycardia. Gastric distention. Mild mucosal thickening is seen within bilateral ethmoid air cells, and a small air-fluid level is seen within the left maxillary and sphenoid sinus. Compared to the previous tracing of ST-T wave changes are new.TRACING #2 The visualized pubic symphysis is grossly normal. IMPRESSION: No significant interval change. NGT in a moderately distended stomach. 11:55 AM FEMUR (AP & LAT) LEFT IN O.R. TECHNIQUE: MDCT helical images were acquired through the head without intravenous contrast. FINAL REPORT STUDY: AP view of the hip . IMPRESSION: 1. IMPRESSION: 1. Right lower lobe atelectasis is new since and has progressed slightly since . Clip # Reason: INTRA-OP FILMS TO EVAL. Cerclage bands are seen within the proximal left femoral shaft. There are lateral surgical skin staples. COMPARISON: MRI of the head and a CT head without contrast . Satisfactory position of newly inserted medical devices. Hardware appears well seated, without periprosthetic fragmentation or lucency. Multiple paranasal sinus disease, likely relates to the endotracheal intubation. Multiple paranasal sinus disease, likely relates to the endotracheal intubation. Severe degenerative change of the lower lumbar spine is seen. The position of the endotracheal tube and right internal jugular central venous catheter is satisfactory without evidence of pneumothorax. No acute intracranial hemorrhage. No acute intracranial hemorrhage. No acute cardiopulmonary pathology. No change in alignment on this single view. The -white matter differentiation is preserved. ; -77 BY DIFFERENT PHYSICIAN # Reason: INTRA-OP EVAL OF HARDWARE Admitting Diagnosis: FAILED TOTAL HIP LEFT/SDA FINAL REPORT INDICATION: 74-year-old male with total left hip arthroplasty. FINDINGS: Comparison is made to previous study from . FINDINGS: Images from the operating suite show placement of an intramedullary rod in the proximal aspect of the residual portion of the proximal femur. FINDINGS: Despite an adequately placed nasogastric tube, the stomach is severely distended with gas. Prominent extra-axial space adjacent to the anterior temporal lobe, likely represents a arachnoid cyst. 1:16 PM FEMUR (AP & LAT) LEFT IN O.R. COMPARISON: Femur radiographs earlier the same day. Moderate cardiomegaly is stable since . ETT ends 5.0 cm above the carina. PACU film. 2. 2. 2. The basal cisterns are normal. The visualized portion of the hardware is intact and unchanged in position. The P-R interval is prolonged. 9:05 AM HIP UNILAT MIN 2 VIEWS LEFT Clip # Reason: POD 2 film Admitting Diagnosis: FAILED TOTAL HIP LEFT/SDA MEDICAL CONDITION: 74 year old man with LTHA revised REASON FOR THIS EXAMINATION: POD 2 film FINAL REPORT STUDY: Left hip, . 6:03 PM CHEST PORT. No major vascular territorial infarction is seen. If there is concern for acute infarction, an MRI with DWI can be obtained for further evaluation. If there is concern for acute infarction, an MRI with DWI can be obtained for further evaluation. LINE PLACEMENT Clip # Reason: intubated, evaluate for central line placement Admitting Diagnosis: FAILED TOTAL HIP LEFT/SDA MEDICAL CONDITION: 74 year old man intubated on pressors, new line placement REASON FOR THIS EXAMINATION: intubated, evaluate for central line placement WET READ: 7:48 PM R IJ CVL ends in the R atrium. | 10 | [
{
"category": "Radiology",
"chartdate": "2118-05-19 00:00:00.000",
"description": "P PELVIS (AP ONLY) PORT",
"row_id": 1191038,
"text": " 6:49 PM\n PELVIS (AP ONLY) PORT Clip # \n Reason: pacu film\n Admitting Diagnosis: FAILED TOTAL HIP LEFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with LTHA revised\n REASON FOR THIS EXAMINATION:\n pacu film\n ______________________________________________________________________________\n WET READ: 7:45 PM\n Unchanged appearance of the L THA and fixation hardware, since the earlier\n study done at 13:28 hours today.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP view of the hip .\n\n COMPARISON: Femur radiographs earlier the same day.\n\n INDICATION: Left total hip arthroplasty revision. PACU film.\n\n FINDINGS: The single AP view of the right hip demonstrates joint space\n narrowing. The visualized pubic symphysis is grossly normal. Status post\n left total hip revision arthroplasty and ORIF of the left femur. The\n visualized portion of the hardware is intact and unchanged in position. No\n change in alignment on this single view.\n\n IMPRESSION: No significant interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-24 00:00:00.000",
"description": "L HIP UNILAT MIN 2 VIEWS LEFT",
"row_id": 1191512,
"text": " 9:05 AM\n HIP UNILAT MIN 2 VIEWS LEFT Clip # \n Reason: POD 2 film\n Admitting Diagnosis: FAILED TOTAL HIP LEFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with LTHA revised\n REASON FOR THIS EXAMINATION:\n POD 2 film\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left hip, .\n\n CLINICAL HISTORY: 74-year-old man with left total hip arthroplasty, postop\n day two.\n\n FINDINGS: Comparison is made to previous study from .\n\n There is a left custom total hip arthroplasty. There are no signs for\n hardware-related complications. There is also a prominent lateral plate along\n the proximal femur with fixation of a greater trochanter fragment. Cerclage\n bands are seen within the proximal left femoral shaft. There are lateral\n surgical skin staples. There are no signs of hardware-related complications.\n Severe degenerative change of the lower lumbar spine is seen. There are\n moderate degenerative changes of the right hip.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-19 00:00:00.000",
"description": "L HIP UNILAT MIN 2 VIEWS LEFT",
"row_id": 1190939,
"text": " 9:41 AM\n HIP UNILAT MIN 2 VIEWS LEFT Clip # \n Reason: LTHA\n Admitting Diagnosis: FAILED TOTAL HIP LEFT/SDA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left THA.\n\n FINDINGS: In comparison with study of , there has been removal of the\n femoral component of the total hip arthroplasty on the left. Separation of\n the greater trochanter is seen. Further information can be gathered from the\n operative report.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-19 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1191035,
"text": " 6:03 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: intubated, evaluate for central line placement\n Admitting Diagnosis: FAILED TOTAL HIP LEFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man intubated on pressors, new line placement\n REASON FOR THIS EXAMINATION:\n intubated, evaluate for central line placement\n ______________________________________________________________________________\n WET READ: 7:48 PM\n R IJ CVL ends in the R atrium. ETT ends 5.0 cm above the carina. NGT in a\n moderately distended stomach. No acute cardiopulmonary pathology.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status changes, recent left hip surgery.\n\n COMPARISON: Radiograph dated and .\n\n FINDINGS: Despite an adequately placed nasogastric tube, the stomach is\n severely distended with gas. The position of the endotracheal tube and right\n internal jugular central venous catheter is satisfactory without evidence of\n pneumothorax. Moderate cardiomegaly is stable since . Right lower lobe\n atelectasis is new since and has progressed slightly since .\n\n IMPRESSION:\n 1. Satisfactory position of newly inserted medical devices.\n 2. Gastric distention.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-19 00:00:00.000",
"description": "LO FEMUR (AP & LAT) LEFT IN O.R.",
"row_id": 1190965,
"text": " 11:55 AM\n FEMUR (AP & LAT) LEFT IN O.R. Clip # \n Reason: INTRA-OP FILMS TO EVAL. PROGRESS AND HARDWARE\n Admitting Diagnosis: FAILED TOTAL HIP LEFT/SDA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intraoperative study to evaluate hardware.\n\n FINDINGS: Images from the operating suite show placement of an intramedullary\n rod in the proximal aspect of the residual portion of the proximal femur.\n Postoperative changes are seen. Further information can be gathered from the\n operative report.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-19 00:00:00.000",
"description": "LO FEMUR (AP & LAT) LEFT IN O.R.",
"row_id": 1190987,
"text": " 1:16 PM\n FEMUR (AP & LAT) LEFT IN O.R.; -77 BY DIFFERENT PHYSICIAN # \n Reason: INTRA-OP EVAL OF HARDWARE\n Admitting Diagnosis: FAILED TOTAL HIP LEFT/SDA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with total left hip arthroplasty.\n\n COMPARISON: Intraoperative left femoral radiographs from at 11:56.\n\n LEFT HIP, AP, TWO VIEWS:\n\n There has been interval total left hip arthroplasty, with acetabular cup,\n femoral shaft, cerclage wires, and lateral fixation plate and screws.\n Hardware appears well seated, without periprosthetic fragmentation or lucency.\n\n IMPRESSION:\n\n Total left hip arthroplasty, without complications.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1191020,
"text": " 8:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o stroke\n Admitting Diagnosis: FAILED TOTAL HIP LEFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with h/o CVA now hypotensive on pressors s/p hip surgery\n REASON FOR THIS EXAMINATION:\n r/o stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:55 PM\n 1. No acute intracranial hemorrhage. If there is concern for acute\n infarction, an MRI with DWI can be obtained for further evaluation.\n 2. Multiple paranasal sinus disease, likely relates to the endotracheal\n intubation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with history of CVA, now is hypotensive status\n post hip surgery.\n\n COMPARISON: MRI of the head and a CT head without contrast\n .\n\n TECHNIQUE: MDCT helical images were acquired through the head without\n intravenous contrast.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, edema, masses, or\n mass effect. No major vascular territorial infarction is seen. The\n -white matter differentiation is preserved. The ventricles and sulci are\n enlarged, consistent with involutional changes. The basal cisterns are\n normal. Prominent extra-axial space adjacent to the anterior temporal lobe,\n likely represents a arachnoid cyst. Mild mucosal thickening is seen within\n bilateral ethmoid air cells, and a small air-fluid level is seen within the\n left maxillary and sphenoid sinus.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage. If there is concern for acute\n infarction, an MRI with DWI can be obtained for further evaluation.\n 2. Multiple paranasal sinus disease, likely relates to the endotracheal\n intubation.\n\n"
},
{
"category": "ECG",
"chartdate": "2118-05-22 00:00:00.000",
"description": "Report",
"row_id": 269782,
"text": "Sinus rhythm with one ventricular premature beat. Right and left arm lead\nreversal. Delayed R wave progression. Compared to the previous tracing\nof arm lead reversal is now present and the rate is slower.\nVentricular ectopy is now present.\n\n"
},
{
"category": "ECG",
"chartdate": "2118-05-20 00:00:00.000",
"description": "Report",
"row_id": 269783,
"text": "Sinus rhythm. Non-specific ST-T wave changes. There are non-diagnostic\nQ waves in the inferior leads. Compared to the previous tracing of \nST-T wave changes are new.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2118-05-19 00:00:00.000",
"description": "Report",
"row_id": 269784,
"text": "Sinus bradycardia. The P-R interval is prolonged. There are non-diagnostic\nQ waves in the inferior leads. Compared to the previous tracing of \nthe QRS duration is shorter and ST-T wave changes are no longer present.\nTRACING #1\n\n"
}
] |
27,144 | 148,994 | VARICEAL BLEED In the ED, he was transfussed 2uPRBC's, 1 uFFP, and given 4L NS. He was started on octreotide and iv PPI. He had NGT placement with 500cc bloody return and melena->BRBPR. He was then transferred to MICU for EGD which showed Grade II non-bleeding varices, clot in stomach, and had 4 varices banded. He remained HD stable (SBP 120-140, HR 80's, sat mid 90's on 2-3L NC) and hct remained stable: 26-27. The octreotide drip was stopped. He will need to return for repeat banding procedure by EGD on . He was placed on nadolol for secondary prevention. He was placed on levofloxacin and carafate for a 10 day course, to stop . CIRRHOSIS The patient will need to follow-up with a hepatologist, Dr. , here at . Baseline AFP was checked and was 3.4. FEVERS Pt experienced low grade fevers when transferred to the floor. Cultures of urine and blood were negative for growth, and cxr showed atelectasis but no infiltrate. He was treated with ciprofloxacin initially with the GIB and this was switched to levofloxacin to complete a 10d course on . His fevers are presumed to be due to atelectasis as all cultures remain negative and his only localizing symptom is a cough. ACUTE RENAL FAILURE Most consistent with pre-renal azotemia as Cr improved to 0.8 on discharge. THROMBOCYTOPENIA The patient dropped his platelet count during this admission, most likely due to heavy consumption. ALCOHOL ABUSE Patient met with social work, and has agreed for inpatient rehab. He was directed that he must never drink alcohol again. | pneumoboots on.Resp-LS clear to diminished.GI-Endoscopy done on admit to CCU. Traceaortic regurgitation is seen. Mildly dilated ascendingaorta. Traceaortic regurgitation. Mild mitral regurgitation. UO low 4-25cc/hr-MDs aware. Tissue Doppler imaging suggests a normal left ventricular fillingpressure (PCWP<12mmHg). There is an anteriorspace which most likely represents a fat pad.IMPRESSION: Mild symmetric left ventricular hypertrophy with normal systolicfunction. ?ARF from hypoprofusion + ATN.ID-cipro as ordered. Syncope.Height: (in) 70Weight (lb): 210BSA (m2): 2.13 m2BP (mm Hg): 120/63HR (bpm): 79Status: InpatientDate/Time: at 09:57Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). Mild (1+) MR.TRICUSPID VALVE: Mild [1+] TR. Again there is somewhat low lung volumes with bibasilar atelectatic change. Physiologic(normal) PR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.Conclusions:The left atrium is mildly dilated. f/u lytes. There is minimally increased density at the lung bases consistent with subsegmental atelectasis or scarring. The ascending aortais mildly dilated. CIWA scale is negative.GI/GU: Pt NPO in am. The remainder of the visualized paranasal sinuses and mastoid air cells remain normally aerated. Continue protonix and octreotide per GI reccs. The aortic arch is mildly dilated. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. CIWA 0 this shift. Non-bleeding varicies x4 banded. IV PPI infusing. SBP 120's-140's.Resp: Lungs rales in bases otherwise clear. Endoscopy procedure note. Small bilateral pleural effusions. carafate QID. AMBER CLEAR URIN. Protonix infusion stopped. Mildly dilated aortic arch.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). last crt 1.6 down from 2.7 admit. The portal vein is patent with normal hepatopetal flow. Upper dentures in.GU-Crt 2.7, BUN 54. Sinus rhythm. "O-62y.o male c Hx ETOH, HTN, Depression. BUN59, CREAT 2.5 DECREASED SINCE EARLIER LABS.CV:NSR HR 84, BP 129/57(74)ACCESS:3 LARGE BORE PIV.A:HYPOVOLEMIC FLUID REPLACEMENT. Update pt on POC. Small amount of ascites is present. Tele sinus rhythm. Mild (1+) mitral regurgitation is seen.There is mild pulmonary artery systolic hypertension. Pt updated on POC. IMPRESSION: Streaky bibasilar density most consistent with subsegmental atelectasis or scarring. INDICATION: Reevaluate basilar lung opacities. Normal right ventricular function. cooperative c care. Foley draining CYU. Minor residual atelectatic changes are present as well as small bilateral pleural effusions. A small amount of perihepatic fluid is present. SINCE HAS RESOLVED. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Pt denies shortness of breath.Neuro: Pt is alert and oriented x's 3 cooperative with care. CCU Nursing noteS-"I feel like I'm going in and out of it. LLL infiltrate on cxray?GI-+BS, -BM. octreotide and protonix gtts as ordered. Follow GI reccs. There is a small amount of ascites, which layers along the liver and in the lower abdominal quadrants. Sinus tachycardia. FFP for INR >1.5. Lung volumes are low, as before. K being repleated overnight via Perpherial IV. "O-see flowsheet for details. TDI E/e' < 8, suggesting normal PCWP (<12mmHg).No resting or Valsalva inducible LVOT gradient. Urine lytes sent in ED. Also recieved 3 units FFP, 4L NS, 1L LR. Hct 29.4 @ admit, then down to 25.6, last check 25.3 s/p 2 units prbc. IMPRESSION: 1. Abd soft, nontender with bowel sounds present. Keep NPO. Octreotide drip dc'd at 12n. IMPRESSION: Unremarkable, limited examination. Comparison with the previous study of . The mitral valve leaflets are mildly thickened.There is no mitral valve prolapse. 4 cords of Grade II varicies were seen in the esophagus. Bibasilar atelectatic changes are again seen with blunting of the costophrenic angles consistent with pleural effusion. URIN OUTPUT GOOD >80CC/HR. Additionally, foci of discoid atelectasis are present on the lateral view in the retrosternal area. Cont to monitor hct and lytes. HEAD CTGU:HYPERNATREMIC UA SHOWED PT DEHYDRATED AND CONTINUES TO RECEIVE IV FLUIDS AND BOLUSES. FINDINGS: This was a limited study to assess for ascites. Monitor HD. CIWA SCALE NOW <5.SKIN:JUANDICE.NEURO:ALERT AND ORIENTEDX3 SOME AGITATION AND DROWSINESS THIS A.M. Otherwise w/d signs negative. Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. pulses palpable. Since the previous tracing of the rate is slower.TRACING #2 One view. Evaluate for cirrhosis. Early R wave progression. One semi-upright portable view. There is mild symmetric left ventricularhypertrophy with normal cavity size and regional/global systolic function(LVEF>55%). Evaluate for bleed. Now on 3rd unit prbc currently infusing. Cipro . 2gm Mag repleated and K repleated. Denies N/V. Has recieved 3 units prbcs, 6 units FFP, and several liters crystaloids for anemia, elevated INR, and hypovolemia. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Since the previous tracing of the Q-T interval is longer.TRACING #1 Please f/u am labs and dose if needed. The -white matter differentiation is preserved. Advance diet as tolerated. ELECTROLYTES REPLACEMNT, ANEMIA.P:MONITOR SERIAL HCT, LYTES TREAT AS NEEDED. 7:56 AM CHEST (PORTABLE AP) Clip # Reason: ? F/U am labs. Comparison with the previous study done . Lung volumes are low. FINDINGS: Extremely low lung volumes when compared to the study of . Admitted to MICU as CCU boarder for suspected ETOH Hepatits and UGIB. Shortness of breath. A non-distended gallbladder is seen containing sludge and stone. Presented c Melena and Hematemesis x 4 days. The heart and mediastinal structures are unchanged. NPO. Underwent endoscopy same day as admit. flat affect. ABDOMINAL ULTRASOUND: Liver demonstrates normal echogenicity without focal mass. Note is made of opacification of scattered ethmoid air cells, likely inflammatory in origin. 25 mg Trazadone for insomnia. 2:52 PM CT HEAD W/O CONTRAST Clip # Reason: ? | 16 | [
{
"category": "Radiology",
"chartdate": "2116-02-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 997542,
"text": " 12:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate?\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with etoh cirrhosis now w/. fever\n REASON FOR THIS EXAMINATION:\n infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Alcoholic cirrhosis with fever.\n\n FINDINGS: Extremely low lung volumes when compared to the study of .\n Bibasilar atelectatic changes are again seen with blunting of the costophrenic\n angles consistent with pleural effusion. No definite focal pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-19 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 997682,
"text": " 1:46 PM\n CHEST (PA & LAT) Clip # \n Reason: reassess opacity at base(s) with pa/lat film\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with new fevers, cirrhosis and s/p UGIB\n REASON FOR THIS EXAMINATION:\n reassess opacity at base(s) with pa/lat film\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST, AT 13:50\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Reevaluate basilar lung opacities.\n\n Lung volumes are slightly improved compared to the previous study with\n associated improving aeration at the lung bases. Minor residual atelectatic\n changes are present as well as small bilateral pleural effusions.\n Additionally, foci of discoid atelectasis are present on the lateral view in\n the retrosternal area.\n\n IMPRESSION:\n\n Improving basilar atelectasis. Small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-19 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 997546,
"text": " 1:50 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: eval for ascites, mark please if fluid present for paracente\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with etoh cirrhosis, now w/ fevers, eval if ascites for sbp?\n REASON FOR THIS EXAMINATION:\n eval for ascites, mark please if fluid present for paracentesis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old male with alcoholic cirrhosis, now with fever and\n concern for possible spontaneous bacterial peritonitis.\n\n FINDINGS: This was a limited study to assess for ascites. There is a small\n amount of ascites, which layers along the liver and in the lower\n abdominal quadrants. The volume of ascites was deemed insufficient for bedside\n paracentesis and thus, no spot was marked.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-17 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 997259,
"text": " 2:15 PM\n CHEST (PA & LAT) Clip # \n Reason: ?LLL infiltrate\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with GIB, ?infiltrate on portable CXR\n REASON FOR THIS EXAMINATION:\n ?LLL infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: GI bleed with some suggested pneumonia on previous chest x-ray.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Again there is somewhat low lung volumes with bibasilar atelectatic\n change. The possibility of a more focal consolidation at the base cannot be\n excluded.\n\n"
},
{
"category": "Echo",
"chartdate": "2116-02-17 00:00:00.000",
"description": "Report",
"row_id": 70192,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath. Syncope.\nHeight: (in) 70\nWeight (lb): 210\nBSA (m2): 2.13 m2\nBP (mm Hg): 120/63\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 09:57\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg).\nNo resting or Valsalva inducible LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Mildly dilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\n(normal) PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling\npressure (PCWP<12mmHg). There is no left ventricular outflow obstruction at\nrest or with Valsalva. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The ascending aorta\nis mildly dilated. The aortic arch is mildly dilated. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Trace\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension. There is an anterior\nspace which most likely represents a fat pad.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with normal systolic\nfunction. Normal right ventricular function. Mild mitral regurgitation. Trace\naortic regurgitation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 997053,
"text": " 10:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for aspiration\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with c/o dyspnea over past several months, mild hypoxia\n REASON FOR THIS EXAMINATION:\n eval for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Shortness of breath, hypoxia, evaluate for aspiration.\n\n One semi-upright portable view. Comparison with the previous study done\n . Lung volumes are low. There is minimally increased density at the\n lung bases consistent with subsegmental atelectasis or scarring. There is no\n definite focal consolidation. The cardiac silhouette is prominent but may be\n exaggerated by portable technique. Mediastinal structures are otherwise\n unremarkable. The bony thorax is grossly intact.\n\n IMPRESSION: Unremarkable, limited examination. PA and lateral views with\n better inspiratory effort are recommended if further evaluation is required.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 997091,
"text": " 7:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? LLL infiltrate on CXR\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with persistent vomiting over the past several days and hypoxia\n REASON FOR THIS EXAMINATION:\n ? LLL infiltrate on CXR\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Vomiting, hypoxia, possible left lower lobe infiltrate.\n\n One view. Comparison with the previous study of . Lung volumes are\n low, as before. There is increased streaky density at the lung bases most\n consistent with subsegmental atelectasis. No definite focal consolidation is\n seen. The heart and mediastinal structures are unchanged.\n\n IMPRESSION: Streaky bibasilar density most consistent with subsegmental\n atelectasis or scarring. The study with better inspiratory effort or PA and\n lateral views would be helpful if further evaluation for basilar consolidation\n is required.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 997125,
"text": " 2:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with fall, alcoholic, coagulopathic, new headache\n REASON FOR THIS EXAMINATION:\n ? bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 62-year-old male status post fall, alcoholic, coagulopathic\n with new headache. Evaluate for bleed.\n\n COMPARISON: head CT scan.\n\n NON-CONTRAST HEAD CT: There is no hemorrhage, mass effect, hydrocephalus, or\n shift of normally midline structures. The -white matter differentiation\n is preserved. No major vascular territorial infarct is apparent. The\n surrounding soft tissue and osseous structures are unremarkable. Note is made\n of opacification of scattered ethmoid air cells, likely inflammatory in\n origin. The remainder of the visualized paranasal sinuses and mastoid air\n cells remain normally aerated.\n\n IMPRESSION: No intracranial hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-17 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 997220,
"text": " 10:20 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: eval for cirrhosis\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with hyperbilirubinemia\n REASON FOR THIS EXAMINATION:\n eval for cirrhosis\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 62-year-old male with hyperbilirubinemia. Evaluate for\n cirrhosis.\n\n COMPARISON: None.\n\n ABDOMINAL ULTRASOUND: Liver demonstrates normal echogenicity without focal\n mass. A non-distended gallbladder is seen containing sludge and stone. There\n is no gallbladder edema or intra/extra-hepatic biliary dilatation. The common\n bile duct measures 6 mm. The portal vein is patent with normal hepatopetal\n flow. A small amount of perihepatic fluid is present. The right kidney\n measures 11.5 cm. The left kidney measures 13.2 cm. There is no\n hydronephrosis, mass, or stone. A 2.3 x 2.2 x 1.9-cm cyst is seen within the\n lower pole of the left kidney. The spleen is normal. The pancreas is not\n well evaluated.\n\n IMPRESSION:\n\n 1. The liver shows no textural or focal abnormality. Small amount of ascites\n is present.\n\n 2. Gallbladder contains sludge and stones. No evidence of acute\n cholecystitis.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-17 00:00:00.000",
"description": "Report",
"row_id": 1617026,
"text": "CCU Nursing note\nS-\"I wonder how long I'll be here?\"\nO-62y.o male c Hx ETOH, HTN, Depression. Presented c Melena and Hematemesis x 4 days. Admitted to MICU as CCU boarder for suspected ETOH Hepatits and UGIB. Underwent endoscopy same day as admit. Non-bleeding varicies x4 banded. Has recieved 3 units prbcs, 6 units FFP, and several liters crystaloids for anemia, elevated INR, and hypovolemia. ARF hypovolemia admit crt 2.7.\n\nN-a/ox3, MAE in bed. Tylenol x1 350mg for knee pain arthritis. 25 mg Trazadone for insomnia. CIWA 0 this shift. Cooperative c care.\n\nCV-Frequent Hct checks, goal >25. FFP for INR >1.5. F/U am labs. K being repleated overnight via Perpherial IV. palpable pulses. 3 large bore IVs. of note baseline Hct 36-40. pneumoboots.\n\nResp-3L NC c sats >95%. Faint bibasler crackles. LLL infiltrate on cxray?\n\nGI-+BS, -BM. octreotide and protonix gtts as ordered. Cipro . carafate QID. NPO.\n\nGU-ARF c rebound auto diuresis overnight 200-400cc/hr. last crt 1.6 down from 2.7 admit. +8.9L LOS s/p blood products and hydration.\n\nskin-intact.\nID-afebrile.\nsocial-sister, 2 daughters. pt wanted sister only to be called in case of emergency. However did mention \"I might call someone tommorrow to let them know I'm here.\" social work consulted.\n\nplan-? US of kidney/liver today? Continue to monitor Hct, INR, and lytes and repleate as needed. Follow GI reccs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-17 00:00:00.000",
"description": "Report",
"row_id": 1617027,
"text": "Nursing Progress note\n\nO: Please see flow sheet for objective data. Tele sinus rhythm. SBP 120's-140's.\n\nResp: Lungs rales in bases otherwise clear. O2 sats 95-98% on 2. On room air 88-90%. Pt denies shortness of breath.\n\nNeuro: Pt is alert and oriented x's 3 cooperative with care. Dangling at side of bed. Able to stand with assistance. CIWA scale is negative.\n\nGI/GU: Pt NPO in am. Denies N/V. Abd soft, nontender with bowel sounds present. No BM today. Protonix infusion stopped. Octreotide drip dc'd at 12n. hct stable at 26. Foley draining CYU. Creat returned to baseline.\n\nSocial: No calls or visitors today.\n\nA&P: hct stable after banding. Cont to monitor hct and lytes. Advance diet as tolerated. Encourage activity. Transfer to floor when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-16 00:00:00.000",
"description": "Report",
"row_id": 1617024,
"text": "CCU Nursing note\nS-\"I feel like I'm going in and out of it.\"\nO-see flowsheet for details. 62y.o male admitted via ED c coffee ground emesis x 4 days (10 x per day) and watery black stools x 3 days. PMHx significant for HTN, ETOH use c pints of beer x 4 days/wk, cigar smoker, depression. Last drink 4 days ago.\n\nN-CIWA only 0-2 c HA. Otherwise w/d signs negative. a/ox3, mae in bed. cooperative c care. flat affect. social work consulted for ETOH use and coping.\n\nCV-3 large bore IVs, SBP 100-130, HR NSR 80s-90s. pulses palpable. Hct 29.4 @ admit, then down to 25.6, last check 25.3 s/p 2 units prbc. Now on 3rd unit prbc currently infusing. Also recieved 3 units FFP, 4L NS, 1L LR. 2gm Mag repleated and K repleated. unable to dose other 2gm mag nor Ca due to need for blood products and access. Please f/u am labs and dose if needed. pneumoboots on.\n\nResp-LS clear to diminished.\n\nGI-Endoscopy done on admit to CCU. See procedure note above. Bands x4 to varicies, however not activley bleeding. NPO. Octreotide @ 25mcg/hr, Protonix @ 8mg/hr. to start carafate. Upper dentures in.\n\nGU-Crt 2.7, BUN 54. Urine lytes sent in ED. UO low 4-25cc/hr-MDs aware. ?ARF from hypoprofusion + ATN.\n\nID-cipro as ordered. afebrile.\n\nskin-intact.\nsocial-pt lives alone. does not appear to be in close contact c any family members requesting sister only to be called in case of an emergency. 2 daughters per pt. no family at time of admit, pt denies need to call anyone at this time.\n\nplan-monitor Hct s/p prbc transfusion. f/u lytes. Monitor HD. Continue protonix and octreotide per GI reccs. Keep NPO. Update pt on POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-16 00:00:00.000",
"description": "Report",
"row_id": 1617025,
"text": "S:\"I HAVE AN AWFUL HEADACHE AND I NEVER HAVE HEADACHES\".\n\n62YO MALE C A PMH OF ETOH ABUSE, HTN, AND DEPRESSION WHO PRESENTS C MELENA AND HEMATEMESIS.\n\nGI:VARICES NO ACTIVE BLEEDING PT CURRENTLY ON OCTREOTIDE GTT 25/HR, CIPRO FOR VARICES AND PROTONIX. HCT 27.6, INR 1.6 GOAL INR<1.5 HCT >25. PT C/O NAUSEA MOST OF AM AND C/O HEADACHES CIWA >10 RECEIVED DIAZEPAM 5MG X2 AND ONDANSERTRON X1 WITH RELIEF OF NAUSEA AND HEADACHE. CIWA SCALE NOW <5.\n\nSKIN:JUANDICE.\n\nNEURO:ALERT AND ORIENTEDX3 SOME AGITATION AND DROWSINESS THIS A.M. SINCE HAS RESOLVED. HEAD CT\n\nGU:HYPERNATREMIC UA SHOWED PT DEHYDRATED AND CONTINUES TO RECEIVE IV FLUIDS AND BOLUSES. URIN OUTPUT GOOD >80CC/HR. AMBER CLEAR URIN. BUN59, CREAT 2.5 DECREASED SINCE EARLIER LABS.\n\nCV:NSR HR 84, BP 129/57(74)\n\nACCESS:3 LARGE BORE PIV.\n\nA:HYPOVOLEMIC FLUID REPLACEMENT. ELECTROLYTES REPLACEMNT, ANEMIA.\n\nP:MONITOR SERIAL HCT, LYTES TREAT AS NEEDED. NPO, PT WILL NEED TO GO TO ULTRA SOUND TOMMORROW FOR KIDNEY AND LIVER.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-16 00:00:00.000",
"description": "Report",
"row_id": 1617023,
"text": "Endoscopy procedure note. 2155-2225. Recieved a total of 4mg Versed, 100mcg Fentanyl and tolerted procedure well. SBP 98-125, MAP >62 throughout case, HR NSR 90s, sats 97-100% on 4L, RR 15-22. 4 cords of Grade II varicies were seen in the esophagus. The varicies however where not activly bleeding. 4 bands were successfully placed. To keep NPO for night, transfused for hct <30, FFP. IV PPI infusing. Pt updated on POC.\n"
},
{
"category": "ECG",
"chartdate": "2116-02-15 00:00:00.000",
"description": "Report",
"row_id": 155062,
"text": "Sinus rhythm. Since the previous tracing of the rate is slower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2116-02-15 00:00:00.000",
"description": "Report",
"row_id": 155063,
"text": "Sinus tachycardia. Leftward axis. Early R wave progression. Increased\nQTc interval. Since the previous tracing of the Q-T interval is longer.\nTRACING #1\n\n"
}
] |
16,406 | 112,560 | The patient is a 59-year-old male with a history of diabetes mellitus, end-stage renal disease, on hemodialysis, and a history of multiple GI bleeds presenting after feeling dizzy and weak, noted to have hypotension. 1. HYPOTENSION: The hospital course on admission in the field had been noted for systolic blood pressures in the 50s to 60s. Upon arrival here, the patient had received pressors for treatment as well as multiple liters of fluid. The etiology of the patient's hypotension/shock is most likely secondary to sepsis versus hypovolemia. With regards to a sepsis workup, the patient was initially started on vancomycin and Flagyl. His blood cultures had been negative upon the time of discharge times 72 hours. During the hospital course, he had been afebrile. Other etiologies regarding the patient's hypotension and shock may have been secondary to hypovolemic shock as the patient had significant improvement with fluids. The patient had been initially weaned from pressors after approximately one day during the hospital MICU stay. Other etiologies of the patient's shock may have included a history of adrenal insufficiency. The patient has had a renal transplant in the past and had been on steroids for suppression. After the transplant had been removed, he had been tried on a prednisone taper, although per report had been told to continue with 5 mg of prednisone for the time being. He initially had been started on hydrocortisone and Florinef during the MICU course. The patient's infectious workup had been negative since the patient had been treated and had been having multiple days of diarrhea, he had recent stool cultures. The stool cultures were negative to date. Of note, the C. dif was also negative. Other workup for the patient's hypotension included abdominal CT and chest CT. This showed that there was no evidence of aortic dissection or pulmonary embolus. No pneumonia. No intra-abdominal abscess. No evidence of ischemic bowel. 3. NEUROLOGY: The patient initially presented with confusion per report upon admission. However, upon arrival to the MICU, the patient had been alert and oriented times three and had been able to give a good history. He had a head CT which had been negative for hemorrhage. 4. RENAL: The patient was continued on hemodialysis throughout this hospital course. Otherwise with regards to the patient's symptoms, he was initially started on hydrocortisone in the Emergency Room. He will be sent home on the steroid taper as the patient is on baseline 5 mg of prednisone per day. Also of note, during his hospital course, he reported that he wanted to leave, although we had recommended keeping the patient in-house for an extra day or to and the patient signed out against medical advise. He was recommended to call or return if he has any symptoms of lightheadedness or dizziness, increased nausea, vomiting, or diarrhea. He also was sent home on an empiric course of Flagyl as well as a steroid taper. The empiric course of Flagyl was possible C. dif. | Sinus rhythmPoor R wave progression - probable within normal limitsSince previous tracing of : no ventricular premature complex Sinus rhythmVentricular premature complexLead(s) unsuitable for analysis: V4Poor R wave progression - probable normal variantSince previous tracing of : lead V4 is missing and ventricular prematurecomplex is seen PATIENT/TEST INFORMATION:Indication: Left ventricular function.BP (mm Hg): 137/54Status: InpatientDate/Time: at 13:01Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The interatrial septum is dynamic, but notfrankly aneurysmal.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. sat 96-98%CV- 100-130/60-70 remains off neo. DUE FOR HD TODAY.ENDO: PT IS ON ROUTINE NPH AND RISS. The visualized (Over) 9:21 AM CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # CTA PELVIS W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Reason: HYPOTENSION, N/V AND ISCHEMIC EKG, COMPLAINTS OF BACK PAIN, R/O AORTIC DISSECTION Field of view: 36 Contrast: OPTIRAY Amt: 150CC FINAL REPORT (Cont) osseous structures are normal. Rule out hemorrhage. Transient EKG changes on admission, EKG done today, no changes seen, enzymes drawn-wnl. RANDOM LEVEL SENT THIS AM, PENDNING.DISPO: PLAN IS FOR HD TODAY. TECHNIQUE: Routine non-contrast head CT. The estimated pulmonary artery systolic pressure isnormal.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is normal in size. Vanco given post dialysis.GI- stool x3 today, loose green. MICU Nsg Progress Note 3-7pMICU trasnfer note written.REsp- Clear BS on 2l NP. The estimated pulmonary artery systolic pressure is normal.There is no pericardial effusion.A mild resting left ventricular outflow tract gradient was noted (27 mm Hg)which went away after the dopamine infusion was decreased.Aortic dissection cannot be adequately assessed or excluded by this study. PT DENIES ANY PAIN.RESP: LS CLEAR/ FINE CRCKELS IN BASES AT START OF SHIFT. There is a non-enlarged hilar lymph node on the right measuring 9 mm in short axis dimension. PT REMOVES O2, SATS 92%.CV: HR 80-90'S NSR, NO ECTOPY. REASON FOR THIS EXAMINATION: bleed No contraindications for IV contrast FINAL REPORT INDICATION: Diabetes, endstage renal disease on hemodialysis, mental status changes, hypotension. TECHNIQUE: Helically acquired CT images were obtained from the aortic arch to the aortic bifurcation following the administration of 150 cc Optiray non- ionic IV contrast. Overall left ventricular systolic functionis normal (LVEF>55%).RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is moderately dilated.AORTIC VALVE: The aortic valve leaflets are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation. SQ Heparin provided for DVT prophylaxis.GU: Pt was slated to receive his HD treatment today. PT REMAINS ON NEO GTT. bp 1teens-130/sys. 9:21 AM CT HEAD W/O CONTRAST Clip # Reason: MS CHANGES, HYPOTENSION? PT TOLERATING . MICU -B Nursing Progress/Transfer Note 7a-3pNeuro-Alert & Oriented x3, , , transfer tochair w/ supervision and spotting only considering visual deficit. PT ON FLAGYL IV Q12. IVF @ d/c @1400ID afebrile, vanco d/c; flagyl changed to po for suspicion of Cdiff in stool, cultures pending.REnal- HD yesterday. CVP ~.GI/GU: ABD SOFT, +BS, +BM. Sinus rhythmAnterolateral ST elevation - possible early repolarizationSince previous tracing of : ST changes are seen CT of head, thorax, torso done in EW negative. CT OF THE ABDOMEN AFTER IV CONTRAST: The liver, gallbladder, pancreas, spleen, and adrenal glands have a normal appearance on this early arterial phase study. IMPRESSION: Right subclavian line tip in right atrium. Pt currently denies pain. Per Renal service, the pt was subsequently bolused c one liter NS to keep MAP above 60 (will favor fluids over Neo gtt to maintain desired MAP > 60 as long as pt is oxygenating well. MAX TEMP 99.0. micu npn 1900-0700 patient remains in trhe micu. Pt to receive this dose tomorrow am and cover w/ ss as needed.A/P-Stable; monitor BS closely. Right ventricular chamber size and free wall motion are normal.The aortic valve leaflets are mildly thickened. The extreme left lung base has been excluded from the exam. The aortic root is moderately dilated.There is mild symmetric left ventricular hypertrophy. The pt is a full code c univ isolation procedures in place. The heart is top normal in size and the mediastinal contour is unremarkable for technique. The splenic and renal arteries are calcified. Pt deneid recent antibiotic use when asked. REASON FOR THIS EXAMINATION: Aortic dissection No contraindications for IV contrast WET READ: DCsc WED 11:00 AM NO DISSECTION NO PE NO PNA NO ISCHEMIC BOWEL BUT NOT ALL THE BOWEL SEEN FINAL REPORT INDICATION: Hypotension, nausea vomiting, EKG changes, back pain. | 13 | [
{
"category": "Radiology",
"chartdate": "2183-07-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 791828,
"text": " 12:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: right subclavian line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with DM, ESRD, hypotension\n REASON FOR THIS EXAMINATION:\n right subclavian line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypotension. Right subclavian line placement.\n\n COMPARISON: \n\n FINDINGS: There is a new right subclavian central venous line with tip in the\n right atrium. No pneumothorax is visible. The extreme left lung base has\n been excluded from the exam. The heart is top normal in size and the\n mediastinal contour is unremarkable for technique. Pulmonary vascularity is\n indistinct, and there is patchy perihilar edema bilaterally. Possible small\n right pleural effusion.\n\n IMPRESSION: Right subclavian line tip in right atrium. No pneumothorax. CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-16 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 791793,
"text": " 9:21 AM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST\n Reason: HYPOTENSION, N/V AND ISCHEMIC EKG, COMPLAINTS OF BACK PAIN, R/O AORTIC DISSECTION\n Field of view: 36 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with DM, ESRD on HD a/w hypotension, diarrhea, N/V and ischemic\n EKG.\n REASON FOR THIS EXAMINATION:\n Aortic dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DCsc WED 11:00 AM\n NO DISSECTION\n NO PE\n NO PNA\n NO ISCHEMIC BOWEL BUT NOT ALL THE BOWEL SEEN\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypotension, nausea vomiting, EKG changes, back pain.\n The patient is on dialysis.\n\n TECHNIQUE: Helically acquired CT images were obtained from the aortic arch to\n the aortic bifurcation following the administration of 150 cc Optiray non-\n ionic IV contrast. Non-ionic contrast was used because of the rapid rate of\n contrast bolus required for the CT angiogram protocol. Oblique sagittal\n reformats were produced.\n\n Comparison is made to CT of the abdomen and pelvis from .\n\n CT ANGIOGRAM OF THE AORTA WITH IV CONTRAST: There is no aortic dissection or\n transection. There is no mediastinal hematoma. Mild atherosclerotic changes\n are seen in the lower abdominal aorta extending into the iliac vessels. No\n mural thrombus is seen within the aortic arch or thoracic aorta. There is no\n pulmonary embolis.\n\n CT OF THE CHEST WITH IV CONTRAST: There is no axillary or mediastinal\n adenopathy. There is a non-enlarged hilar lymph node on the right measuring 9\n mm in short axis dimension. The airways are patent. Evaluation of the lungs\n is somewhat compromised by respiratory artifact. There are no consolidations.\n There is dependent atelectasis bilaterally.\n\n CT OF THE ABDOMEN AFTER IV CONTRAST: The liver, gallbladder, pancreas,\n spleen, and adrenal glands have a normal appearance on this early arterial\n phase study. The splenic and renal arteries are calcified. The kidneys are\n small bilaterally. There is an exophytic cyst in the right kidney.\n There has been surgical resection of the previously seen right lower\n quadrant transplant kidney. Post surgical changes and surgical clips are seen\n in this region. There is no mesenteric or retroperitoneal adenopathy. The\n visualized aspects of the large and small bowel are not opacified but there\n are no areas of wall thickening or luminal dilatation. There is no free air or\n ascites. There is a small fat containing umbilical hernia. The visualized\n (Over)\n\n 9:21 AM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST\n Reason: HYPOTENSION, N/V AND ISCHEMIC EKG, COMPLAINTS OF BACK PAIN, R/O AORTIC DISSECTION\n Field of view: 36 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n osseous structures are normal.\n\n REFORMATS: The oblique sagittal reconstructions confirm the above findings.\n\n IMPRESSION: No aortic dissection or pulmonary embolis. No pneumonia. No\n intra-abdominal abscess. No evidence of ischemic bowel (note that the loops\n of bowel located within the pelvis are incompletely evaluated).\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 791794,
"text": " 9:21 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: MS CHANGES, HYPOTENSION? FALL/BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with DM, ESRD on HD a/w hypotension, diarrhea, N/V and ischemic\n EKG and MS changes. Pt blind, ? fall.\n REASON FOR THIS EXAMINATION:\n bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diabetes, endstage renal disease on hemodialysis, mental status\n changes, hypotension. Questionable fall. Rule out hemorrhage.\n\n TECHNIQUE: Routine non-contrast head CT.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage. There is no mass\n effect or shift of normally midline structures. The -white matter\n differentiation is preserved. The ventricles, cisterns, and sulci are\n unremarkable without effacement. The visualized paranasal sinuses and\n mastoids are unremarkable. No fractures are identified.\n\n IMPRESSION: No evidence for hemorrhage.\n\n"
},
{
"category": "Echo",
"chartdate": "2183-07-16 00:00:00.000",
"description": "Report",
"row_id": 67520,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nBP (mm Hg): 137/54\nStatus: Inpatient\nDate/Time: at 13:01\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 interatrial septum is dynamic, but not\nfrankly aneurysmal.\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 moderately dilated.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened.\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\nConclusions:\nThe left atrium is normal in size. The aortic root is moderately dilated.\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.\nThe aortic valve leaflets are mildly thickened. The mitral valve leaflets are\nmildly thickened. The estimated pulmonary artery systolic pressure is normal.\nThere is no pericardial effusion.\n\nA mild resting left ventricular outflow tract gradient was noted (27 mm Hg)\nwhich went away after the dopamine infusion was decreased.\n\nAortic dissection cannot be adequately assessed or excluded by this study.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2183-07-18 00:00:00.000",
"description": "Report",
"row_id": 142670,
"text": "Sinus rhythm\nPoor R wave progression - probable within normal limits\nSince previous tracing of : no ventricular premature complex\n\n"
},
{
"category": "ECG",
"chartdate": "2183-07-17 00:00:00.000",
"description": "Report",
"row_id": 142671,
"text": "Sinus rhythm\nVentricular premature complex\nLead(s) unsuitable for analysis: V4\nPoor R wave progression - probable normal variant\nSince previous tracing of : lead V4 is missing and ventricular premature\ncomplex is seen\n\n"
},
{
"category": "ECG",
"chartdate": "2183-07-16 00:00:00.000",
"description": "Report",
"row_id": 142672,
"text": "Sinus rhythm\nAnterolateral ST elevation - possible early repolarization\nSince previous tracing of : ST changes are seen\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-07-16 00:00:00.000",
"description": "Report",
"row_id": 1476946,
"text": "Nursing Admit/Progress Note.\n\nBriefly, this is a 59 yr old male who developed N/V on the evening of F/B diarrheal stools times three O/N and alt MS this AM. Wife activated EMS, pt found to be agitated, hypotensive c ST changes in EW. CT of head, thorax, torso done in EW negative. Pt transiently started on a Dopamine gtt, subsequently changed to IV Phenylephrine 2nd tachycardia. Pt bolused c a total of 3 L NS IV in EW and also given 1gm IV Vancomycin and started on IV Flagyl. PMH includes; ESRD s/p failed renal transplant (surgically removed on ), HD treatments are received M/W/F (LUE fistulae noted) Anuria, Anemia (admit HCT = 39.8), UGIB, tear, Gastritis (AVM's, gastritis). The pt is a full code c univ isolation procedures in place. Pt transferred to MICU-B for continuation of care.\n\n\nCV: Pt received c Neo gtt infusing @ 0.5mcg/kg/min via TLC c MAP in the 55-high 60 range per NBP. Per Renal service, the pt was subsequently bolused c one liter NS to keep MAP above 60 (will favor fluids over Neo gtt to maintain desired MAP > 60 as long as pt is oxygenating well. The pts TLC was placed in EW, placement confirmed by CXR, +brisk blood return noted from all three lumens. Second set of CPK's sent @ 17:00 as scheduled, results are currently pending. SQ Heparin provided for DVT prophylaxis.\n\nGU: Pt was slated to receive his HD treatment today. Per Renal service, will hold off on HD today and schedule a treatment for tomorrow (). L UE fistulae noted, will avoid BP, PIV's, FS, blood spec draws from this apendage.\n\nGI: Pt incontinent of foul smelling loose -colored stool. C.Diff spec sent for analysis as requested by team. Pt deneid recent antibiotic use when asked. Pt to start on a renal/cardiac diet for dinner tonight.\n\nRESP: Pt on 2LNCO2 c nl sats and no SOB/dyspnea. LSCTA, diminished @ bases.\n\nMS: AAO times three, following commands, pleasant/cooperative. Pt currently denies pain. The pt is sleepy, taking naps on/off, easily aroused.\n\nFAMILY: Wife visited c pt earlier, cousin currently visiting @ BS. Wife kept up-to-date c POC/pt status.\n\nOTHER: Please see CareVue for additional pt care data/comments.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-07-17 00:00:00.000",
"description": "Report",
"row_id": 1476947,
"text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT ALERT, OX3, MAE, FOLLOWS COMMANDS. EARLY IN SHIFT DURING EPISODE OF LOW SBP, PT SLIGHTLY CONFUSED FOR SHORT PERIOD OF TIME. PT DENIES ANY PAIN.\n\nRESP: LS CLEAR/ FINE CRCKELS IN BASES AT START OF SHIFT. O2 2LNC W/ SATS 94-100%. PT REMOVES O2, SATS 92%.\n\nCV: HR 80-90'S NSR, NO ECTOPY. PT REMAINS ON NEO GTT. PT HAD INCREASED REQUIREMENT THROUGHT OUT NIGHT, GTT HAS HIGH AS 1MCG/KG/MIN. 500CC NS BOLUS GIVEN W/ LITTLE EFFECT. NEO GTT CURRENTLY AT .6MCG/KG/MIN. GOAL FOR MAP OF 60. MAX TEMP 99.0. CVP ~.\n\nGI/GU: ABD SOFT, +BS, +BM. PT TOLERATING . PT HAS GOLDEN LOOSE STOOLX1. PT ANURIC. DUE FOR HD TODAY.\n\nENDO: PT IS ON ROUTINE NPH AND RISS. BS 163/110.\n\nID: AM WBC 26.7. PT ON FLAGYL IV Q12. PT WAS DOSED W/VANCO IN EW ON AT 1300. RANDOM LEVEL SENT THIS AM, PENDNING.\n\nDISPO: PLAN IS FOR HD TODAY. CONTINUE TO ATTEPT TO WEAN OF NEO GTT. MONITOR TEMP, CULTURE IS SPIKES. MULTIPLE FAMILY MEMBERS IN TO VISIT DURING EVENING. PT IS A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-07-17 00:00:00.000",
"description": "Report",
"row_id": 1476948,
"text": "NURSING PROGRESS NOTE 0700-1500\nFOR NURSING PROGRESS NOTE, PLS REFER TO NURSES TRANSFER NOTE IN \"NURSING TRANSFER NOTE\"SECTION OF CAREVIEW. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-07-17 00:00:00.000",
"description": "Report",
"row_id": 1476949,
"text": "MICU Nsg Progress Note 3-7p\nMICU trasnfer note written.\nREsp- Clear BS on 2l NP. sat 96-98%\n\nCV- 100-130/60-70 remains off neo. 80-90's sr\nIV NS @ 10/hr kvo.\n\nRenal- Dialysis today w/o event. L arm fistula w/o blding. Vanco given post dialysis.\nGI- stool x3 today, loose green. stool to be sent in not already.\nEndo- Appetite excellent w/ eating assistance. BS @ 1900 =174, 4u reg given after dinner.\nFixed Insulin type and dose changed per pt and pt wife. takes 70/30 20u @ 8am, w/ control 150-160 @ home. Pt to receive this dose tomorrow am and cover w/ ss as needed.\nA/P-\nStable; monitor BS closely. cont antibiotic course.\nWife and daughter visiting this evening. Informed of pt status, progress and plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-07-18 00:00:00.000",
"description": "Report",
"row_id": 1476950,
"text": "micu npn 1900-0700\n patient remains in trhe micu. vss o/n. bp 1teens-130/sys. pt alert and oriented x3. asking when he can go home. 2 episodes of diarreah, specs peding still for c diff/multiple studies, all cont to be negative. pt afebrile. no c/o pain/sob. no complaints o/n. blood sugar 112 last night, no coverage given by sliding scale. to start back on 70/30 regimine this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-07-18 00:00:00.000",
"description": "Report",
"row_id": 1476951,
"text": "MICU -B Nursing Progress/Transfer Note 7a-3p\n\nNeuro-\nAlert & Oriented x3, , , transfer tochair w/ supervision and spotting only considering visual deficit. Able to participate w/ self care and feeding.\n\nCV- 110-130/70 w/ 90's NSR. Transient EKG changes on admission, EKG done today, no changes seen, enzymes drawn-wnl. Will follow EKG.\nGI- NT, ND, + BS; Eating po/meals well, fluids taken w/o problem. IVF @ d/c @1400\nID afebrile, vanco d/c; flagyl changed to po for suspicion of Cdiff in stool, cultures pending.\nREnal- HD yesterday. Labs near pt baseline.\nEndo- Insulin am 70/30 20 units given this am; following SS rest of day. BS 136-148.\nA/P\nStable; Pt awaiting transfer to floor.\nCV- Monitor BP, EKG.\nRenal- cont HD as scheduled\nID- Flagyl po for suspected C diff\nEndo- am insulin of 70/30, cover throughout day w/ ss regular\nSocial- Discharge planning as needed. VNA to be notified upon pt d/c to home. Contact # in front of chart.\n"
}
] |
2,620 | 155,289 | 34y woman presents with recurrent R frontal hemorrhage with possible seizure following previous similar episode in . . The patient was admitted to the intensive care unit overnight under neurosurgical care and transferred to the step down unit under neurology care the following day. Dilantin was restarted to prevent seizures, and pt. was transitioned to Trileptal on the floor because the team felt that this would be a more appropriate drug for outpatient seizure prophylaxis. She was discharged with instructions to taper off Dilantin and increase Trileptal over the next several weeks. EEG was perfomed and showed no evidence of epileptiform activity. She was covered with Decadron given concern for possible swellling with the hemorrhage, and this was tapered down, and should be tapered off the day after discharge. CTA was performed to evaluate the etiology of the hemorrhage and showed no underlying mass or AVM (although they felt that AVM could not be excluded) Angiography was performed and showed no aneurysms or vascular malformations. Transient vasospasm of the cervical portion of the left internal carotid artery was noted. Pt. was given a 21 day course of Nimodipine for this. Neurologic exam was normal on the day of discharge. Pt. was asked to follow up with Dr. from Neurology and with her PCP. should have repeat angiogram in months to evaluate for AVM or aneurysm that may have been obscured acutely by hemorrhage. | On the prior MR studies, a tiny enhancing vessel, likely a cortical vein, was noted at the anteromedial aspect of the resolving hematoma in the right frontal lobe. CT ANGIOGRAM OF THE CIRCLE OF : Bilateral intracranial ICA, ECA and MCA are patent and normal in caliber. MRI showed frontal intraperichmal hemmorrhage w/areas of subacute/actue deposition. Transient vasospasm of the cervical portion of the left internal carotid artery which resolved without sequela. (Over) 7:39 AM CAROT/CEREB Clip # Reason: Anterior circulation angiogram to r/o AVM. CT scan showed ?mass vs pocket bleeding. 7:39 AM CAROT/CEREB Clip # Reason: Anterior circulation angiogram to r/o AVM. New 2.1 x 1.4 cm right inferior frontal parenchymal hematoma, in roughly the same distribution as the hemorrhage in . REASON FOR THIS EXAMINATION: Anterior circulation angiogram to r/o AVM. Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE Contrast: NON IONIC Amt: 256 ********************************* CPT Codes ******************************** * SEL CATH 3RD ORDER SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER * * ADD'L 2ND/3RD ORDER CAROTID/CERVICAL UNILAT * * CAROTID/CEREBRAL BILAT EXT CAROTID BILAT * * MOD SEDATION, FIRST 30 MIN. OPERATORS: Dr. and Dr. . Treated w/prn morphine. Admitted to SICU from ICU in for further workup & monitoring.PLEASE SEE CAREVUE FOR SPECIFICSCV: NBP stable, 110-140s w/NSR HR 76-110s. Delayed-phase images were obtained to evaluate the cerebral venous sinuses. Manipulate catheter to help alleviate.SKIN: Intact. 1-inch nitro paste was administered with resolution of the vasospasm. Bilateral distal vertebral, basilar and bilateral PCA are patent and normal in caliber. Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE Contrast: NON IONIC Amt: 256 FINAL REPORT (Cont) After all images were reviewed, all wires, sheaths, and catheters were removed and hemostasis was obtained by manual compression. COMMENT: The findings were discussed with Dr. by Dr. , with strong (Over) 11:18 AM CTA HEAD W&W/O C & RECONS Clip # Reason: r/o AVM/aneurysm also want CTV (per Dr. not able to Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE Field of view: 25 Contrast: OPTIRAY Amt: FINAL REPORT (Cont) recommendation for conventional catheter angiography to exclude underlying vascular abnormality AP, lateral, and rotational views of the right internal carotid artery. Note is made of filling of the right posterior cerebral artery as well as crossfilling of the left anterior cerebral artery. Cough/gag intact.NEURO: Pt appears lethargic, A&Ox3 (Pt in & out of periods of confusion, quick to reorient). f/u with dilantin level. However, this study is of poor quality due to delay in obtaining the arterial and the venous phase images FINDINGS: On the non-contrast CT, there is a new, 2.1 x 1.4 cm hyperdense area in the right inferior frontal lobe, with some surrounding hypodensity consistent with intraprenchymal hematoma with some surrounding edema. TECHNIQUE: 3D CT angiography for the evaluation of the circle of was performed with IV contrast. However, the new hematoma, noted on the present study, in the same region, limits assessment of vascularity in this region. Assess for underlying vascular lesions. No sz x5 yrs, stopped follow up w/Dr in '. AP and lateral of the right external carotid artery. AP, lateral, and rotational views of the left internal carotid artery. The following vessels were selected and angiograms performed. 1% lidocaine buffered with sodium bicarbonate was used to obtain local anesthesia. A 19-gauge needle was used to access the right common femoral artery via a single wall puncture. IMPRESSION: Cerebral angiogram of the internal and external carotid arteries bilaterally showing no aneurysms or vascular malformations. FINDINGS: The right internal carotid artery injection shows no aneurysms or vascular malformations. AP, lateral, oblique, and rotational views of the left common carotid artery in its cervical portion. | 3 | [
{
"category": "Nursing/other",
"chartdate": "2134-12-01 00:00:00.000",
"description": "Report",
"row_id": 1296312,
"text": "Admission Note\nPt is a 34 yo woman allergic to PCN & Doxycyclin, only history is of seizures, recieved no meds for, seen @ . No sz x5 yrs, stopped follow up w/Dr in '. Pt presented to OSH ED with c/o headache x3 days & trouble expressing herself w/increased memory deficits. CT scan showed ?mass vs pocket bleeding. MRI showed frontal intraperichmal hemmorrhage w/areas of subacute/actue deposition. Admitted to SICU from ICU in for further workup & monitoring.\n\nPLEASE SEE CAREVUE FOR SPECIFICS\n\nCV: NBP stable, 110-140s w/NSR HR 76-110s. No ectopy. Occassionally tachy.\n\nRESP: Pt sat'ing 98-100% room air. LCTAB. Cough/gag intact.\n\nNEURO: Pt appears lethargic, A&Ox3 (Pt in & out of periods of confusion, quick to reorient). Gets slightly agitated w/increasing headaches. Headaches range all over head w/constant pain, using pain scale to rate. Treated w/prn morphine. Able to follow commands, lifts a& holds all extremities. Sister stayed at BS (per pts request, sister remained ) for night to help calm pt & reorient when wakes up from dozing, having exreme fluctuations in moods/emotions. Pupils brisk & reactive, 3-4mm. CT reviewed by neuro stating pt appears w/small mass.\n\nGI/ENDO: Pt tolerating Regular diet. ABD soft, slightly distended. +BS. No BM. Blood sugars checked QID, treated per ordered sliding scale.\n\nGU: Foley patent drainging adequate amounts of clear yellow urine. Pt c/o feeling the constant urge to void. Manipulate catheter to help alleviate.\n\nSKIN: Intact. No edema. + pedal pulses.\n\nSOCIAL: Pt is 1 of 10 children. Strong social support. Lives w/14 year old son. Sister remained at BS w/aunt & brothers in to visit. Father, , is to be pts spokesperson (pt stated should make father HCP as she currently does not have one).\n\nPLAN OF CARE: Monitor LOC with Q2hr neuro checks. Maintain pts comfort. ?further imaging today. Check labs as ordered. HO aware of above, will call w/any changes. f/u with dilantin level.\n"
},
{
"category": "Radiology",
"chartdate": "2134-12-01 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 942457,
"text": " 11:18 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: r/o AVM/aneurysm also want CTV (per Dr. not able to\n Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE\n Field of view: 25 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with stroke\n REASON FOR THIS EXAMINATION:\n r/o AVM/aneurysm also want CTV (per Dr. not able to find on look up\n page if additional order needed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 34-year-old woman with stroke, prior right frontal hemorrhage, to\n evaluate for vascular malformation.\n\n PRIOR STUDIES: Several prior studies, including the non-contrast CT head done\n on , and cranial MRs , , were reviewed for\n comparison.\n\n TECHNIQUE: 3D CT angiography for the evaluation of the circle of was\n performed with IV contrast. Delayed-phase images were obtained to evaluate\n the cerebral venous sinuses. However, this study is of poor quality due to\n delay in obtaining the arterial and the venous phase images\n\n FINDINGS:\n\n On the non-contrast CT, there is a new, 2.1 x 1.4 cm hyperdense area in the\n right inferior frontal lobe, with some surrounding hypodensity consistent with\n intraprenchymal hematoma with some surrounding edema. Rest of the brain is\n unremarkable on the non- contrast study.\n\n CT ANGIOGRAM OF THE CIRCLE OF :\n\n Bilateral intracranial ICA, ECA and MCA are patent and normal in caliber.\n Bilateral distal vertebral, basilar and bilateral PCA are patent and normal in\n caliber.\n\n On the prior MR studies, a tiny enhancing vessel, likely a cortical vein, was\n noted at the anteromedial aspect of the resolving hematoma in the right\n frontal lobe. However, the new hematoma, noted on the present study, in the\n same region, limits assessment of vascularity in this region. Hence, it is\n impossible to exclude vascular malformation on the study.\n\n IMPRESSION:\n 1. New 2.1 x 1.4 cm right inferior frontal parenchymal hematoma, in roughly\n the same distribution as the hemorrhage in .\n 2. As the hematoma limits accurate assessment of enhancing vessels in this\n region, underlying vascular lesion, such as arteriovenous malformation, in\n this region cannot be excluded.\n\n COMMENT: The findings were discussed with Dr. by Dr. , with strong\n (Over)\n\n 11:18 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: r/o AVM/aneurysm also want CTV (per Dr. not able to\n Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE\n Field of view: 25 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n recommendation for conventional catheter angiography to exclude underlying\n vascular abnormality\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-12-02 00:00:00.000",
"description": "SEL CATH 3RD ORDER THOR",
"row_id": 942587,
"text": " 7:39 AM\n CAROT/CEREB Clip # \n Reason: Anterior circulation angiogram to r/o AVM.\n Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE\n Contrast: NON IONIC Amt: 256\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER CAROTID/CERVICAL UNILAT *\n * CAROTID/CEREBRAL BILAT EXT CAROTID BILAT *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old woman with question of AVM.\n REASON FOR THIS EXAMINATION:\n Anterior circulation angiogram to r/o AVM.\n ______________________________________________________________________________\n FINAL REPORT\n CEREBRAL ANGIOGRAM\n\n HISTORY: 34-year-old female with recurrent right frontal hemorrhage. Assess\n for underlying vascular lesions.\n\n TECHNIQUE: Informed written consent was obtained from the patient after\n extensive discussion of the risks, benefits, and alternative management\n therapies. The risks discussed included stroke, loss of vision both temporary\n and permanent, and possible treatment with stenting and angioplasty.\n\n The patient was brought to the interventional neuroradiology suite and a\n timeout was performed, confirming the patient's identity and the procedure to\n be performed. The patient was placed on the biplane table in the supine\n position and was prepped and draped in the usual sterile fashion. 1%\n lidocaine buffered with sodium bicarbonate was used to obtain local\n anesthesia. A #2 scalpel was used to make a skin incision. A 19-gauge needle\n was used to access the right common femoral artery via a single wall puncture.\n An 0.035 wire was placed through the needle and the needle exchanged for a 4\n French vascular sheath. The sheath was connected to a continuous saline\n infusion (500 units heparin and 500 cc of saline). A 4 French Berenstein\n catheter was then connected to a continuous saline infusion (1000 units of\n heparin and 1000 cc of saline) and placed over the wire into the aorta, where\n the wire was then removed and exchanged with a Glidewire. The\n following vessels were selected and angiograms performed.\n\n 1. AP, lateral, and rotational views of the right internal carotid artery.\n 2. AP and lateral of the right external carotid artery.\n 3. AP, lateral, and rotational views of the left internal carotid artery.\n 4. AP and lateral views of the left external carotid artery.\n 5. AP, lateral, oblique, and rotational views of the left common carotid\n artery in its cervical portion.\n (Over)\n\n 7:39 AM\n CAROT/CEREB Clip # \n Reason: Anterior circulation angiogram to r/o AVM.\n Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE\n Contrast: NON IONIC Amt: 256\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n After all images were reviewed, all wires, sheaths, and catheters were removed\n and hemostasis was obtained by manual compression.\n\n Moderate sedation was provided by administering divided doses of 25 mcg of\n fentanyl and 0.5 mg of Versed throughout the total intraservice time of 2\n hours during which the patient's hemodynamically parameters were continuously\n monitored.\n\n OPERATORS: Dr. and Dr. . The Attending Neuroradiologist, Dr. ,\n was present and supervising throughout the entire procedure.\n\n FINDINGS: The right internal carotid artery injection shows no aneurysms or\n vascular malformations. Note is made of filling of the right posterior\n cerebral artery as well as crossfilling of the left anterior cerebral artery.\n\n No abnormalities of the right external carotid artery circulation are seen.\n\n No aneurysms or vascular malformations are seen with the left internal carotid\n artery injection. Post-injection, the patient developed vasospasm of the\n cervical portion of the left internal carotid artery. However, there was no\n compromise of distal flow. 1-inch nitro paste was administered with\n resolution of the vasospasm.\n\n The left external carotid artery injection shows no significant abnormalities.\n\n IMPRESSION: Cerebral angiogram of the internal and external carotid arteries\n bilaterally showing no aneurysms or vascular malformations.\n\n Transient vasospasm of the cervical portion of the left internal carotid\n artery which resolved without sequela.\n\n"
}
] |
10,426 | 125,310 | INITIAL IMPRESSION: year-old woman with h/o of HTN p/w substernal chest pain shortly after exercise at nursing home, with EKG showing ST depressions in V1-V4 and troponin 0.07. Likely NSTEMI. . HOSPITAL COURSE BY SYSTEM: . * CV: The patient's family refused coronary artery catheterization. The patient was given ASA, Plavix, heparin drip x 24 hours, nitro drip, atorvastatin, metoprolol, and lisinopril. Her chest pain was controlled with morphine. Her SBP remained in the 160s-170s on hospital day 1 and she was gently diuresed. On hospital day 2 she experienced atrial fibrillation with HR in the 140s. Her metoprolol dose was increased from 25 mg PO bid to 50 mg PO bid then 75 mg PO tid. Her HR decreased to 70s-80s. Her BP remained stable. An ECHO showed that she had preserved EF and no wall motion abnormalities. We decided given her age that she would not be a good candidate for cardioversion for her afib nor would she be a good candidate for coumadin. Therefore we will continue rate control with metoprolol this can be titrated if needed, and aspirin and plavix for anti-coagulation. She should also continue on lipitor and lisinopril. She should have her chem 7 checked next week given the start of her new meds. Will also need LFT's checked in months. . * Pulmonary: Bilateral crackles at bases and midlungs, elevated JVP, trace bilateral ankle edema, and CXR with diffuse opacities suggest possible pulmonary edema, likely secondary to acute MI. Her O2 sat was stable at 94-97% on 2.5L of supplemental O2. She experienced no respiratory difficulty during the hospital stay. She was diuresed small amount. Her CXR prior to discharge showed mild pulm edema and thus was given 40 of lasix prior to going to rehab. She can be given prn lasix for weight gain or shortness of breath. . * Leukocytosis- She developed mild elevated WBC. UA had WBC's, few bacteria. She was initially started on Bactrim, but this was stopped as she was afebrile. SHe has a culture pending which needs to be followed up at the nursing home and treated if positive. . * Code: DNR/DNI | Pt experienced n/v which resolved with Anzimet. secondary to acute MI.GI/GU: Pt increasingly aggitated overnoc. Moderate mitral annularcalcification. Moderate PA systolic hypertension.PERICARDIUM: No pericardial effusion.Conclusions:1. Old CXR suggests CHF ? No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. IMPRESSION: Mild congestive heart failure. ability to tolerate po meds. CPKs/mb last pm 1471/ 207. She was sent to EW and was found to have ST depressions V1-4. The aorta is calcified. PATIENT/TEST INFORMATION:Indication: Myocardial infarction.Weight (lb): 157BP (mm Hg): 121/45HR (bpm): 85Status: InpatientDate/Time: at 15:33Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). No MR.TRICUSPID VALVE: Mild [1+] TR. Cautious in given po meds. F/C placed. Atrial fibrillationRight bundle branch blockLeft anterior fascicular blockPosterolateral myocardial infarction with ST-T wave configuration consistentwith acute/recent/in evolution processSince previous tracing of , atrial fibrillation now present Troponin 6.0. HR improved and SBP decreased to 130s-140s. Ptt this am 118.3. HCT 28.9. R/I per cardiac enzymes. medical mgmt. There is mild symmetric left ventricular hypertrophy with normal cavitysize and systolic function (LVEF>55%). Sinus rhythmRight bundle branch blockLeft anterior fascicular blockPosterolateral myocardial infarction with ST-T wave configuration consistentwith acute/recent/in evolution processSince previous tracing of , further QRS and ST-T wave changes present This am CPK 634. Given total of 30 mg IV Lasix overnoc w/ fair response.ID: Afebrile. +BS. SBP initially 180s. Titrate po meds and wean IV Nitro gtt as tolerated. There are likely small bilateral pleural effusions and fluid is seen in the right minor fissure. IMPRESSION: Slight worsening in still mild pulmonary edema. PTT at 2100 supratherapeutic > 150. WBC 13.2.Skin: Intact.Dispo: DNR/DNIA/P: yo female STEMI. Sinus bradycardiaRight bundle branch blockLeft anterior fascicular blockConsider posterolateral myocardial infarction with ST-T wave configurationsuggesting acute process/injuryClinical correlation is suggestedNo previous tracing available for comparison Regional left ventricular wall motionis normal.2. Pt given Morphine IV for c/o vague pain. Decrease Heparin gtt per sliding scale and follow ptt. The aortic valve leaflets are mildly thickened.3. Normal regional LV systolic function.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. The mitral valve leaflets are mildly thickened.4.There is moderate pulmonary artery systolic hypertension. Troponin was elevated at .07. Note is made of the report of the prior radiograph of . Received pt on 900U/hr Heparin. There is slight worsening of the still mild pulmonary edema. Abd soft. Upper lung zone redistribution of the pulmonary vasculature and mild bilateral perihilar haziness is consistent with congestive heart failure. Small right pleural effusion is stable. Electrolytes wnl.Resp: Crackles - ^. Held x 2 hrs and decreased to 750U/hr per sliding scale. Restless overnoc. SINGLE AP VIEW OF THE CHEST. UPRIGHT CHEST RADIOGRAPH: The heart size is within normal limits. Unable to ascertain level of orientation d/t significant hearing loss. OB negative. CCU NSG NOTE: CPS: "Where am I? Hr in 50-low 60s SB/NSR and BP conts elevated in 160-170s/60-70s on IV nitro at 1.76mic/kilo. O2 sats 92-97%. Cont supportive care. Aggitation heightened at approx 2200 with pt attempting to get OOB despite nursing instruction. Pt high risk for falls.CV: NSR w/ PVCs. HR 60-100. CCU Nursing Progress Note 1900-0700S: "I have to pee".O: Please see careview for complete VS/additional objective data.MS: AAOx2-3. HO notified and Heparin off at 0645. Titrated Nitro gtt to 2 mcg/kg/min. Received 5 mg IV Metoprolol. RR 20-40s. MAPs>65. O2 increased to 4L NC. She received sl nitro, iv nitro, iv heparin and finally 2mg IV MSO4 and pain completely resolved. Cardiac size is normal. ? BP came down from 190s to 150/60 with hr in high 50s SB. Pt also blind secondary to macular degeneration. Pt having difficulty following direction. Assist pt with position changes. Pt then received 5 mg IV Haldol in total overnoc. Comparison is made to prior study from . She has pmh of hypertension, hysterectomy, frequent UTIs, is completely deaf in R ear and extremely HOH in R ear with hearing aid, and is blind. Keep family w/ POC. She was sent to CCU for observation and support.CV: Pt has remained pain free. "O: For complete VS see CCU flow sheet.This y old Rehab resident developed chest pressure while exercising today. Thick brown stool x3. Pt family refused cardiac catheterization. She will yell if she needs help.A: Probable Nstemi/DNR-DNIP: Attempt to ensure pt confort. No abx regimen at present. Check CK and PTT at 9pm. 5:38 PM CHEST (PORTABLE AP) Clip # Reason: r/o pulmonary edema Admitting Diagnosis: CHEST PAIN MEDICAL CONDITION: year old woman with NSTEMI and bilateral crackles REASON FOR THIS EXAMINATION: r/o pulmonary edema FINAL REPORT INDICATION: -year-old female with non-ST elevation MI and bilateral crackles. Heparin conts at 900u/hr with PTT due at 9pm.RESP: Pt has rales up ~. Family arrived and as per discussions with pt in past she is DNR/DNI and will not have any interventions. By yelling in her left ear you can occasionally communicate with her. The images are not available on PACS. Pt dozing overnoc in naps. There is no pneumothorax. She is sating 92-05% on 2L NP.RENAL: Pt does not have foley and family would like to avoid one due to frequent UTIs.GI: Pt ate only a few bites of ice cream and refused anything else.MS/COMUNICATION: Pt appears alert, but for the most part does not speak. | 8 | [
{
"category": "Echo",
"chartdate": "2130-09-19 00:00:00.000",
"description": "Report",
"row_id": 60804,
"text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nWeight (lb): 157\nBP (mm Hg): 121/45\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 15:33\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. No MR.\n\nTRICUSPID VALVE: Mild [1+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. There is mild symmetric left ventricular hypertrophy with normal cavity\nsize and systolic function (LVEF>55%). Regional left ventricular wall motion\nis normal.\n2. The aortic valve leaflets are mildly thickened.\n3. The mitral valve leaflets are mildly thickened.\n4.There is moderate pulmonary artery systolic hypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2130-09-20 00:00:00.000",
"description": "Report",
"row_id": 116081,
"text": "Atrial fibrillation\nRight bundle branch block\nLeft anterior fascicular block\nPosterolateral myocardial infarction with ST-T wave configuration consistent\nwith acute/recent/in evolution process\nSince previous tracing of , atrial fibrillation now present\n\n"
},
{
"category": "ECG",
"chartdate": "2130-09-19 00:00:00.000",
"description": "Report",
"row_id": 116124,
"text": "Sinus rhythm\nRight bundle branch block\nLeft anterior fascicular block\nPosterolateral myocardial infarction with ST-T wave configuration consistent\nwith acute/recent/in evolution process\nSince previous tracing of , further QRS and ST-T wave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2130-09-18 00:00:00.000",
"description": "Report",
"row_id": 116125,
"text": "Sinus bradycardia\nRight bundle branch block\nLeft anterior fascicular block\nConsider posterolateral myocardial infarction with ST-T wave configuration\nsuggesting acute process/injury\nClinical correlation is suggested\nNo previous tracing available for comparison\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-09-19 00:00:00.000",
"description": "Report",
"row_id": 1400107,
"text": "CCU Nursing Progress Note 1900-0700\nS: \"I have to pee\".\n\nO: Please see careview for complete VS/additional objective data.\n\nMS: AAOx2-3. Unable to ascertain level of orientation d/t significant hearing loss. Pt also blind secondary to macular degeneration. Restless overnoc. Aggitation heightened at approx 2200 with pt attempting to get OOB despite nursing instruction. Pt given Morphine IV for c/o vague pain. Pt experienced n/v which resolved with Anzimet. Pt then received 5 mg IV Haldol in total overnoc. Pt dozing overnoc in naps. Soft wrist restraints applied in addition to posey to maintain safety. Pt high risk for falls.\n\nCV: NSR w/ PVCs. HR 60-100. SBP initially 180s. Titrated Nitro gtt to 2 mcg/kg/min. Pt having difficulty following direction. ? ability to tolerate po meds. Received 5 mg IV Metoprolol. HR improved and SBP decreased to 130s-140s. MAPs>65. Received pt on 900U/hr Heparin. PTT at 2100 supratherapeutic > 150. Held x 2 hrs and decreased to 750U/hr per sliding scale. Ptt this am 118.3. HO notified and Heparin off at 0645. CPKs/mb last pm 1471/ 207. Troponin 6.0. This am CPK 634. HCT 28.9. Electrolytes wnl.\n\nResp: Crackles - ^. RR 20-40s. O2 sats 92-97%. O2 increased to 4L NC. Old CXR suggests CHF ? secondary to acute MI.\n\nGI/GU: Pt increasingly aggitated overnoc. Cautious in given po meds. Abd soft. +BS. Thick brown stool x3. OB negative. F/C placed. Given total of 30 mg IV Lasix overnoc w/ fair response.\n\nID: Afebrile. No abx regimen at present. WBC 13.2.\n\nSkin: Intact.\n\nDispo: DNR/DNI\n\nA/P: yo female STEMI. R/I per cardiac enzymes. Pt family refused cardiac catheterization. medical mgmt. Titrate po meds and wean IV Nitro gtt as tolerated. Decrease Heparin gtt per sliding scale and follow ptt. Cont supportive care. Keep family w/ POC.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-09-18 00:00:00.000",
"description": "Report",
"row_id": 1400106,
"text": "CCU NSG NOTE: CP\nS: \"Where am I?\"\nO: For complete VS see CCU flow sheet.\nThis y old Rehab resident developed chest pressure while exercising today. She has pmh of hypertension, hysterectomy, frequent UTIs, is completely deaf in R ear and extremely HOH in R ear with hearing aid, and is blind. She was sent to EW and was found to have ST depressions V1-4. She received sl nitro, iv nitro, iv heparin and finally 2mg IV MSO4 and pain completely resolved. BP came down from 190s to 150/60 with hr in high 50s SB. Troponin was elevated at .07. Family arrived and as per discussions with pt in past she is DNR/DNI and will not have any interventions. She was sent to CCU for observation and support.\nCV: Pt has remained pain free. Hr in 50-low 60s SB/NSR and BP conts elevated in 160-170s/60-70s on IV nitro at 1.76mic/kilo. Heparin conts at 900u/hr with PTT due at 9pm.\nRESP: Pt has rales up ~. She is sating 92-05% on 2L NP.\nRENAL: Pt does not have foley and family would like to avoid one due to frequent UTIs.\nGI: Pt ate only a few bites of ice cream and refused anything else.\nMS/COMUNICATION: Pt appears alert, but for the most part does not speak. She is so hard of hearing it is very difficult to get across to her what is happening. By yelling in her left ear you can occasionally communicate with her. She will yell if she needs help.\nA: Probable Nstemi/DNR-DNI\nP: Attempt to ensure pt confort. Assist pt with position changes. Check CK and PTT at 9pm.\n"
},
{
"category": "Radiology",
"chartdate": "2130-09-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927479,
"text": " 5:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulmonary edema\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with NSTEMI and bilateral crackles\n REASON FOR THIS EXAMINATION:\n r/o pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old female with non-ST elevation MI and bilateral\n crackles.\n\n Note is made of the report of the prior radiograph of . The\n images are not available on PACS.\n\n UPRIGHT CHEST RADIOGRAPH: The heart size is within normal limits. The aorta\n is calcified. Upper lung zone redistribution of the pulmonary vasculature and\n mild bilateral perihilar haziness is consistent with congestive heart failure.\n There are likely small bilateral pleural effusions and fluid is seen in the\n right minor fissure.\n\n IMPRESSION: Mild congestive heart failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-09-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927732,
"text": " 2:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pneumonia, CHF\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with NSTEMI and bilateral crackles, elev WBC\n\n REASON FOR THIS EXAMINATION:\n assess for pneumonia, CHF\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Bilateral crackles, elevated white blood count.\n\n Comparison is made to prior study from .\n\n SINGLE AP VIEW OF THE CHEST. There is slight worsening of the still mild\n pulmonary edema. There is no pneumothorax. Small right pleural effusion is\n stable. Cardiac size is normal.\n\n IMPRESSION: Slight worsening in still mild pulmonary edema.\n\n\n"
}
] |
21,819 | 144,995 | Vanco and Zosyn were started on and Urology was consulted. It was felt that he had bulbar urethral injury with extravasation and abscess. On CT with contrast showed multiple loculated fluid collections within the perineal region adjacent to the urethra. There was concern for urethral fistula from the pancreatic graft. Peri-anal fistula was thought to be less likely given the location of the loculated collections. On a retro urogram revealed no evidence of bladder or urethral leak. Irregularity along the membranous urethra extending to the prostatic urethra was suggestive of chronic inflammatory or edematous state. On he had incision and drainage of perineal abscess and exam under anesthesia for pernieal abscess. A swab revealed 2+ PMNs and no growth. Wound dressings consisted of packed with Iodiform and external gauze. A foley catheter remained in place. On CT without contrast showed significant improvement. Stable peripenile multiloculated fluid collections stable surrounding inflammatory change. New air within the renal pelvis of the left pelvic transplanted kidney. On he underwent re-exploration of perineum for perineal abscess on by Dr. . On , he had successful CT fluoroscopic-guidance drainage of multiloculated fluid perineal collection. This aspirate has been negative to date including AFB. Fluid was sent for amylase and lipase of which both were high. Nephrology followed him during this hospital stay. The plan was to send him to Rehab for iv vanco and po augmentin for 2 weeks with left buttock dressing changes qd. The wound tract was ~8cm and was loosely packed with saline wet to dry kerlex ~5cm. A foley was left in place. UA was repeated on for wbc of 13.1. UA demonstrated wbc, lg RBC, mod leukocytes, 1 eosinophil and negative nitrites. A urine culture was also sent. The long term plan is to convert the pancreas transplant from bladder drainage to enteric drainage once the infection resolved and the wound healed. Foley needs to remain in place until surgery. | CT ABDOMEN WITHOUT AND WITH IV CONTRAST: There is dependent bibasilar atelectasis. CT PELVIS WITHOUT IV CONTRAST: There has been interval incision and drainage of the left penile and left perineal fluid collections and surrounding inflammatory change leaving what is now a large defect in the medial left gluteal subcutaneous tissues extending into the perineal region. Following administration of IV Optiray contrast, images of the abdomen and pelvis were obtained. TECHNIQUE/PROCEDURE: Using sterile technique and local anesthesia, a guidewire was placed through the existing right-sided PICC line. The patient is status post incision and drainage of the left gluteal/posterior left perineal fluid collection, with a large defect in the medial left gluteal subcutaneous tissues extending into the perineal region, without fluid collection at this level. The left pelvic transplant kidney is of similar size and contains a focus of hyperdensity along its left/upper pole, which may represent retained contrast (partial persistent nephrogram). FOCUSED NURSING NOTEPlease see carevue flowsheet for further detailsD: s/p CT A/P with and without contrast- shows "peri-urethral fluid collections" ?fistula/abscess- On-call to OR this am. Stable peripenile multiloculated fluid collections stable surrounding (Over) 5:45 PM CT PELVIS W/O CONTRAST Clip # Reason: Evaluate status of previouy seen penile fluid collections Admitting Diagnosis: STATUS POST KIDNEY-PANCREAS TRANSPLANT FINAL REPORT (Cont) inflammatory change. POST-PROCEDURE CT: Post-procedure CT demonstrates marked reduction in the perineal multiloculated fluid collection, minimal fluid remains. TECHNIQUE: MDCT axial images through the abdomen were obtained without IV contrast. NPN (SEE CAREVUE FOR SPECIFICS)PT TO OR THIS AM FOR DEBRIDEMENT OF PERINEUM COLLECTION, AND TO FLOURO FOR CYSTOGRAM SHOWING NO LEAKAGE IN BLADDER. There is a fat- containing right paraumbilical hernia. A second, different 19- gaugae needle was placed into a right-sided collection. Discussed with resident, changed regiment to Dilaudid- 1mg IVP x 2 given with improvement in pain level #. Skin integrity impaired to pubis area- dried ulcer secondary to edema and friction per pt. TECHNIQUE: MDCT acquired axial images of the pelvis were obtained without IV contrast with an elevated creatinine. Urethral caliber is slightly narrowed, and there is a striated appearance suggestive of inflammation. No contraindications for IV contrast FINAL REPORT CT-GUIDED DRAINAGE INDICATION: Perineal fluid collections to drain. There is irregularity along the urethra extending from the membranous portion to the beginning of the prostatic portion. Catheter was secured to the skin, flushed, and sterile dressing applied. There was mild bilateral ureteral reflux. Possible etiologies for the air include air extending from the bladder through the short urethra into the renal pelvis, infection, or unknown fistulous tract to either the ureter or renal pelvis that is not visualized. There is a moderate-sized hiatal hernia/gastric pull-up with surgical sutures seen surrounding the stomach. The existing PICC line was exchanged for a peel-away sheath, through which a new 49 cm PICC line was placed with tip positioned in the SVC under fluoroscopic guidance. Scrotum/buttock red/edematous/firm.A: D5W w/ 150 meq NaHCO3 infusing at 75ml/hr as ordered, mucomyst given pre-CT scan. Please assess for possible urethral or bladder leak. Delayed imaging or a retrograde urethrogram would be helpful in further evaluation. Status post incision and drainage of the left gluteal/posterior left perineal fluid collections with significant improvement. 12:04 PM PICC LINE PLACMENT SCH Clip # Reason: please repo r picc Admitting Diagnosis: STATUS POST KIDNEY-PANCREAS TRANSPLANT ********************************* CPT Codes ******************************** * PERIPHERAL W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN * * FLUORO GUID PLCT/REPLCT/REMOVE * **************************************************************************** MEDICAL CONDITION: 60 year old man with need for VANCO/Zosyn after pancreas transplant REASON FOR THIS EXAMINATION: please repo r picc FINAL REPORT INDICATION: Re-position PICC line for vancomycin. Its central course differs from expected, terminating at the presumed junction of the subclavian vein and the internal jugular vein, or in the caudal portion of the internal jugular vein. NON-CONTRAST CT OF THE PELVIS: CT of the pelvis was performed to evaluate the site of the perineal collection. Foci of air within the bladder are likely secondary to Foley catheter placement. There are a few scattered periportal lymph nodes not meeting CT criteria for pathologic enlargment. | 8 | [
{
"category": "Radiology",
"chartdate": "2148-03-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 957359,
"text": " 10:28 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check placement r med picc for abx (49 cm.)call beepe\n Admitting Diagnosis: STATUS POST KIDNEY-PANCREAS TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with\n REASON FOR THIS EXAMINATION:\n please check placement r med picc for abx (49 cm.)call beeper with wet\n read asap Thanks\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: PICC line placement evaluation.\n\n TECHNIQUE AND FINDINGS: A portable AP chest radiograph was reviewed.\n\n The PICC line seems to be entering via the right cephalic vein and then right\n subclavian vein. Its central course differs from expected, terminating at the\n presumed junction of the subclavian vein and the internal jugular vein, or in\n the caudal portion of the internal jugular vein. The tip of the PICC is\n pointing cranially.\n\n Heart size, mediastinal contours, and the lungs are unremarkable.\n\n These findings were discussed with the IV nurse at the time of interpretation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-03-17 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 957017,
"text": " 5:45 PM\n CT PELVIS W/O CONTRAST Clip # \n Reason: Evaluate status of previouy seen penile fluid collections\n Admitting Diagnosis: STATUS POST KIDNEY-PANCREAS TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with perineal and penile fluid collections. Assess residual\n collections s/p I&D\n REASON FOR THIS EXAMINATION:\n Evaluate status of previouy seen penile fluid collections\n CONTRAINDICATIONS for IV CONTRAST:\n renal Tx with elev Cr\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old male with perineal and penile fluid collections.\n Assess residual collections post I&D.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT acquired axial images of the pelvis were obtained without IV\n contrast with an elevated creatinine.\n\n CT PELVIS WITHOUT IV CONTRAST: There has been interval incision and drainage\n of the left penile and left perineal fluid collections and surrounding\n inflammatory change leaving what is now a large defect in the medial left\n gluteal subcutaneous tissues extending into the perineal region. There has\n been significant reduction of the fluid within this region now with only\n residual soft tissue stranding present.\n\n Along the suprapubic region, there is again demonstrated soft tissue\n stranding, which ends inferiorly to the stable-appearing multiloculated fluid\n collection surrounding the proximal penis. Soft tissue stranding is seen\n throughout the perineal fat, similar compared to prior study.\n\n The left pelvic transplant kidney is of similar size and contains a focus of\n hyperdensity along its left/upper pole, which may represent retained contrast\n (partial persistent nephrogram). There is retained barium within visualized\n portions of the colon. Vascular calcifications are seen at the bifurcation of\n the aorta and along the iliac arteries.\n\n Of note, there appears to be air within the collecting system of the\n transplanted kidney which was not apparent on prior study. Possible\n etiologies for the air include air extending from the bladder through the\n short urethra into the renal pelvis, infection, or unknown fistulous tract to\n either the ureter or renal pelvis that is not visualized.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic bony lesions.\n\n IMPRESSION:\n 1. Status post incision and drainage of the left gluteal/posterior left\n perineal fluid collections with significant improvement.\n\n 2. Stable peripenile multiloculated fluid collections stable surrounding\n (Over)\n\n 5:45 PM\n CT PELVIS W/O CONTRAST Clip # \n Reason: Evaluate status of previouy seen penile fluid collections\n Admitting Diagnosis: STATUS POST KIDNEY-PANCREAS TRANSPLANT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n inflammatory change.\n\n 3. New air within the renal pelvis of the left pelvic transplanted kidney.\n These findings either represent air introduced from the urinary bladder via\n catheterization, infection, or a fistulous tract connecting to the ureter or\n renal pelvis.\n\n These findings were discussed with Dr. at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-03-18 00:00:00.000",
"description": "PUNC ASP ABS HEM BUL CYST",
"row_id": 957110,
"text": " 3:51 PM\n PUNC ASP ABS HEM BUL CYST; PUNC ASP ABS HEM BUL CYST Clip # \n -59 DISTINCT PROCEDURAL SERVICE; CT GUIDED NEEDLE PLACTMENT\n CT GUIDED NEEDLE PLACTMENT; -59 DISTINCT PROCEDURAL SERVICE\n MOD SEDATION, FIRST 30 MIN.\n Reason: want the penile fluid collections drained.\n Admitting Diagnosis: STATUS POST KIDNEY-PANCREAS TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with penile fluid collections\n REASON FOR THIS EXAMINATION:\n want the penile fluid collections drained.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT-GUIDED DRAINAGE\n\n INDICATION: Perineal fluid collections to drain.\n\n Comparison is made with prior study, abdomen CT performed the day before.\n\n PROCEDURE: The risks and benefits of the procedure were explained to the\n patient, and written informed consent was obtained. A pre-procedure timeout\n was called to confirm the patient's identity and the procedure to be\n performed.\n\n NON-CONTRAST CT OF THE PELVIS:\n CT of the pelvis was performed to evaluate the site of the perineal\n collection. Multiloculated fluid collection surrounding the proximal penis is\n unchanged as is the soft tissue stranding throughout the perineal fat. The\n patient is status post incision and drainage of the left gluteal/posterior\n left perineal fluid collection, with a large defect in the medial left gluteal\n subcutaneous tissues extending into the perineal region, without fluid\n collection at this level.\n\n CT PELVIS DRAINAGE: A suitable site was prepped and draped in the usual\n standard fashion. Under CT fluoroscopic guidance, a 19-gauge needle was\n placed in the perineal collection. Approximately 17 ml of hemorrhagic turbid\n fluid was removed from a left sided, collection. A second, different 19-\n gaugae needle was placed into a right-sided collection. Approximately 7 cc of\n yellow fluid was removed.\n\n POST-PROCEDURE CT: Post-procedure CT demonstrates marked reduction in the\n perineal multiloculated fluid collection, minimal fluid remains.\n\n The patient tolerated the procedure well. There were no immediate\n complications. Approximately 6 ml of 1% lidocaine was used as local\n anesthesia. Moderate sedation consisting of divided doses of fentanyl and\n Versed were administrated by nursing staff for a total intraservice time of 20\n minutes. The patient's hemodynamic parameters were continuously monitored.\n\n IMPRESSION: Technically successful CT fluoroscopic-guidance drainage of\n multiloculated fluid perineal collection.\n (Over)\n\n 3:51 PM\n PUNC ASP ABS HEM BUL CYST; PUNC ASP ABS HEM BUL CYST Clip # \n -59 DISTINCT PROCEDURAL SERVICE; CT GUIDED NEEDLE PLACTMENT\n CT GUIDED NEEDLE PLACTMENT; -59 DISTINCT PROCEDURAL SERVICE\n MOD SEDATION, FIRST 30 MIN.\n Reason: want the penile fluid collections drained.\n Admitting Diagnosis: STATUS POST KIDNEY-PANCREAS TRANSPLANT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Samples were sent for lab.\n\n Dr. was present and performed the procedure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-03-20 00:00:00.000",
"description": "PERIPHERAL W/O PORT",
"row_id": 957374,
"text": " 12:04 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please repo r picc\n Admitting Diagnosis: STATUS POST KIDNEY-PANCREAS TRANSPLANT\n ********************************* CPT Codes ********************************\n * PERIPHERAL W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with need for VANCO/Zosyn after pancreas transplant\n\n REASON FOR THIS EXAMINATION:\n please repo r picc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Re-position PICC line for vancomycin.\n\n RADIOLOGISTS: Drs. and Dr. , the attending radiologist was\n present and supervising throughout.\n\n TECHNIQUE/PROCEDURE: Using sterile technique and local anesthesia, a\n guidewire was placed through the existing right-sided PICC line. The existing\n PICC line was exchanged for a peel-away sheath, through which a new 49 cm PICC\n line was placed with tip positioned in the SVC under fluoroscopic guidance.\n Position of the catheter was confirmed by fluoroscopic spot view of the chest.\n\n Peel-away sheath and guidewire were then removed. Catheter was secured to the\n skin, flushed, and sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated fluoroscopically-guided single lumen PICC line\n exchange. Final length of new PICC line is 49 cm, with tip positioned in SVC.\n Line is ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-03-16 00:00:00.000",
"description": "RETRO UROGRAM (74450,51610)",
"row_id": 956881,
"text": " 11:03 AM\n RETRO UROGRAM (,) Clip # \n Reason: ASSESS FOR POSSSIBLE LEAK SCROTAL SWELLING S/P CATHETER PLACEMENT\n Admitting Diagnosis: STATUS POST KIDNEY-PANCREAS TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with s/p pancreatic transplant to bladder with excessive\n scrotal edema and multiple fluid collections on CT\n REASON FOR THIS EXAMINATION:\n assess for possible leak\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old male status post pancreatic transplant to bladder,\n with scrotal edema and fluid collection seen on recent CT. Please assess for\n possible urethral or bladder leak.\n\n RETROGRADE URETHROGRAM: The patient was placed supine on the fluoroscopy\n table. The patient's urethral meatus was prepped with Betadine, and a Foley\n catheter was inserted into the distal penis and the balloon was then inflated\n with 2 cc of air and saline. Retrograde urethrogram was then performed which\n demonstrated no extravasation of contrast.\n\n There is irregularity along the urethra extending from the membranous portion\n to the beginning of the prostatic portion. Urethral caliber is slightly\n narrowed, and there is a striated appearance suggestive of inflammation.\n\n Balloon was then deflated, and Foley catheter was then advanced into the\n bladder, and the balloon re-inflated and cystogram performed. Multiple\n fluoroscopic images taken in AP and oblique views demonstrate no evidence of\n extravasation. There was mild bilateral ureteral reflux. Contrast was then\n evacuated, and no residual contrast was seen within the bladder or urethra.\n\n IMPRESSION:\n 1. No evidence of bladder or urethral leak.\n 2. Irregularity along the membranous urethra extending to the prostatic\n urethra suggestive of chronic inflammatory or edematous state.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-03-15 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 956816,
"text": " 8:12 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n Reason: pt s/p Pancreas / Kidney transplant (panc likely bladder dra\n Admitting Diagnosis: STATUS POST KIDNEY-PANCREAS TRANSPLANT\n Field of view: 38 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with\n REASON FOR THIS EXAMINATION:\n pt s/p Pancreas / Kidney transplant (panc likely bladder drained) - getting\n bicarb - please do ABD / PELVIS with PO and IV contrast - please page \n with results\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Swelling in the scrotal and perineal area. Evaluate.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT axial images through the abdomen were obtained without IV\n contrast. Following administration of IV Optiray contrast, images of the\n abdomen and pelvis were obtained. Multiplanar images were reconstructed.\n\n CT ABDOMEN WITHOUT AND WITH IV CONTRAST: There is dependent bibasilar\n atelectasis. There is a moderate-sized hiatal hernia/gastric pull-up with\n surgical sutures seen surrounding the stomach. The liver, gallbladder,\n spleen, and adrenal glands are unremarkable. The native kidneys are atrophic\n and there are left kidney cysts. There are a few scattered periportal lymph\n nodes not meeting CT criteria for pathologic enlargment. There is no free air\n or free fluid within the abdomen. There is a fat- containing right\n paraumbilical hernia.\n\n CT PELVIS WITH IV CONTRAST: The transplanted kidney lies within the left\n lower quadrant and measures 11 cm. No hydronephrosis or perinephric fluid\n collection. The transplanted pancreas lies within the right lower quadrant\n and enhances homogenously with no adjacent peripancreatic stranding. A conduit\n extends to the bladder, which is thick-walled, likely secondary to chronic\n inflammation. Foci of air within the bladder are likely secondary to Foley\n catheter placement.\n\n There is soft tissue stranding anterior to the pubic symphysis extending into\n the perineal region. Additionally, multiple loculated fluid collections lie\n within the floor of the perineum adjacent to the membranous and penile\n urethra, the largest measuring 5.5 x 2.5 cm. There is significant soft tissue\n stranding within the left perianal subcutaneous soft tissues. No fistulous\n connection is appreciated, although evaluation is limited secondary to lack of\n contrast within the bladder and urethra.\n\n Osseous structures demonstrate no suspicious or lytic lesions.\n\n IMPRESSION:\n 1. Multiple loculated fluid collections within the perineal region adjacent\n to the urethra. These may be secondary to urethral fistula, the presence of\n (Over)\n\n 8:12 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n Reason: pt s/p Pancreas / Kidney transplant (panc likely bladder dra\n Admitting Diagnosis: STATUS POST KIDNEY-PANCREAS TRANSPLANT\n Field of view: 38 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n which cannot be adequately evaluated on this study. Delayed imaging or a\n retrograde urethrogram would be helpful in further evaluation. Peri-anal\n fistula is thought to be less likely given the location of the loculated\n collections. MRI would be best for evaluation of peri-anal fistulous tract.\n\n\n Findings discussed with Dr. on /\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-16 00:00:00.000",
"description": "Report",
"row_id": 1548433,
"text": "FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\nD: s/p CT A/P with and without contrast- shows \"peri-urethral fluid collections\" ?fistula/abscess- On-call to OR this am. Afebrile, VSS. GCS 15. Excellent u.o., pre CT scan Cr 1.3, am labs pending. NPO since 2100, sips H2o with meds. Abd soft, + BS, no n/v. C/O scrotal and left buttock/gluteal pain, aching and constant- pain level #.\nIV access poor. Skin integrity impaired to pubis area- dried ulcer secondary to edema and friction per pt. Scrotum/buttock red/edematous/firm.\n\nA: D5W w/ 150 meq NaHCO3 infusing at 75ml/hr as ordered, mucomyst given pre-CT scan. Medicated with escalating doses of morphine for pain, pt reports \"some relief\" not lasting long. Pain level returns to # within 60 minutes of dose. Discussed with resident, changed regiment to Dilaudid- 1mg IVP x 2 given with improvement in pain level #. Pre-op checklist initiated. Pt aware of surgical plan today. #20G inserted RUA with some difficulty- pt needs better IV access for surgery, long-term antibiotics and lab draws.\n\nR: Pt calm/coop, improved pain control with Dilaudid. F/U tacrolimus level. Plan to OR this am, ?time. Monitor u.o., labs, sx infection. Emotional support and education to pt ongoing. Discuss IV acces with SICU team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-16 00:00:00.000",
"description": "Report",
"row_id": 1548434,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\nPT TO OR THIS AM FOR DEBRIDEMENT OF PERINEUM COLLECTION, AND TO FLOURO FOR CYSTOGRAM SHOWING NO LEAKAGE IN BLADDER. PT HAS BEEN DOZING OFF AND ON ALL SHIFT, CURRENTLY AWAKE AND EATING DINNER WITHOUT A PROBLEM. WILL BE NPO AT MIDNIGHT FOR REPEAT OR IN AM TO CHANGE PACKING. HR AND BP STABLE, O2 SAT 100% ON 2L NC. PT C/O MILD PAIN IN INCISION, DILAUDID PCA STARTED WITH GOOD EFFECT. UOP ADEQUATE, FLUIDS KVO'D FOR NOW. AFEBRILE\n"
}
] |
20,571 | 134,461 | Patient was admitted and underwent coronary artery bypass grafting by Dr. . For surgical details, please see separate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. Low dose beta blockade and gentle diuresis were initiated. He maintained stable hemodynamics and weaned from inotropic support without difficulty. His CSRU course was otherwise uneventful and he transferred to the SDU on postoperative day one. On postoperative day two, he experienced bouts of paroxysmal atrial fibrillation(PAF) for which Amiodarone therapy was initiated. Beta blockade was continued and advanced as tolerated. Despite medical therapy, he continued to experience PAF. He was therefore anticoagulated with Heparin with transition to Warfarin. Warfarin was dosed daily for a goal INR between 2.0 - 3.0. He converted to SR on amiodarone. Chest tubes and pacing wires were removed and he continued to make good progress on the floor. He will have his coumadin managed by Dr. and first blood draw will be Sat. .Coumadin held on day of discharge. Discharged to home with VNA on POD #7. | Normaldescending aorta diameter. Normal ascending aorta diameter. There are simple atheroma in the descendingthoracic aorta. PA and lateral upright chest radiograph compared to . Mildly thickened aortic valveleaflets. Mild to moderate(+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. There is a small apical and mild-to-moderate anterior left pneumothorax. +pp bilat.resp: lungs clear but dim at bases. There is no pericardial effusion.Post-CPB: nl biventricular systolic function, MR now 1+, other parameters aspre-bypass, aorta intact. No AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. Small left apical pneumothorax after chest tube removal. Mild to moderate (+) mitralregurgitation is seen. No LVmass/thrombus.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. cont cardiac rehab. The previously seen left apical pneumothorax has completely resolved. Low normal LVEF. There is a small left apical pneumothorax. tolerating sips of h2o w/o difficulty. Otherwise, the heart size, mediastinal contours, and the rest of the lungs are unchanged. Normal LV wall thicknesses and cavity size. Bilateral small pleural effusions. The cardiomediastinal silhouette is stable with stable appearance of the post-surgical sutures. Right ventricular chamber size andfree wall motion are normal. The aortic valveleaflets are mildly thickened. atrial bigeminy,pvc's,rare couplets seen that improved after elyte replacement,ventricular more than atrial.pacer off due to sensing of premature beats despite sensitivity changes,paces well in both aai & vvi modes.hemodynamically stable as indicated by flow sheet. Portable AP chest radiograph compared to the preoperative film from . Improvement of the lung aeration. Simple atheroma in descending aorta.AORTIC VALVE: Three aortic valve leaflets. PATIENT/TEST INFORMATION:Indication: CABGStatus: InpatientDate/Time: at 10:04Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2Dimages. There is atelectasis at the left lung base vs. an early infiltrate. ci>2.0. SINGLE AP PORTABLE RADIOGRAPH OF THE CHEST: There has been interval removal of endotracheal tube, NG tube, Swan-Ganz catheter and two chest tubes. pulmonary toilet. oozy from o.r.,resolved after warming,increased peep,platelets & protamine. There is improvement in the aeration of the left lower lobe with small pleural effusion remaining as well as small right pleural effusion. extubated top np's w/o incident. A portable AP chest radiograph compared to . The right lung is clear. The patient was undergeneral anesthesia throughout the procedure.Conclusions:Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage.Left ventricular wall thicknesses and cavity size are normal. Atrial fibrillationDiffuse nonspecific ST-T wave abnormalitiesSince previous tracing of , further ST-T wave changes present IMPRESSION: 1. IMPRESSION: 1. pain relieved w/repositioning. arrouse to voice. cont to monitor hemodynamics. Midline sternotomy wires and mediastinal surgical clips are seen. pac's w occas. ct drainage 20-110cc/hr. The NG tube is in the stomach. lethargic but cooperative with deep breathing. Otherwise, the lungs are clear with no significant pleural effusion or pulmonary edema. t&r q1-2hrs. The Swan-Ganz tip is in the main pulmonary artery. appropriate. Comparison is made to . oriented x3. uop adequate.endo: insulin gtt per protocol.social: no family contact overnight.plan: pain management. hct at 2300 25 aware. I certifyI was present in compliance with HCFA regulations. sat's>97% on 2l nc.gi/gu: +hypo bs. sbp stable but does drop to high 80's when asleep. The mitralvalve leaflets are moderately thickened. There is worsening of the left lower lobe atelectasis. The lungs otherwise are clear with no evidence of congestive heart failure or local infiltrates. The ET tube tip is very high at the level of the thoracic inlet. refused pain med when offered.cv/skin: nsr w/occas pac & rare pvc's. These findings were discussed with Dr. . The position of the two mediastinal drains and the left chest tube is unremarkable. mae. Overall leftventricular systolic function is low normal (LVEF 50-55%). 2. There are three aortic valve leaflets. Atrial fibrillation with rapid ventricular responseDiffuse ST-T wave abnormalities with anterolateral ST segment elevation -clinical correlation is suggested for possible in part injury/ ischemiaNo previous tracing available for comparison transfer to 2. glucoses rising,insulin gtt started & titrated generally per protocol,see flow sheet & remarks. am labs pending. change insulin gtt to sq in am. This has been communicated to Dr. at 10:30 a.m. on . No aortic regurgitation is seen. No masses orthrombi are seen in the left ventricle. 9:22 AM CHEST (PORTABLE AP) Clip # Reason: chest tube removal, r/o PTX Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 69 year old man s/p CABG REASON FOR THIS EXAMINATION: chest tube removal, r/o PTX FINAL REPORT ^ INDICATION: Status post CABG, chest tube removal, rule out pneumothorax. 3:34 PM CHEST (PORTABLE AP) Clip # Reason: Pleural effusion, tamponade, pulmonary edema, pneumothorax Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 69 year old man s/p CABG REASON FOR THIS EXAMINATION: Pleural effusion, tamponade, pulmonary edema, pneumothorax FINAL REPORT REASON FOR EXAMINATION: Followup after CABG. | 9 | [
{
"category": "Nursing/other",
"chartdate": "2184-05-29 00:00:00.000",
"description": "Report",
"row_id": 1532466,
"text": "shift update:\n\nneuro: slept most of shift. arrouse to voice. appropriate. oriented x3. mae. t&r q1-2hrs. pain relieved w/repositioning. refused pain med when offered.\n\ncv/skin: nsr w/occas pac & rare pvc's. sbp stable but does drop to high 80's when asleep. ci>2.0. hct at 2300 25 aware. am labs pending. ct drainage 20-110cc/hr. +pp bilat.\n\nresp: lungs clear but dim at bases. sat's>97% on 2l nc.\n\ngi/gu: +hypo bs. tolerating sips of h2o w/o difficulty. uop adequate.\n\nendo: insulin gtt per protocol.\n\nsocial: no family contact overnight.\n\nplan: pain management. cont to monitor hemodynamics. cont cardiac rehab. pulmonary toilet. change insulin gtt to sq in am. transfer to 2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-05-28 00:00:00.000",
"description": "Report",
"row_id": 1532465,
"text": "oozy from o.r.,resolved after warming,increased peep,platelets & protamine. pac's w occas. atrial bigeminy,pvc's,rare couplets seen that improved after elyte replacement,ventricular more than atrial.pacer off due to sensing of premature beats despite sensitivity changes,paces well in both aai & vvi modes.hemodynamically stable as indicated by flow sheet. extubated top np's w/o incident. lethargic but cooperative with deep breathing. glucoses rising,insulin gtt started & titrated generally per protocol,see flow sheet & remarks.\n"
},
{
"category": "Echo",
"chartdate": "2184-05-28 00:00:00.000",
"description": "Report",
"row_id": 80906,
"text": "PATIENT/TEST INFORMATION:\nIndication: CABG\nStatus: Inpatient\nDate/Time: at 10:04\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thicknesses and cavity size. Low normal LVEF. No LV\nmass/thrombus.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\ndescending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild to moderate\n(+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial 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.\n\nConclusions:\nPre-CPB: No spontaneous echo contrast is seen in the left atrial appendage.\nLeft ventricular wall thicknesses and cavity size are normal. Overall left\nventricular systolic function is low normal (LVEF 50-55%). No masses or\nthrombi are seen in the left ventricle. Right ventricular chamber size and\nfree wall motion are normal. There are simple atheroma in the descending\nthoracic aorta. There are three aortic valve leaflets. The aortic valve\nleaflets are mildly thickened. No aortic regurgitation is seen. The mitral\nvalve leaflets are moderately thickened. Mild to moderate (+) mitral\nregurgitation is seen. There is no pericardial effusion.\nPost-CPB: nl biventricular systolic function, MR now 1+, other parameters as\npre-bypass, aorta intact.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2184-06-02 00:00:00.000",
"description": "Report",
"row_id": 201386,
"text": "Atrial fibrillation\nDiffuse nonspecific ST-T wave abnormalities\nSince previous tracing of , further ST-T wave changes present\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2184-05-30 00:00:00.000",
"description": "Report",
"row_id": 201387,
"text": "Atrial fibrillation with rapid ventricular response\nDiffuse ST-T wave abnormalities with anterolateral ST segment elevation -\nclinical correlation is suggested for possible in part injury/ ischemia\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-06-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 915210,
"text": " 3:22 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf., eff\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p CABG\n\n REASON FOR THIS EXAMINATION:\n r/o inf., eff\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of patient after CABG.\n\n PA and lateral upright chest radiograph compared to .\n\n The cardiomediastinal silhouette is stable with stable appearance of the\n post-surgical sutures.\n\n There is improvement in the aeration of the left lower lobe with small pleural\n effusion remaining as well as small right pleural effusion. The lungs\n otherwise are clear with no evidence of congestive heart failure or local\n infiltrates.\n\n There is no evidence of apical pneumothorax.\n\n IMPRESSION:\n\n 1. Improvement of the lung aeration.\n\n 2. Bilateral small pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-05-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 914453,
"text": " 3:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pleural effusion, tamponade, pulmonary edema, pneumothorax\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n Pleural effusion, tamponade, pulmonary edema, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup after CABG.\n\n Portable AP chest radiograph compared to the preoperative film from .\n\n The ET tube tip is very high at the level of the thoracic inlet. These\n findings were discussed with Dr. .\n\n The Swan-Ganz tip is in the main pulmonary artery. The NG tube is in the\n stomach. The position of the two mediastinal drains and the left chest tube\n is unremarkable. There is a small apical and mild-to-moderate anterior left\n pneumothorax. These findings were also discussed with Dr. .\n\n Otherwise, the lungs are clear with no significant pleural effusion or\n pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-05-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 914604,
"text": " 9:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: chest tube removal, r/o PTX\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p CABG\n\n REASON FOR THIS EXAMINATION:\n chest tube removal, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n ^\n INDICATION: Status post CABG, chest tube removal, rule out pneumothorax.\n\n Comparison is made to .\n\n SINGLE AP PORTABLE RADIOGRAPH OF THE CHEST: There has been interval removal\n of endotracheal tube, NG tube, Swan-Ganz catheter and two chest tubes. There\n is a small left apical pneumothorax. There is atelectasis at the left lung\n base vs. an early infiltrate. Midline sternotomy wires and mediastinal\n surgical clips are seen. The right lung is clear.\n\n IMPRESSION:\n 1. Small left apical pneumothorax after chest tube removal.\n\n This has been communicated to Dr. at 10:30 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-05-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 914729,
"text": " 12:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval ptx\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup pneumothorax in patient after CABG.\n\n A portable AP chest radiograph compared to .\n\n The previously seen left apical pneumothorax has completely resolved. There\n is worsening of the left lower lobe atelectasis. Otherwise, the heart size,\n mediastinal contours, and the rest of the lungs are unchanged.\n\n\n"
}
] |
32,607 | 185,206 | 80 year old female with history of CHF (diastolic dysfunction), atrial fibrillation on coumadin, CAD, AVR with stenosis, DM, PPM, pulmonary fibrosis on 2.5L O2 at baseline presented with fevers, diarrhea, and hypotension. She was rehydrated with IVF, and subsequently experienced pulmonary edema. In MICU, diuresed and treated empirically for possible GI source for fevers. On floor, was further diuresed and treated for possible diverticulitis. Brief hospital course, by problem, is as follows: . 1. Hypotension, now resolved: On presentation, the ICU team felt the patient's low blood pressure (systolic in 80s) were secondary to early sepsis etiology, given fevers, but on further labs and cultures there was no clear source and no leukocytosis. She responded transiently to 2L fluids, but then seemed to have worsened pulmonary edema on chest film. Despite this, she had a drop in her BP again. Was resuscitated with IVF. It was thought that given her underlying heart disease, she could not maintain the forward flow for such a sudden increase in venous return. Additionally, she did not have a compensatory increase in her HR to aid in increasing her cardiac output. Given hypotension and acute renal failure with low serum sodium on labs, etiology of hypotension was thought to be due to volume depletion. Pulmonary embolism was also considered, however, the patient was on chronic anticoagulation for atrial fibrillation and AVR so this was unlikely. Pericardial effusion was also explored but no evidence of this on exam. While in the she was given gentle IVFs, urine lytes assessed, monitored urine output with goal >35cc/hr. Diuretics were initially held. Furosemide 80mg twice daily per home regimen was restarted in with good urine output. On medicine floor, spironolactone 25mg daily and metolazone 10mg QMonday, Friday were restarted in succession. Patient had good diuresis, with over 1 liter net negative each day. Creatine stayed in the range of 1.4-1.5, with BUN/creatinine ratio greater than 20. We considered that patient may be intravascularly depleted, although clinically she looked excellent. We asked that she have her chemistries checked again at the rehabilitation facility to ensure that she does not experience renal failure. Potassium also had to be repleted on a daily basis. Given her possibility for renal failure, we did not send her out with potassium. Rather we asked that she have her labs checked within the week to reassess potassium status. . 2. Fevers: On presentation, patient reported fevers to 102 in context of diarrhea, abdominal pain, and isolated elevations in ALT and Tbili. Unclear etiology, did not seem to be a pattern of biliary obstruction. Of note, ALT was more double than AST, but this ratio appears to be chronic. Urinalysis was unremarkable and portable chest film did not have any obvious consolidation. Pain was in location of ventral hernia which when evaluated by CT showed no obstruction or entrapment of bowel. Blood cultures were without growth. WBC remained in normal range. CT abdomen/pelvis showed diverticulosis but no diverticulitis. In ED, was given ciprofloxacin which was later stopped fever. She was then covered with Zosyn in the given concern for sepsis with low blood pressure as above. In , fevers and diarrhea resolved. On medicine floor, patient remained afebrile. Given that likely etiology of fevers and abdominal pain was diverticulitis, antibiotic regimen was changed to Bactrim and Flagyl. Abdominal pain resolved, and as above patient remained afebrile and with normal WBC count. C diff panel was negative. She was discharged with Flagyl and Bactrim for full 7 day course. Of note, repeat 2 view CXR on day prior to discharge showed consolidation that was considered to be pneumonia. Clinically, the patient did not appear to have pneumonia - afebrile, without cough or pleuritic chest pain, and improving on baseline oxygen requirement. We decided not to treat for a pneumonia, but sent off for urine legionella given presentation with abdominal pain; she had been on antibiotic treatment for 4 days when it was sent; it was negative. . 3. Hypoxia - Patient is on 2.5L home O2. In the , she was satting in mid 90's on 3L O2. This was felt to be secondary to mild pulmonary edema given aggressive fluid resuscitation. Diuresis was initially held given that it was felt that she was intravascularly depleted. On medicine floor, patient diuresed well and was satting 99-100% on 2L O2. Tachypnea also resolved. She has persistent bibasilar crackles, although this may have been in part due to her reported pulmonary fibrosis. . 4. Diastolic dysfunction heart failure, acute on chronic - LVEF >= 55% by TTE . Initial portable CXR with volume overload after 2 liters of fluid (initial chest film in ED actually indicated improvement from last imaging in ). Improved with diuresis per home medications (furosemide, spironlactone, and metolazone). As above, persistent basilar crackles although this may be her baseline given pulmonary fibrosis. . 5. Coronary artery disease - Continued statin, aspirin. Not on beta blocker, paced in the 60s. Was on amiodarone for SSS, but stopped secondary to IPF and progressive hypoxia. . 6. Aortic valve replacement with severe stenosis: s/p AVR in . Likely contributed to acute on chronic heart failure as above. . 7. Pulmonary Fibrosis: On admission, slightly more hypoxic than at her baseline. Required 3L in ICU, and on floor came down nicely to 2L. Continue advair and as needed albuterol nebs per home regimen. . 8. Diabetes mellitus, type II: In hospital, oral hypoglycemics held. Continued on sliding scale insulin with good blood glucose control. . 9. Atrial Fibrillation: Continued coumadin. After start of antibiotics, INR increased to 3.5. Coumadin held on the day of discharge, and on discharge gave instructions to the rehabilitation facility to monitor INR and dose accordingly while on antibiotics, with likely return to home dose after completing antibiotics. . 10. Anemia: Iron-deficiency. Hematocrit stable at baseline. Continue iron supplentation per home regimen. . 11. Hypothyroidism: Continued synthroid per home regimen. . 12. Hyperlipidemia: Continued statin per home regimen. . 13. Thrombocytopenia - Trasient. Given elevated LFTs and cirrhosis noted on CT abdomen, may be to reduced TPO production. Also given mild splenomegaly, may be sequestration. On discharge, platelets trending up and in normal range. | Extremities: no c/c, trace pretibial edema, good pulses. Was on amiodarone for SSS, but stopped secondary to IPF and progressive hypoxia. # Atrial Fibrillation: Continued coumadin. Mild splenomegaly, likely portal hypertension. CT Abd/pelvis (prelim): diverticulosis without itis. Also c/o L-sided CP that is now starting to subside. LS clear and diminished at bases. (Over) 4:08 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: NO IV CONTRAST-pls po contrast and eval for obstruction, div FINAL REPORT (Cont) 2. Check C.diff. + Bowel Sounds. Intermiten tachypnea. Unable to reduce hernia. Sig: One (1) Capsule, Delayed Release(E.C.) C/O mild abd. AAOx3 HEENT: EOMI, PERRL, no scleral icterus, very dry MM, OP clear, poor dentition Lungs: bibasilar rales Cardiac: RR, nl. Will defer central venous line for now. Compared to theprevious tracing atrial sensing is now present.TRACING #1 Chief Complaint: Reason for MICU Admission: hypotension HPI: This is an 80 yo F with a past medical history of SSS s/p pacer, hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV Replacement, presents to the ED with weakness, found to be febrile to 102, with a distended tender abdomen. Sig: One (1) Tablet, Delayed Release (E.C.) Tender to palpation. CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: The lung bases show mild interlobular septal thickening and atelectasis. # Hypothyroidism: - Continue synthroid . PA AND LATERAL RADIOGRAPHS OF THE CHEST: Demonstrate a retrocardiac opacity. This is an 80 yo F with a past medical history of SSS s/p pacer, hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV Replacement, presents to the ED with weakness, found to be febrile to 102, with a distended tender abdomen. This is an 80 yo F with a past medical history of SSS s/p pacer, hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV Replacement, presents to the ED with weakness, found to be febrile to 102, with a distended tender abdomen. Leads of pacemaker terminate within the right atrium and ventricle. # CAD: continue statin, aspirin. # Hyperlipidemia: Continue statin . Currently, her BP is 115/42, and she is asymptomatic with a temp of 98.6. IMPRESSION: Non-obstructive bowel gas pattern. IMPRESSION: Non-obstructive bowel gas pattern. Found to have a temp of 102 and hypotensive to 80s. Trachea is midline. Trachea is midline. Persistent left-sided pleural effusion. Holding diuretics (spironolactone, lasix and metolazone) overnight. Updates: 1) Hypotension: essentially resolved. # Atrial Fibrillation: Continued coumadin. # Atrial Fibrillation: Continued coumadin. Was on amiodarone for SSS, but stopped secondary to IPF and progressive hypoxia. Was on amiodarone for SSS, but stopped secondary to IPF and progressive hypoxia. Hernia, other Assessment: Pt. Hernia, other Assessment: Pt. Hernia, other Assessment: Pt. Hct down with fluids resuscitation. Thrombocytopenia present on admission, now slighly lower. Thrombocytopenia present on admission, now slighly lower. Leukocytosis has resolved. Leukocytosis has resolved. diurising Pt. diurising Pt. # Dispo: call out today to floor as dyspnea improved, BP stable. 7) Pulm fibrosis: continue current meds, O2. 4) Abdominal hernia: abd exam stable. # CAD: continue statin, aspirin. # CAD: continue statin, aspirin. # Hyperlipidemia: Continue statin . # Hyperlipidemia: Continue statin . Stool for c-diff when Pt. - Diuresed yesterday with good effect- pt still appears somewhat volume overloaded with crackles on lung auscultation. # Hypothyroidism: - Continue synthroid . # Hypothyroidism: - Continue synthroid . Diurese carefully today 6) Thrombocytopenia: Pt has low-normal plt count at baseline. Holding diuretics (spironolactone, lasix and metolazone) overnight. + Bowel Sounds. Intermiten tachypnea. Intermiten tachypnea. f/u Cx, C-diff. Consider checking smear; changing abx. Consider checking smear; changing abx. Tender to palpation. preload dependent. preload dependent. Tenderness over LLQ hernia; concern about bowel ischemia. Attempting diuresis w/ PO and IV lasix. Attempting diuresis w/ PO and IV lasix. LS clear and diminished at bases. LS clear and diminished at bases. I/O Goal: -0.5-1L. # Comm: patient ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 01:18 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: # Comm: patient ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 01:18 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Repleting K w/ total 80 PO and 40 IV. Repleting K w/ total 80 PO and 40 IV. This is an 80 yo F with a past medical history of SSS s/p pacer, hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV Replacement, IPF, presents to the ED with weakness, found to be febrile to 102, with a distended tender abdomen. This is an 80 yo F with a past medical history of SSS s/p pacer, hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV Replacement, IPF, presents to the ED with weakness, found to be febrile to 102, with a distended tender abdomen. | 28 | [
{
"category": "Radiology",
"chartdate": "2162-08-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025354,
"text": " 11:51 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o PTX\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with s/p RIJ attempt without success\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Unsuccessful right IJ attempt, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with earlier study of this date, there is little\n change. Specifically, there is no evidence of pneumothorax following failed\n IJ attempt.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025536,
"text": " 4:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval status\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with hypotension, fevers, abd pain\n REASON FOR THIS EXAMINATION:\n interval status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever. Pain.\n\n A single portable radiograph of the chest demonstrates a persistent left-sided\n pleural effusion. Bibasilar atelectasis is again seen. Increased airspace\n opacities reflect mild pulmonary edema. Dual-lead cardiac pacemaker is\n unchanged as are sternotomy wires. Trachea is midline. No pneumothorax.\n\n IMPRESSION:\n Persistent CHF. Pneumonia is not excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-08-08 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1025685,
"text": " 1:57 PM\n CHEST (PA & LAT) Clip # \n Reason: Fluid overloaded?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with heart failure, pulmonary fibrosis wiht home O2\n requirement, AVR, s/ stay for fluid overload after fluid resuscitation\n for hypotension\n REASON FOR THIS EXAMINATION:\n Fluid overloaded?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Congestive heart failure.\n\n PA AND LATERAL RADIOGRAPHS OF THE CHEST: Demonstrate a retrocardiac opacity.\n The finding is obscured by overlying dual-lead cardiac pacemaker on the PA\n view, but clearly identified on the lateral projection. There is a small\n left-sided pleural effusion. The right costophrenic angle is sharp. There is\n mild right basilar atelectasis. Increased airspace opacities involving the\n perihilar regions may represent mild pulmonary edema. Trachea is midline. No\n pneumothorax is evident.\n\n IMPRESSION:\n\n Left lower lung consolidation, best seen on the lateral projection. Finding\n represents pneumonia. Persistent left-sided pleural effusion. There may be\n superimposed mild pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-08-05 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1025319,
"text": " 4:16 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval for \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with abd distention and pain\n REASON FOR THIS EXAMINATION:\n eval for \n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE ABDOMEN AT 1620 HOURS.\n\n HISTORY: Abdominal distention and pain.\n\n COMPARISON: None.\n\n FINDINGS: Single view is somewhat limited by body habitus. There is an\n overall generalized paucity of bowel gas with no definite dilated loops of\n small bowel evident. There is no ascites or organomegaly detected.\n Degenerative changes are noted throughout the lumbar spine, particularly at\n the lumbosacral junction. Surgical clips are noted in the upper left\n hemipelvis. Phleboliths are noted throughout the lower pelvis.\n\n IMPRESSION: Non-obstructive bowel gas pattern.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-08-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025375,
"text": " 5:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CHF and hypotension, slightly increase O2 requirement\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Congestive failure and hypotension.\n\n FINDINGS: In comparison with study of , there is little overall change.\n Again there is enlargement of the cardiac silhouette with elevation of\n pulmonary venous pressure in a patient with intact midline sternal suture and\n dual-channel pacemaker device in place. Some atelectatic changes are seen at\n the left base. Dense mitral annulus calcification is obscured by the\n generator of the pacemaker device.\n\n IMPRESSION: Little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-08-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025302,
"text": " 3:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with weakness\n REASON FOR THIS EXAMINATION:\n ? pna\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 80-year-old female with weakness. Evaluate for pneumonia.\n\n Single AP chest radiograph compared to show mild interstitial\n edema slightly improved compared to prior exam. Bibasilar atlectasis persists.\n The heart size remains moderately enlarged, unchanged, with incidentally noted\n dense mitral annulus calcification. There is no pneumothorax or pleural\n effusion. Post surgical changes related to median sternotomy are pressent.\n Dual leads of a left chest wall pacemaker terminate in the right atrium and\n right ventricle.\n\n IMPRESSION: Very mild interstitial edema slightly improved compared to prior\n exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-08-05 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1025317,
"text": " 4:08 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: NO IV CONTRAST-pls po contrast and eval for obstruction, div\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with fever and distended abdomen + TTP L side\n REASON FOR THIS EXAMINATION:\n NO IV CONTRAST-pls po contrast and eval for obstruction, diverticulitis,\n abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 7:04 PM\n diverticulosis without itis. no obstruction. small amount of free fluid in the\n abdomen, which may relate to volume overload.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 80-year-old female with fever and distended abdomen.\n Evaluate for obstruction, diverticulitis, abscess.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the abdomen and pelvis\n from the lung bases to the pubic symphysis. Multiplanar reformatted images\n were obtained.\n\n CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: The lung bases show mild\n interlobular septal thickening and atelectasis. The heart shows extensive\n mitral annular calcification. Leads of pacemaker terminate within the right\n atrium and ventricle.\n\n The liver is shrunken and nodular suggestive of underlying cirrhosis. The\n spleen is enlarged and measures 15cm in length reflecting likely underlying\n portal hypertension. The adrenal glands and kidneys are normal. The pancreas\n is atrophic. A capacious ventral hernia is present containing loops of large\n and small bowel.The intra- abdominal loops of large and small bowel maintain a\n normal caliber without evidence of obstruction. There are scattered colonic\n diverticuli without evidence of diverticulitis. There is no free air or\n lymphadenopathy. A small amount of free fluid is seen surrounding the liver\n and bowel loops. Patient is status post cholecystectomy. Multiple surgical\n clips are seen within the retroperitoneum.\n\n CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: The rectum, bladder, and\n pelvic loops of small bowel are within normal limits. There are scattered\n sigmoid diverticuli without evidence of diverticulitis. A small amount of\n free fluid is seen within the pelvis. Multiple clips are identified along the\n pelvic sidewalls, which may relate to hysterectomy. No lymphadenopathy is\n appreciated.\n\n No suspicious lytic or sclerotic lesion is identified.\n\n IMPRESSION:\n 1. Large ventral hernia containing loops of large and small bowel. No bowel\n obstruction.\n (Over)\n\n 4:08 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: NO IV CONTRAST-pls po contrast and eval for obstruction, div\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Colonic diverticulosis without evidence of diverticulitis. No evidence of\n bowel obstruction or intra- abdominal abscess.\n\n 3. Small amount of fluid within the abdomen and pelvis. Given interlobular\n septal thickening in the lung bases and mild body wall anasarca, these\n findings are suggestive of mild fluid overload.\n\n 4. The liver is shrunken and nodular, which is suggestive of cirrhosis. Mild\n splenomegaly, likely portal hypertension.\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2162-08-05 00:00:00.000",
"description": "Report",
"row_id": 202065,
"text": "Sinus rhythm. Atrial sensing with ventricular pacing. Compared to the\nprevious tracing there is no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2162-08-05 00:00:00.000",
"description": "Report",
"row_id": 202066,
"text": "Sinus rhythm. Atrial sensing with ventricular pacing. Compared to the\nprevious tracing atrial sensing is now present.\nTRACING #1\n\n"
},
{
"category": "Nursing",
"chartdate": "2162-08-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 410529,
"text": "This is an 80 yo F with a past medical history of SSS s/p pacer,\n hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV\n Replacement, presents to the ED with weakness, found to be febrile to\n 102, with a distended tender abdomen. She said that the abdominal pain\n started today, her stools have been relatively normal, no\n brbpr/hematochezia. In the ED, she underwent a CT abd/pelvis which\n showed evidence of diverticulosis but no diverticulitis, and a small\n amount of free fluid in the abdomen.\n"
},
{
"category": "Nursing",
"chartdate": "2162-08-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 410530,
"text": "This is an 80 yo F with a past medical history of SSS s/p pacer,\n hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV\n Replacement, presents to the ED with weakness, found to be febrile to\n 102, with a distended tender abdomen. She said that the abdominal pain\n started today, her stools have been relatively normal, no\n brbpr/hematochezia. In the ED, she underwent a CT abd/pelvis which\n showed evidence of diverticulosis but no diverticulitis, and a small\n amount of free fluid in the abdomen.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Pt. with fluid overload per CXR after reciving 2L Fluid bolus in ED for\n transient hypotension. LS clear and diminished at bases. O2 at 2L NC.\n Intermiten tachypnea.\n Action:\n Restarted home dose of Lasix.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-08-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 410509,
"text": "This is an 80yo female with an extensive PMH who presented to EW with\n poor po intake, diarrhea, weakness and abd. Pain. Found to have a temp\n of 102 and hypotensive to 80\ns. Given 2L NS and brought for CT of\n abdomen which showed no obstruction but some free fluid. Boluses at\n that time stopped. Attempts made at placing central line unsuccessful,\n now pt. refusing. Pt. pan cultured, given antibiotics and transferred\n here for further work-up and management.\n Upon arrival here pt. found to be hemodynamically stable. C/O mild abd.\n Pain but with movement only. Will monitor closely but if remains\n stable ? c/o to floor. Culture results pending. Continue with\n antibiotics.\n A+Ox3. MAE. Pt. is legally blind but lives in an independent living\n facility performing self ADLs.\n Pt. on 2L nasal cannula with sats >94%. Breath sounds clear with\n crackles in bases bilat. No c/o SOB. Pt. does have a hx. Of pulmonary\n fibrosis for which she wears 2L of O2 at home.\n Pt. is AV paced. BP has remained high 90\ns to low 120\ns here in unit.\n + pulses. Afebrile at this time.\n Abd. Soft/distended. Tender to palpation. + Bowel Sounds. No bm this\n shift.\n Foley in place draining clear yellow urine. Good output.\n Skin Intact\n 2 18g PIVs placed in EW.\n"
},
{
"category": "Physician ",
"chartdate": "2162-08-06 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 410511,
"text": "Chief Complaint: Reason for MICU Admission: hypotension\n HPI:\n This is an 80 yo F with a past medical history of SSS s/p pacer,\n hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV\n Replacement, presents to the ED with weakness, found to be febrile to\n 102, with a distended tender abdomen. She said that the abdominal pain\n started today, her stools have been relatively normal, no\n brbpr/hematochezia. In the ED, she underwent a CT abd/pelvis which\n showed evidence of diverticulosis but no diverticulitis, and a small\n amount of free fluid in the abdomen. Out of concern for a possible GI\n source, the patient was to receive cipro/flagyl, but got cipro and\n subsequently got hives. She was then given a dose of zosyn. Surgery saw\n the patient in the ED and felt that her abdominal exam, initially was\n concerning, but over time had improved and given no obvious findings on\n CT, did not feel that there should be any surgical intervention at this\n time.\n .\n She was to be admitted to the floor initially for further work up, but\n her initial BP of 115/93 dropped to the 80's without compensatory HR\n elevation. She then received 2L of NS, despite concern that she was\n volume overloaded. A RIJ was attempted, but was unsuccessful. BP's\n returned to the 110's but then just prior to transfer to , they\n were back in the high 80's systolic, satting 99% 2L.\n .\n Notable labs were no leukocytosis but a small left shift, mild anemia,\n thrombocytopenia, lactate of 1.5, creatinine of 1.6, TB 1.7 in the\n setting of normal LFT's. She is transferred to the for\n stabilization of her hypotension and further work up of her fevers.\n .\n Currently, her BP is 115/42, and she is asymptomatic with a temp of\n 98.6. She c/o abdominal pain. She also claims she had chest pain in the\n emergency department, but it has been going away gradually over the\n last few hours. She denies loose stool.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Quinidine\n Unknown;\n Iodine\n Unknown;\n Indocin (Oral) (Indomethacin)\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 03:43 AM\n Infusions:\n Other ICU medications:\n Other medications:\n 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY\n 2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)\n Capsule, Delayed Release(E.C.) PO once a day.\n 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS\n 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:\n One (1) Disk with Device Inhalation (2 times a day).\n 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\n PO DAILY\n 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID\n 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID\n 8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY\n 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY\n 11. Hexavitamin Tablet Sig: One (1) Tablet PO once a day.\n 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)\n Tablet PO DAILY (Daily).\n 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:\n One (1) Capsule, Sustained Release PO once a day.\n 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)\n Tablet, Delayed Release (E.C.) PO DAILY (Daily).\n 15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times\n a day).\n 16. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 5X/WEEK\n (MO,TU,WE,TH,FR).\n 17. Metolazone 10mg qmonday, friday\n Past medical history:\n Family history:\n Social History:\n - Diabetes\n - Dyslipidemia\n - Hypertension\n - Pacemaker placement for SSS s/p generator replacement\n \n - Legal blindness\n - Pulmonary Fibrosis on 2 L O2 at home; fibrosis @ lung bases\n bilaterally (reported as unlikely to be amiodarone related)\n - Diastolic CHF (last EF wnl in )\n - AS s/p AVR -with \"horse valve\"- by Dr. \n - Paroxysmal atrial fibrillation/AVJ ablation - \n - Hypothyroidism, (two thyroid surgeries as a child)\n - s/p Appendectomy\n - Uterine cancer, s/p complete hysterectomy\n - s/p Hernia repair\n - s/p cholecystectomy\n - Severe aortic stensois of the AVR\n - R Humerus Neck Fracture\n - R Knee Hemarthrosis, r knee hemarthrosis\n Mother deceased from kidney disease and ruptured aorta, father\n deceased from CHF.\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: Patient is widowed and lives alone. She lives in an independent\n living facility. Her son lives a few blocks away and helps her with her\n medications.\n Review of systems: c/o abdominal pain, otherwise, ROS is negative in\n detail. No f/c/n/v/d.\n Flowsheet Data as of 05:22 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98.1\n HR: 65 (65 - 71) bpm\n BP: 110/45(60) {110/42(60) - 116/46(64)} mmHg\n RR: 18 (16 - 22) insp/min\n SpO2: 96%\n Heart rhythm: AV Paced\n Height: 59 Inch\n Total In:\n 203 mL\n PO:\n TF:\n IVF:\n 203 mL\n Blood products:\n Total out:\n 0 mL\n 360 mL\n Urine:\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -157 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///24/\n Physical Examination\n VS T = 98.6 P = 65 BP = 115/42 RR = 28 O2Sat = 95% 3L NC\n General: Elderly female NAD. AAOx3\n HEENT: EOMI, PERRL, no scleral icterus, very dry MM, OP clear, poor\n dentition\n Lungs: bibasilar rales\n Cardiac: RR, nl. obliteration of S1, normal S2, loud holosytolic,\n harsh decrescendo murmur with radiation to the carotids, L>R.\n Abdomen: soft, mildly distended, normoactive bowel sounds, well healed\n scar midline, with ventral hernia, with significant ttp just below the\n umbilicus into the suprapubic region. Unable to reduce hernia. No\n rebound or guarding.\n Extremities: no c/c, trace pretibial edema, good pulses.\n Neurologic: Moves all extremities. Alert, oriented x 3.\n Skin: scattered ecchymoses on arms.\n Labs / Radiology\n 10.0 g/dL\n 100 mg/dL\n 1.4 mg/dL\n 33 mg/dL\n 24 mEq/L\n 100 mEq/L\n 4.5 mEq/L\n 135 mEq/L\n 31.5 %\n 11.2 K/uL\n [image002.jpg]\n \n 2:33 A8/1/ 04:16 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 11.2\n Hct\n 31.5\n Cr\n 1.4\n Glucose\n 100\n Other labs: PT / PTT / INR:20.7/36.7/2.0, ALT / AST:26/64, Alk Phos / T\n Bili:64/1.4, Albumin:3.1 g/dL, LDH:815 IU/L, Ca++:7.7 mg/dL, Mg++:2.5\n mg/dL, PO4:4.0 mg/dL\n Imaging: KUB: FINDINGS: Single view is somewhat limited by body\n habitus. There is an overall generalized paucity of bowel gas with no\n definite dilated loops of small bowel evident. There is no ascites or\n organomegaly detected. Degenerative changes are noted throughout the\n lumbar spine, particularly at the lumbosacral junction. Surgical clips\n are noted in the upper left hemipelvis. Phleboliths are noted\n throughout the lower pelvis. IMPRESSION: Non-obstructive bowel gas\n pattern.\n .\n CXR: Single AP chest radiograph compared to show mild\n interstitial edema slightly improved compared to prior exam. Bibasilar\n atlectasis persists. The heart size remains moderately enlarged,\n unchanged, with incidentally noted dense mitral annulus calcification.\n There is no pneumothorax or pleural effusion. Post surgical changes\n related to median sternotomy are pressent. Dual leads of a left chest\n wall pacemaker terminate in the right atrium and right ventricle.\n IMPRESSION: Very mild interstitial edema slightly improved compared to\n prior exam.\n .\n CT Abd/pelvis (prelim): diverticulosis without itis. no obstruction.\n small amount of free fluid in the abdomen, which may relate to volume\n overload. Liver, small and nodular suggestive of underlying cirrhosis.\n No free air or LAD. s/p cck. Mild body wall anasarca.\n Microbiology: BLOOD CULTURE Blood Culture, Routine-PENDING\n BLOOD CULTURE Blood Culture, Routine-PENDING\n ECG: V-paced @ 75, left axis. TWI in AVL. No changes from prior.\n Assessment and Plan\n A/P: 80 y.o. F with CHF, atrial fibrillation on coumadin, CAD, AV\n replacement with AS, DM, PPM, pulm fibrosis (on home O2) who presented\n with fevers and hypotension.\n .\n # Hypotension: could be secondary to early sepsis etiology, given\n fevers, but there is no clear source and no leukocytosis. She responded\n transiently to 2L fluids, but then seemed to have worsened pulmonary\n edema on chest film and despite this, had a drop in her BP again. It\n may be that the patient is infected but when given large volumes of\n fluid for resuscitation, she can't maintain the forward flow for such a\n sudden increase in venous return. Additionally, she doesn't have a\n compensatory increase in her HR, to aid in increasing her cardiac\n output in the setting of early sepsis/dehydration. Given hypotension\n and ARF with low serum sodium on labs, etiology of hypotension is\n likely due to volume depletion. This is likely exacerbated by\n patient's aggressive diuretic regimen.\n Other etiology could be a pulmonary embolus - the patient is on\n chronic anticoagulation for afib and AVR, but is subtherapeutic today.\n This could explain fever, hypotension and hypoxia, and she could not be\n manifesting a tachycardia secondary to v-pacing. Pericardial effusion\n is also a concern but no evidence of this on exam.\n - gentle IVF\n - urine lytes if not correcting\n - monitor urine output\n - hold diuretics tonight\n - check pulsus - wnl\n - consider repeat echo\n - follow cultures - check blood, urine, c diff\n - continue zosyn\n .\n # Fevers: patient with isolated elevations in ALT and Tbili. Unclear\n etiology, does not seem to be a pattern of biliary obstruction. UA is\n unremarkable and chest film doesn't have any obvious consolidation. No\n diarrhea despite abd pain - pain is in location of hernias. Surgical\n eval initially concerning, then patient's symptoms seemed to have\n improved. Blood cultures are pending. WBC is normal with slight left\n shift. Could have been diverticulitis that was resolving by the time\n she had CT abd/pelvis, but less likely.\n - continue broad spectrum abx for now, given ?early sepsis\n - monitor culture data\n - serial abd exams - have surgery re-eval patient in AM\n - c diff, pancultures as above\n - continue zosyn\n .\n # Hypoxia: patient is on 2.5L home o2, is on 3L here satting in mid\n 90's. Likely secondary to mild pulmonary edema. Would hold on diuresis\n however, unless patient is symptomatic, as she is likely still\n intravascularly deplete.\n .\n # CAD: continue statin, aspirin. Not on beta blocker, paced in the\n 60's. Was on amiodarone for SSS, but stopped secondary to IPF and\n progressive hypoxia.\n .\n # CHF (EF = 65% 03/07): CXR with volume overload after 2 liters of\n fluid (initial chest film in ED actually indicated improvement from\n last imaging in ). Can reconsider echo as noted above. Holding\n diuretics (spironolactone, lasix and metolazone) overnight.\n .\n # AVR with severe stenosis: Aortic valve area of 0.9 on C.cath in \n and 0.7 cm2 on Echo in , s/p AVR in .\n - Closely monitor fluid status and BP, diurese gently\n .\n # Pulmonary Fibrosis/Hypoxia: Currently slightly more hypoxic than\n baseline likely to CHF. (baseline oxygen requirement of 2 L NC)\n - Continue advair\n - PRN albuterol nebs\n .\n # Type 2 DM: FS qid. RISS\n .\n # Atrial Fibrillation: Continued coumadin.\n .\n # Anemia: iron deficiency. Hct stable at baseline.\n - continue iron supplentation\n .\n # Hypothyroidism:\n - Continue synthroid\n .\n # Hyperlipidemia: Continue statin\n .\n # FEN: diabetic, heart healthy\n .\n # PPX: on coumadin, on home PPI\n .\n # Code: Full\n .\n # Access: piv's\n .\n # Dispo: in ICU overnight for BP monitoring\n .\n # Comm: patient\n ICU Care\n Nutrition:\n Glycemic Control: RISS\n Lines:\n 18 Gauge - 01:18 AM\n Prophylaxis:\n DVT: on coumadin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU until stable\n"
},
{
"category": "Physician ",
"chartdate": "2162-08-06 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 410512,
"text": "Chief Complaint: Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 80 yo woman with a h/o sick sinus syndrome, s/p pcer, CAD, afib, AVR,\n presented to ED with weakness overnight. Found to have fever to 102,\n abd tender. CT abd/pelvis showed diverticulosis but no\n diverticulitis. Got dose of cipro --> hives. Got dose of Zosyn\n following. Abd exam improved over serial exams in ED. SBP in 80s,\n without improvement with 2L NS. Failed attempt for IJ central line in\n ED. Transferred to ICU. BP 115/42 on arrival to ICU. Also c/o\n L-sided CP that is now starting to subside.\n Patient admitted from: ER\n History obtained from Medical records, ICU team\n Allergies:\n Quinidine\n Unknown;\n Iodine\n Unknown;\n Indocin (Oral) (Indomethacin)\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 03:43 AM\n Infusions:\n Other ICU medications:\n Other medications:\n singulair, nexium, , 81, levothyroxine, sirinolactone, iron,\n coumadin, metalozone, lasix, advair\n Past medical history:\n Family history:\n Social History:\n DM2\n Hyperlipid\n HTN\n s/p pacer for SSS\n Legally blind\n H/O pulmonary fibrosis of unclear etiology on 2L home O2 at baseline\n Diastolic heart failure\n Afib s/p ablation \n AS s/p AVR\n s/p R humeral fracture\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fever\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Chest pain\n Nutritional Support: No(t) NPO\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: Abdominal pain\n Genitourinary: No(t) Dysuria\n Integumentary (skin): No(t) Jaundice\n Heme / Lymph: Anemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Allergy / Immunology: No(t) Immunocompromised\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 05:50 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98.1\n HR: 65 (65 - 71) bpm\n BP: 110/45(60) {110/42(60) - 116/46(64)} mmHg\n RR: 18 (16 - 22) insp/min\n SpO2: 96%\n Heart rhythm: AV Paced\n Height: 59 Inch\n Total In:\n 208 mL\n PO:\n TF:\n IVF:\n 208 mL\n Blood products:\n Total out:\n 0 mL\n 360 mL\n Urine:\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -152 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, mucous membranes dry\n Cardiovascular: (S1: Normal), No(t) S3, No(t) S4\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases)\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Distended,\n Tender: over hernia, non-reducible, ventral hernia\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 31.5 %\n 10.0 g/dL\n 100 mg/dL\n 1.4 mg/dL\n 33 mg/dL\n 24 mEq/L\n 100 mEq/L\n 4.5 mEq/L\n 135 mEq/L\n 11.2 K/uL\n [image002.jpg]\n 04:16 AM\n WBC\n 11.2\n Hct\n 31.5\n Cr\n 1.4\n Glucose\n 100\n Other labs: PT / PTT / INR:20.7/36.7/2.0, ALT / AST:26/64, Alk Phos / T\n Bili:64/1.4, Albumin:3.1 g/dL, LDH:815 IU/L, Ca++:7.7 mg/dL, Mg++:2.5\n mg/dL, PO4:4.0 mg/dL\n Imaging: KUB: non-obstructive bowel gas pattern\n CT abd/pelvis: Liver suggestive of cirrhosis, diverticulosis\n ECG: V-paced @ 75\n Assessment and Plan\n 80 yo woman with multiple medical problems presenting with fevers and\n hypotension, along with abd pain.\n 1. Hypotension: Unclear etiology - but probable combination of\n infection from an abd source, poor cardiac compensatory mechanisms, and\n hypovolemia. Will need to give fluid back gently given propensity to\n develop pulmonary edema in setting of afib. Follow cultures. Will\n defer central venous line for now.\n 2. Abd pain: Ongoing tenderness over vental hernia, CT unrevealing.\n Surgery following. Given high LDH and hypotension --> possible\n transient incarceration of hernia? Check C.diff.\n 3. Hypoxemia: On 2L home O2 at baseline in setting of fibrosis, on 3L\n currently due to possible pulmonary edema in setting of fluid\n resusitation.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 01:18 AM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2162-08-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 410553,
"text": "Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Pt was fluid positive following treatment in ED. Attempting diuresis\n w/ PO and IV lasix.\n Action:\n Given on PO standing dose lasix which pt takes @ home.\n Response:\n Diuresing very well overnight. K this AM was 2.9\n Plan:\n Continue to monitor I&O. Repleting K w/ total 80 PO and 40 IV.\n Pt slept very well overnight. No c/o discomfort @ rest. Does get SOB\n w/ activity but LS better now w/ pt diuresing well.\n Pt asking when she\nll be able to go home.\n No stool yet this shift (get c.diff cx when she does). Asking for MOM\n which she states works for her.\n"
},
{
"category": "Nursing",
"chartdate": "2162-08-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 410555,
"text": "Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Pt was fluid positive following treatment in ED. Attempting diuresis\n w/ PO and IV lasix.\n Action:\n Gave 80mg PO standing dose lasix which pt takes @ home.\n Response:\n Diuresing very well overnight. K this AM was 2.9. Remains on 3L NC (on\n 2L NC @ home)\n Plan:\n Continue to monitor I&O. Repleting K w/ total 80 PO and 40 IV.\n Pt slept very well overnight. No c/o discomfort @ rest. Does get SOB\n w/ activity but LS better now w/ pt diuresing well.\n Pt asking when she\nll be able to go home.\n No stool yet this shift (get c.diff cx when she does). Asking for MOM\n which she states works for her.\n"
},
{
"category": "Physician ",
"chartdate": "2162-08-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 410556,
"text": "Chief Complaint: fevers, hypotension\n 24 Hour Events:\n +700cc since admission to ICU at 1 AM till 4 PM yesterday, despite\n Lasix 80 mg PO BID (pt's usual home dose). Was given Lasix IV 20 mg x\n 1--> voided 70cc after 1hour. Gave Metolazone 5 mg x 1 followed by 40\n mg Lasix IV, with good effect.\n Pt feeling SOB at times, but maintains O2 sat at above 95% on 3 L NC.\n This morning, pt is comfortably resting in bed. Pt has new complaints\n other than constipation. Pt received MoM for this.\n Allergies:\n Quinidine\n Unknown;\n Iodine\n Unknown;\n Indocin (Oral) (Indomethacin)\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 04:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Furosemide (Lasix) - 06:26 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.5\nC (95.9\n HR: 89 (65 - 95) bpm\n BP: 120/45(67) {98/41(57) - 130/75(79)} mmHg\n RR: 18 (17 - 25) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Height: 59 Inch\n Total In:\n 1,844 mL\n 312 mL\n PO:\n 760 mL\n 200 mL\n TF:\n IVF:\n 1,084 mL\n 112 mL\n Blood products:\n Total out:\n 2,090 mL\n 1,710 mL\n Urine:\n 2,090 mL\n 1,710 mL\n NG:\n Stool:\n Drains:\n Balance:\n -246 mL\n -1,398 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 86 K/uL\n 9.9 g/dL\n 92 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 2.9 mEq/L\n 38 mg/dL\n 98 mEq/L\n 138 mEq/L\n 29.8 %\n 7.8 K/uL\n [image002.jpg]\n 04:16 AM\n 03:15 AM\n WBC\n 11.2\n 7.8\n Hct\n 31.5\n 29.8\n Plt\n 87\n 86\n Cr\n 1.4\n 1.4\n Glucose\n 100\n 92\n Other labs: PT / PTT / INR:25.9/39.5/2.5, ALT / AST:24/63, Alk Phos / T\n Bili:68/1.3, Albumin:3.1 g/dL, LDH:815 IU/L, Ca++:8.0 mg/dL, Mg++:2.4\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n A/P: 80 y.o. F with CHF, atrial fibrillation on coumadin, CAD, AV\n replacement with AS, DM, PPM, pulm fibrosis (on home O2) who presented\n with fevers and hypotension.\n # Hypotension: could be secondary to early sepsis etiology, given\n fevers, but there is no clear source and no leukocytosis. She responded\n transiently to 2L fluids, but then seemed to have worsened pulmonary\n edema on chest film and despite this, had a drop in her BP again. It\n may be that the patient is infected but when given large volumes of\n fluid for resuscitation, she can't maintain the forward flow for such a\n sudden increase in venous return. Additionally, she doesn't have a\n compensatory increase in her HR, to aid in increasing her cardiac\n output in the setting of early sepsis/dehydration. Given hypotension\n and ARF with low serum sodium on labs, etiology of hypotension is\n likely due to volume depletion. This is likely exacerbated by\n patient's aggressive diuretic regimen.\n Other etiology could be a pulmonary embolus - the patient is on\n chronic anticoagulation for afib and AVR, but is subtherapeutic today.\n This could explain fever, hypotension and hypoxia, and she could not be\n manifesting a tachycardia secondary to v-pacing. Pericardial effusion\n is also a concern but no evidence of this on exam.\n - gentle IVF\n - urine lytes if not correcting\n - monitor urine output\n - hold diuretics tonight\n - check pulsus - wnl\n - consider repeat echo\n - follow cultures - check blood, urine, c diff\n - continue zosyn\n .\n # Fevers: patient with isolated elevations in ALT and Tbili. Unclear\n etiology, does not seem to be a pattern of biliary obstruction. UA is\n unremarkable and chest film doesn't have any obvious consolidation. No\n diarrhea despite abd pain - pain is in location of hernias. Surgical\n eval initially concerning, then patient's symptoms seemed to have\n improved. Blood cultures are pending. WBC is normal with slight left\n shift. Could have been diverticulitis that was resolving by the time\n she had CT abd/pelvis, but less likely.\n - continue broad spectrum abx for now, given ?early sepsis\n - monitor culture data\n - serial abd exams - have surgery re-eval patient in AM\n - c diff, pancultures as above\n - continue zosyn\n .\n # Hypoxia: patient is on 2.5L home o2, is on 3L here satting in mid\n 90's. Likely secondary to mild pulmonary edema. Would hold on diuresis\n however, unless patient is symptomatic, as she is likely still\n intravascularly deplete.\n .\n # CAD: continue statin, aspirin. Not on beta blocker, paced in the\n 60's. Was on amiodarone for SSS, but stopped secondary to IPF and\n progressive hypoxia.\n .\n # CHF (EF = 65% 03/07): CXR with volume overload after 2 liters of\n fluid (initial chest film in ED actually indicated improvement from\n last imaging in ). Can reconsider echo as noted above. Holding\n diuretics (spironolactone, lasix and metolazone) overnight.\n .\n # AVR with severe stenosis: Aortic valve area of 0.9 on C.cath in \n and 0.7 cm2 on Echo in , s/p AVR in .\n - Closely monitor fluid status and BP, diurese gently\n .\n # Pulmonary Fibrosis/Hypoxia: Currently slightly more hypoxic than\n baseline likely to CHF. (baseline oxygen requirement of 2 L NC)\n - Continue advair\n - PRN albuterol nebs\n .\n # Type 2 DM: FS qid. RISS\n .\n # Atrial Fibrillation: Continued coumadin.\n .\n # Anemia: iron deficiency. Hct stable at baseline.\n - continue iron supplentation\n .\n # Hypothyroidism:\n - Continue synthroid\n .\n # Hyperlipidemia: Continue statin\n .\n # FEN: diabetic, heart healthy\n .\n # PPX: on coumadin, on home PPI\n .\n # Code: Full\n .\n # Access: piv's\n .\n # Dispo: in ICU overnight for BP monitoring\n .\n # Comm: patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:18 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": "2162-08-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 410581,
"text": "This is an 80 yo F with a past medical history of SSS s/p pacer,\n hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV\n Replacement, IPF, presents to the ED with weakness, found to be febrile\n to 102, with a distended tender abdomen. She said that the abdominal\n pain started today, her stools have been relatively normal, no\n brbpr/hematochezia. In the ED, she underwent a CT abd/pelvis which\n showed evidence of diverticulosis but no diverticulitis, and a small\n amount of free fluid in the abdomen. Surgery evaluated Pt. but no\n surgical intervention. While in Pt.\ns BP droped to 80\ns and Pt. was\n bloused with 2L NS after which Pt. developed pulmonary edema and\n required transfer to ICU.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Pt. with pulmonary edema on per CXR with increased SOB and O2\n requierments.\n Action:\n Diuresed last night with good results and remains on home dose of\n Lasix.\n Response:\n LS clear with faint crackels at bases. Cont. to diurese with urine\n output >100cc/hr. O2 waned down to home setting of 2L/min with O2 sat\n >95%. BP stable.\n Plan:\n Cont. diurising Pt. and f/u CXR for resolution of pulmonary edema.\n Monitor BP as Pt. preload dependent.\n Hernia, other\n Assessment:\n Pt. with large hernias over abdomen. C/O pain on palpation over hernia\n sites. Also c/o being constipated. Abd. Soft, BS+.\n Action:\n MOM this Am and daily bowel regiment.\n Response:\n Pt. had large loose stool this shift, OB negative. States abd. Feels\n better.\n Plan:\n Cont. to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2162-08-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 410582,
"text": "This is an 80 yo F with a past medical history of SSS s/p pacer,\n hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV\n Replacement, IPF, presents to the ED with weakness, found to be febrile\n to 102, with a distended tender abdomen. She said that the abdominal\n pain started today, her stools have been relatively normal, no\n brbpr/hematochezia. In the ED, she underwent a CT abd/pelvis which\n showed evidence of diverticulosis but no diverticulitis, and a small\n amount of free fluid in the abdomen. Surgery evaluated Pt. but no\n surgical intervention. While in Pt.\ns BP droped to 80\ns and Pt. was\n bloused with 2L NS after which Pt. developed pulmonary edema and\n required transfer to ICU.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Pt. with pulmonary edema on per CXR with increased SOB and O2\n requierments.\n Action:\n Diuresed last night with good results and remains on home dose of\n Lasix.\n Response:\n LS clear with faint crackels at bases. Cont. to diurese with urine\n output >100cc/hr. O2 waned down to home setting of 2L/min with O2 sat\n >95%. BP stable.\n Plan:\n Cont. diurising Pt. and f/u CXR for resolution of pulmonary edema.\n Monitor BP as Pt. preload dependent.\n Hernia, other\n Assessment:\n Pt. with large hernias over abdomen. C/O pain on palpation over hernia\n sites. Also c/o being constipated. Abd. Soft, BS+.\n Action:\n MOM this Am and daily bowel regiment.\n Response:\n Pt. had large loose stool this shift, OB negative. States abd. Feels\n better.\n Plan:\n Cont. to monitor.\n Hypokalemia (Low potassium, hypopotassemia)\n Assessment:\n K level 2.9 this AM after agresive diuresis last night.\n Action:\n K repleated with 80 meq PO and 40 meq IV.\n Response:\n No ectopy on tele. Repeat lytes at 1700.\n Plan:\n Repeat lytes at 1700.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE;EXACERBATION\n Code status:\n Full code\n Height:\n 59 Inch\n Admission weight:\n 76 kg\n Daily weight:\n Allergies/Reactions:\n Quinidine\n Unknown;\n Iodine\n Unknown;\n Indocin (Oral) (Indomethacin)\n Unknown;\n Precautions:\n PMH: Diabetes - Oral \n CV-PMH: Arrhythmias, CAD, CHF, Hypertension, Pacemaker\n Additional history: Legal blindness, Pulmonary Fibrosis, (on 2L NC at\n home), hypothyroidism, Uterine CA (s/p total hysterectomy), Paroxysmal\n AFib s/p AVJ ablation ', AS s/p AVR ', appendectomy, hernia repair,\n cholecystectomy,\n Surgery / Procedure and date: hysterectomy, hernia repair,\n cholecystectomy, appendectomy, AVJ ablation, AVR.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:117\n D:41\n Temperature:\n 96.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 65 bpm\n Heart rhythm:\n A Flut (Atrial Flutter)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,473 mL\n 24h total out:\n 3,585 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:15 AM\n Potassium:\n 2.9 mEq/L\n 03:15 AM\n Chloride:\n 98 mEq/L\n 03:15 AM\n CO2:\n 27 mEq/L\n 03:15 AM\n BUN:\n 38 mg/dL\n 03:15 AM\n Creatinine:\n 1.4 mg/dL\n 03:15 AM\n Glucose:\n 92 mg/dL\n 03:15 AM\n Hematocrit:\n 29.8 %\n 03:15 AM\n Finger Stick Glucose:\n 142\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 2 PIVs, foley\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with Pt.\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: MICU 406\n Transferred to: 322\n Date & time of Transfer: 1449\n"
},
{
"category": "Physician ",
"chartdate": "2162-08-07 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 410569,
"text": "Chief Complaint: fever and abdominal pain and hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 80F with severe AS, severe MR, ventral hernias, present with fevers and\n abdominal pain:\n 24 Hour Events:\n *sob yesterday pm; given lasix iv and metolazone with good uop and\n resolution of sx\n *constipated but good bm this am\n *no more fever or abdominal pain\n Allergies:\n Quinidine\n Unknown;\n Iodine\n Unknown;\n Indocin (Oral) (Indomethacin)\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:26 PM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n coumadin, synthroid, asa, advair, singuliar, heparin sq, lasix 80 ,\n colace, riss, senna, pentoprazole\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 Ear, Nose, Throat: No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain\n Nutritional Support: No(t) NPO\n Respiratory: No(t) Cough, Dyspnea, improved\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, Constipation\n Genitourinary: No(t) Dysuria, Foley\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 65 (65 - 95) bpm\n BP: 84/64(68) {84/41(57) - 130/70(77)} mmHg\n RR: 30 (17 - 30) insp/min\n SpO2: 95%\n Heart rhythm: AV Paced\n Height: 59 Inch\n Total In:\n 1,844 mL\n 907 mL\n PO:\n 760 mL\n 540 mL\n TF:\n IVF:\n 1,084 mL\n 367 mL\n Blood products:\n Total out:\n 2,090 mL\n 2,850 mL\n Urine:\n 2,090 mL\n 2,850 mL\n NG:\n Stool:\n Drains:\n Balance:\n -246 mL\n -1,943 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n Systolic), 3/6rlusb and at apex\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n 1/2 up), imrpved since yesterday\n Abdominal: Soft, Bowel sounds present, Tender: minimally\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Cool, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 86 K/uL\n 92 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 2.9 mEq/L\n 38 mg/dL\n 98 mEq/L\n 138 mEq/L\n 29.8 %\n 7.8 K/uL\n [image002.jpg]\n 04:16 AM\n 03:15 AM\n WBC\n 11.2\n 7.8\n Hct\n 31.5\n 29.8\n Plt\n 87\n 86\n Cr\n 1.4\n 1.4\n Glucose\n 100\n 92\n Other labs: PT / PTT / INR:25.9/39.5/2.5, ALT / AST:24/63, Alk Phos / T\n Bili:68/1.3, Albumin:3.1 g/dL, LDH:815 IU/L, Ca++:8.0 mg/dL, Mg++:2.4\n mg/dL, PO4:3.1 mg/dL\n Imaging: cxr: subtle improvement in bibasilar opacitis\n Assessment and Plan\n 1. fever\n 2. thrombocytopenia\n 3. abdominal pain\n 4. CHF\n 5. Afib\n 6. Pulmonary fibrosis\n 80F with chf, afib on a/c, pulm fibrosis, presesnt with fever and\n hypotension without a source. bp improved without much intervention.\n started on zosyn for empiric treatment of an abdominal source. The\n source of the fever remains unclear. Leukocytosis has resolved.\n Will continue to complete a 7-day course for a presumed GI infection\n (?early strangulation vs. ct-negative diverticulitis given known\n diverticulosis) given improved abdominal symptoms and resolution of\n leukocytosis. Will follow-up cultures.\n Cardiac issues are the major issue now; pt is improving but needs more\n diuresis. Will monitor blood pressure closely and renal function.\n Thrombocytopenia present on admission, now slighly lower. Will stop sq\n heparin since patient is already on coumadin and will continue to\n monitor. Consider checking smear; changing abx.\n If continues to improved will consider transfer to floor later today or\n tomorrow; communicating with primary cardiologist Dr .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:18 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2162-08-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 410570,
"text": "Chief Complaint: fevers, hypotension\n 24 Hour Events:\n +700cc since admission to ICU at 1 AM till 4 PM yesterday, despite\n Lasix 80 mg PO BID (pt's usual home dose). Pt c/o worsening dyspnea\n with increased crackles on lung auscultation.\n Was given Lasix IV 20 mg x 1--> voided 70cc after 1hour. Gave\n Metolazone 5 mg x 1 followed by 40 mg Lasix IV, with good effect.\n Pt still feeling SOB at times, but maintains O2 sat at above 95% on 3 L\n NC.\n This morning, pt is comfortably resting in bed. Pt has new complaints\n other than constipation. Pt received MoM for this. (\nPt had a large BM\n just before rounds)\n Allergies:\n Quinidine\n Unknown;\n Iodine\n Unknown;\n Indocin (Oral) (Indomethacin)\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 04:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Furosemide (Lasix) - 06:26 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.5\nC (95.9\n HR: 89 (65 - 95) bpm\n BP: 120/45(67) {98/41(57) - 130/75(79)} mmHg\n RR: 18 (17 - 25) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Height: 59 Inch\n Total In:\n 1,844 mL\n 312 mL\n PO:\n 760 mL\n 200 mL\n TF:\n IVF:\n 1,084 mL\n 112 mL\n Blood products:\n Total out:\n 2,090 mL\n 1,710 mL\n Urine:\n 2,090 mL\n 1,710 mL\n NG:\n Stool:\n Drains:\n Balance:\n -246 mL\n -1,398 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///27/\n Physical Examination\n Gen: alert, talkative\n Heart: RRR, harsh, cres-decres systolic murmur radiating to\n carotids\n Lungs: good air movement, bibasilar crackles\n Abd: soft, obese, mildly tender over LLQ mass (hernia). Less tender\n today than yesterday.\n Ext: Trace edema\n Labs / Radiology\n 86 K/uL\n 9.9 g/dL\n 92 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 2.9 mEq/L\n 38 mg/dL\n 98 mEq/L\n 138 mEq/L\n 29.8 %\n 7.8 K/uL\n [image002.jpg]\n 04:16 AM\n 03:15 AM\n WBC\n 11.2\n 7.8\n Hct\n 31.5\n 29.8\n Plt\n 87\n 86\n Cr\n 1.4\n 1.4\n Glucose\n 100\n 92\n Other labs: PT / PTT / INR:25.9/39.5/2.5, ALT / AST:24/63, Alk Phos / T\n Bili:68/1.3, Albumin:3.1 g/dL, LDH:815 IU/L, Ca++:8.0 mg/dL, Mg++:2.4\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n A/P: 80 y.o. F with CHF, atrial fibrillation on coumadin, CAD, AV\n replacement with AS, DM, PPM, pulm fibrosis (on home O2) who presented\n with fevers and hypotension.\n # Hypotension: could be secondary to early sepsis etiology, given\n fevers, but there is no clear source and no leukocytosis. She responded\n transiently to 2L fluids, but then seemed to have worsened pulmonary\n edema on chest film and despite this, had a drop in her BP again. It\n may be that the patient is infected but when given large volumes of\n fluid for resuscitation, she can't maintain the forward flow for such a\n sudden increase in venous return. Additionally, she doesn't have a\n compensatory increase in her HR, to aid in increasing her cardiac\n output in the setting of early sepsis/dehydration. Given hypotension\n and ARF with low serum sodium on labs, etiology of hypotension is\n likely due to volume depletion. This is likely exacerbated by\n patient's aggressive diuretic regimen.\n Other etiology could be a pulmonary embolus - the patient is on\n chronic anticoagulation for afib and AVR, but is subtherapeutic today.\n This could explain fever, hypotension and hypoxia, and she could not be\n manifesting a tachycardia secondary to v-pacing. Pericardial effusion\n is also a concern but no evidence of this on exam.\n - Diuresed yesterday with good effect- pt still appears somewhat volume\n overloaded with crackles on lung auscultation. Goal I/O today= - 1L.\n - follow cultures - check blood, urine, c diff\n .\n # Fevers: patient with isolated elevations in ALT and Tbili. Unclear\n etiology, does not seem to be a pattern of biliary obstruction. UA is\n unremarkable and chest film doesn't have any obvious consolidation. No\n diarrhea despite abd pain - pain is in location of hernias. Surgical\n eval initially concerning, then patient's symptoms seemed to have\n improved. Blood cultures are pending. WBC is normal with slight left\n shift. Could have been diverticulitis that was resolving by the time\n she had CT abd/pelvis (non contrast), but less likely.\n - continue broad spectrum abx for now, given ?early sepsis\n - monitor culture data\n - serial abd exams - - c diff, pancultures as above\n - continue zosyn for a 7-day course for presumed abdominal infection\n hernias\n - appreciate surgery recs\n no surgical interventions at this time\n # Thrombocytopenia: pt was put on Heparin subQ on admission. Timing of\n her plt count drop is not typical of HIT. Will check trend and if\n continues downward direction, will work it up.\n .\n # Hypoxia: patient is on 2.5L home o2, is on 3L here satting in mid\n 90's. Likely secondary to mild pulmonary edema. Would continue to\n diuresis gently and monitor for improvement.\n .\n # CAD: continue statin, aspirin. Not on beta blocker, paced in the\n 60's. Was on amiodarone for SSS, but stopped secondary to IPF and\n progressive hypoxia.\n .\n # CHF (EF = 65% 03/07): CXR with volume overload after 2 liters of\n fluid (initial chest film in ED actually indicated improvement from\n last imaging in ).\n .\n # AVR with severe stenosis: Aortic valve area of 0.9 on C.cath in \n and 0.7 cm2 on Echo in , s/p AVR in .\n - Closely monitor fluid status and BP, diurese gently\n .\n # Pulmonary Fibrosis/Hypoxia: Currently slightly more hypoxic than\n baseline likely to CHF. (baseline oxygen requirement of 2 L NC)\n - Continue advair\n - PRN albuterol nebs\n .\n # Type 2 DM: FS qid. RISS\n .\n # Atrial Fibrillation: Continued coumadin.\n .\n # Anemia: iron deficiency. Hct stable at baseline.\n - continue iron supplementation\n .\n # Hypothyroidism:\n - Continue synthroid\n .\n # Hyperlipidemia: Continue statin\n .\n # FEN: diabetic, heart healthy\n .\n # PPX: on coumadin, on home PPI\n .\n # Code: Full\n .\n # Access: piv's\n .\n # Dispo: call out today to floor as dyspnea improved, BP stable.\n .\n # Comm: patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:18 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": "2162-08-07 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 410575,
"text": "Chief Complaint: fever and abdominal pain and hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 80F with severe AS, severe MR, ventral hernias, present with fevers and\n abdominal pain:\n 24 Hour Events:\n *sob yesterday pm; given lasix iv and metolazone with good urine output\n and resolution of sx\n *constipated but good bm this am\n *no more fever or abdominal pain\n Allergies:\n Quinidine\n Unknown;\n Iodine\n Unknown;\n Indocin (Oral) (Indomethacin)\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:26 PM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n coumadin, synthroid, asa, advair, singuliar, heparin sq, lasix 80 ,\n colace, riss, senna, pentoprazole\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 Ear, Nose, Throat: No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain\n Nutritional Support: No(t) NPO\n Respiratory: No(t) Cough, Dyspnea, improved\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, Constipation\n Genitourinary: No(t) Dysuria, Foley\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 65 (65 - 95) bpm\n BP: 84/64(68) {84/41(57) - 130/70(77)} mmHg\n RR: 30 (17 - 30) insp/min\n SpO2: 95%\n Heart rhythm: AV Paced\n Height: 59 Inch\n Total In:\n 1,844 mL\n 907 mL\n PO:\n 760 mL\n 540 mL\n TF:\n IVF:\n 1,084 mL\n 367 mL\n Blood products:\n Total out:\n 2,090 mL\n 2,850 mL\n Urine:\n 2,090 mL\n 2,850 mL\n NG:\n Stool:\n Drains:\n Balance:\n -246 mL\n -1,943 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n Systolic), 3/6rlusb and at apex\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n 1/2 up), impoved since yesterday\n Abdominal: Soft, Bowel sounds present, Tender: minimally\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Cool, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 86 K/uL\n 92 mg/dL\n 1.4 mg/dL\n 27 mEq/L\n 2.9 mEq/L\n 38 mg/dL\n 98 mEq/L\n 138 mEq/L\n 29.8 %\n 7.8 K/uL\n [image002.jpg]\n 04:16 AM\n 03:15 AM\n WBC\n 11.2\n 7.8\n Hct\n 31.5\n 29.8\n Plt\n 87\n 86\n Cr\n 1.4\n 1.4\n Glucose\n 100\n 92\n Other labs: PT / PTT / INR:25.9/39.5/2.5, ALT / AST:24/63, Alk Phos / T\n Bili:68/1.3, Albumin:3.1 g/dL, LDH:815 IU/L, Ca++:8.0 mg/dL, Mg++:2.4\n mg/dL, PO4:3.1 mg/dL\n Imaging: cxr: subtle improvement in bibasilar opacitis\n Assessment and Plan\n 1. fever\n 2. thrombocytopenia\n 3. abdominal pain\n 4. CHF\n 5. Afib\n 6. Pulmonary fibrosis\n 80F with chf, afib on a/c, pulm fibrosis, presesnt with fever and\n hypotension without a source. bp improved without much intervention.\n started on zosyn for empiric treatment of an abdominal source. The\n source of the fever remains unclear. Leukocytosis has resolved.\n Will continue to complete a 7-day course for a presumed GI infection\n (?early strangulation vs. ct-negative diverticulitis given known\n diverticulosis) given improved abdominal symptoms and resolution of\n leukocytosis. Will follow-up cultures.\n Cardiac issues are the major issue now; pt is improving. Will continue\n to diurese but would aim for only 0.5 L negative fluid balance. Will\n monitor blood pressure closely and renal function.\n Thrombocytopenia present on admission, now slighly lower. Will stop sq\n heparin since patient is already on coumadin and will continue to\n monitor. Consider checking smear; changing abx.\n If continues to improved will consider transfer to floor later today or\n tomorrow; communicating with primary cardiologist Dr .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:18 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2162-08-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 410576,
"text": "This is an 80 yo F with a past medical history of SSS s/p pacer,\n hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV\n Replacement, presents to the ED with weakness, found to be febrile to\n 102, with a distended tender abdomen. She said that the abdominal pain\n started today, her stools have been relatively normal, no\n brbpr/hematochezia. In the ED, she underwent a CT abd/pelvis which\n showed evidence of diverticulosis but no diverticulitis, and a small\n amount of free fluid in the abdomen. Surgery evaluated Pt. but no\n surgical intervention.\n"
},
{
"category": "Nursing",
"chartdate": "2162-08-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 410537,
"text": "This is an 80 yo F with a past medical history of SSS s/p pacer,\n hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV\n Replacement, presents to the ED with weakness, found to be febrile to\n 102, with a distended tender abdomen. She said that the abdominal pain\n started today, her stools have been relatively normal, no\n brbpr/hematochezia. In the ED, she underwent a CT abd/pelvis which\n showed evidence of diverticulosis but no diverticulitis, and a small\n amount of free fluid in the abdomen.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Pt. with fluid overload per CXR after reciving 2L Fluid bolus in ED for\n transient hypotension. LS clear and diminished at bases. O2 at 2L NC.\n Intermiten tachypnea.\n Action:\n Restarted home dose of Lasix. And additional dose of IV lasix 20mg\n given due to decreased urine output and LS with crackels. Pt. also\n given a dose of Metolazone followed by Lasix 40mg IV for better\n diurisis.\n Response:\n Urine output slightly improved from 30-80cc/hr. No resp. distress at\n this time. O2 sat 94-96%.\n Plan:\n Cont. to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2162-08-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 410539,
"text": "This is an 80 yo F with a past medical history of SSS s/p pacer,\n hypertension, diabetes, atrial fibrillation on coumadin, CAD, AV\n Replacement, presents to the ED with weakness, found to be febrile to\n 102, with a distended tender abdomen. She said that the abdominal pain\n started today, her stools have been relatively normal, no\n brbpr/hematochezia. In the ED, she underwent a CT abd/pelvis which\n showed evidence of diverticulosis but no diverticulitis, and a small\n amount of free fluid in the abdomen.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Pt. with fluid overload per CXR after reciving 2L Fluid bolus in ED for\n transient hypotension. LS clear and diminished at bases. O2 at 2L NC.\n Intermiten tachypnea.\n Action:\n Restarted home dose of Lasix. And additional dose of IV lasix 20mg\n given due to decreased urine output and LS with crackels. Pt. also\n given a dose of Metolazone followed by Lasix 40mg IV for better\n diurisis.\n Response:\n Urine output slightly improved from 30-80cc/hr. No resp. distress at\n this time. O2 sat 94-96%.\n Plan:\n Cont. to monitor.\n Hernia, other\n Assessment:\n Pt. with old ventral hernias to mid and LLQ of abdomen. Presented to\n hospital with new onset pain over hernias, mostly to palpation. Last BM\n prior to admission. States she feel gasy.\n Action:\n Started on Zosyn. Surgery consulted. Started on Senna and Colace.\n Response:\n No BM today. No surgical intervention at this time.\n Plan:\n Cont. to monitor. Stool for c-diff when Pt. has BM. Surgery recs.\n"
},
{
"category": "Physician ",
"chartdate": "2162-08-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 410522,
"text": "Chief Complaint:\n 24 Hour Events:\n This is an 80yo female with an extensive PMH who presented to EW with\n poor po intake, diarrhea, weakness and abd. Pain. Found to have a temp\n of 102 and hypotensive to 80\ns. Given 2L NS and brought for CT of\n abdomen which showed no obstruction but some free fluid. Boluses at\n that time stopped. Attempts made at placing central line unsuccessful,\n now pt. refusing. Pt. pan cultured, given antibiotics and transferred\n here for further work-up and management.\n Upon arrival here pt. found to be hemodynamically stable. C/O mild abd.\n Pain but with movement only. Will monitor closely but if remains\n stable ? c/o to floor. Culture results pending. Continue with\n antibiotics.\n A+Ox3. MAE. Pt. is legally blind but lives in an independent living\n facility performing self ADLs.\n Pt. on 2L nasal cannula with sats >94%. Breath sounds clear with\n crackles in bases bilat. No c/o SOB. Pt. does have a hx. Of pulmonary\n fibrosis for which she wears 2L of O2 at home.\n Pt. is AV paced. BP has remained high 90\ns to low 120\ns here in unit.\n + pulses. Afebrile at this time.\n Abd. Soft/distended. Tender to palpation. + Bowel Sounds. No bm this\n shift.\n Foley in place draining clear yellow urine. Good output.\n Skin Intact\n 2 18g PIVs placed in EW.\n Allergies:\n Quinidine\n Unknown;\n Iodine\n Unknown;\n Indocin (Oral) (Indomethacin)\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 03:43 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 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98.1\n HR: 65 (65 - 71) bpm\n BP: 114/45(63) {110/42(60) - 116/46(64)} mmHg\n RR: 20 (16 - 22) insp/min\n SpO2: 98%\n Heart rhythm: AV Paced\n Height: 59 Inch\n Total In:\n 406 mL\n PO:\n TF:\n IVF:\n 406 mL\n Blood products:\n Total out:\n 0 mL\n 360 mL\n Urine:\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 46 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 87 K/uL\n 10.0 g/dL\n 100 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 33 mg/dL\n 100 mEq/L\n 135 mEq/L\n 31.5 %\n 11.2 K/uL\n [image002.jpg]\n 04:16 AM\n WBC\n 11.2\n Hct\n 31.5\n Plt\n 87\n Cr\n 1.4\n Glucose\n 100\n Other labs: PT / PTT / INR:20.7/36.7/2.0, ALT / AST:26/64, Alk Phos / T\n Bili:64/1.4, Albumin:3.1 g/dL, LDH:815 IU/L, Ca++:7.7 mg/dL, Mg++:2.5\n mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:18 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": "2162-08-06 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 410525,
"text": "Chief Complaint: Fever, hypotension, aortic stenosis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n In MICU, BP has been acceptable. Given boluses of fluid to maintain\n urine output. Abdominal tenderness persists over ventral hernia.\n 24 Hour Events:\n History obtained from Patient\n Allergies:\n Quinidine\n Unknown;\n Iodine\n Unknown;\n Indocin (Oral) (Indomethacin)\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 03:43 AM\n Infusions:\n Other ICU medications:\n Other medications:\n coumadin, thyroxine, ASA, advair, protonix, singulair, lipitor, heparin\n sc\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 11:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98.1\n HR: 65 (65 - 71) bpm\n BP: 110/75(79) {110/42(60) - 122/75(79)} mmHg\n RR: 19 (16 - 22) insp/min\n SpO2: 96%\n Heart rhythm: AV Paced\n Height: 59 Inch\n Total In:\n 850 mL\n PO:\n TF:\n IVF:\n 850 mL\n Blood products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 300 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n 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), III/VI harsh systolic murmur at base radiating to apex\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), Carotid pulse mildly delayed\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Crackles : Approximately of the way up the chest,\n No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent :\n , No(t) Rhonchorous: )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t)\n Distended, Tender: LLQ hernia most prominent tenderness. No rebound\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Not assessed,\n No(t) Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 10.0 g/dL\n 87 K/uL\n 100 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 33 mg/dL\n 100 mEq/L\n 135 mEq/L\n 31.5 %\n 11.2 K/uL\n [image002.jpg]\n 04:16 AM\n WBC\n 11.2\n Hct\n 31.5\n Plt\n 87\n Cr\n 1.4\n Glucose\n 100\n Other labs: PT / PTT / INR:20.7/36.7/2.0, ALT / AST:26/64, Alk Phos / T\n Bili:64/1.4, Albumin:3.1 g/dL, LDH:815 IU/L, Ca++:7.7 mg/dL, Mg++:2.5\n mg/dL, PO4:4.0 mg/dL\n Fluid analysis / Other labs: BNP 7000\n Imaging: CXR: left hemidiaphragm obscured suggestive of atelectasis or\n infil\n Assessment and Plan\n 1) Fever\n 2) Hypotension\n 3) Aortic Stenosis\n 4) CHF - chronic, diastolic\n 5) Anemia\n Fever may be related to intra-abdominal process. Tenderness over LLQ\n hernia; concern about bowel ischemia. Surgery following. Patient\n continues on antibiotics. With severe aortic stenosis, surgery would\n pose more than usual operative risk. No metabolic acidosis now.\n BP improved. Patient probably now volume overloaded given exam and\n declining oxygen saturation. Will diurese.\n Hct down with fluids resuscitation. No need for transfusion now.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:18 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2162-08-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 410533,
"text": "Chief Complaint:\n 24 Hour Events:\n Admitted at 1 AM this morning.\n BP WNL\n Abd exam stable throughout the night\n Pt has no new complaints. Feeling better. Abdominal discomfort at\n baseline.\n Allergies:\n Quinidine\n Unknown;\n Iodine\n Unknown;\n Indocin (Oral) (Indomethacin)\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 03:43 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 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98.1\n HR: 65 (65 - 71) bpm\n BP: 114/45(63) {110/42(60) - 116/46(64)} mmHg\n RR: 20 (16 - 22) insp/min\n SpO2: 98%\n Heart rhythm: AV Paced\n Height: 59 Inch\n Total In:\n 406 mL\n PO:\n TF:\n IVF:\n 406 mL\n Blood products:\n Total out:\n 0 mL\n 360 mL\n Urine:\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 46 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n GEN: Alert, oriented x 3. NAD\n Heart: RRR, cresc/decresc systolic murmur radiating to carotids.\n Lungs: good air movement bilaterally. Crackles at bilateral bases\n Abd: obese, soft, TTP in LLQ where a soft-ball sized soft mass is\n palpable (hernia). + BS\n Ext: trace-1+edema\n Labs / Radiology\n 87 K/uL\n 10.0 g/dL\n 100 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 33 mg/dL\n 100 mEq/L\n 135 mEq/L\n 31.5 %\n 11.2 K/uL\n [image002.jpg]\n 04:16 AM\n WBC\n 11.2\n Hct\n 31.5\n Plt\n 87\n Cr\n 1.4\n Glucose\n 100\n Other labs: PT / PTT / INR:20.7/36.7/2.0, ALT / AST:26/64, Alk Phos / T\n Bili:64/1.4, Albumin:3.1 g/dL, LDH:815 IU/L, Ca++:7.7 mg/dL, Mg++:2.5\n mg/dL, PO4:4.0 mg/dL\n Assessment and Plan:\n Please see Dr. \ns admission note dated today for full A/P.\n Updates:\n 1) Hypotension: essentially resolved. Will restart lasix at home\n dose. Will hold off on restarting Metolazone. I/O Goal: -0.5-1L. Will\n monitor closely as pt is very preload dependent due to critical AS.\n 2) Fevers: Afebrile overnight. f/u Cx, C-diff. continue zosyn\n prophylactically for GI infection related to hernia.\n 3) Hypoxia: pt satting in high 90s on 3L O2 via NC, which is near\n baseline for her (on 2L at home).\n 4) Abdominal hernia: abd exam stable. Surgery to come by today for\n re-eval and ?surgery (vs conservative therapy as pt is a poor surgical\n candidate)\n 5) CHF: Was given fluid bolus in ED\nflashed. Diurese carefully\n today\n 6) Thrombocytopenia: Pt has low-normal plt count at baseline. Will\n work-up.\n 7) Pulm fibrosis: continue current meds, O2.\n 8) DM: FS , order ISS\n 9) A fib: continue Coumadin, monitor INR\n 10) Anemia: continue Fe supp, monitor Hct (stable so far)\n 11) Hypothyroid: continue synthroid\n 12) Hyperlipidemia: continue statin\n 13) FEN: diabetic, heart healthy, fluid restriction <1.5 L\n 14) PPx: coumadin, home PPI, MRSA\n 15) Full code, ICU for volume status monitoring and work up of\n infectious source\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:18 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
}
] |
81,240 | 174,171 | Patient is a 50F electively admitted to the hospital on for planned resection of spenoid mass. On , she went had an angiogram to attempt to embolize the blood supply to said mass; however defined vasculature could not be identified. On , she went to the OR for left sided crani. The mass was decompressed, and frozen section pathology(intraop) identified a metastatic carcinoma. After the OR, she was returned to the PACU overnight for frequent neuro checks, which were uneventful. on POD#1, she transferred from the ICU to the floor. Neuro and Radiation oncology were consulted. PT/OT were also consutled, and recommended she be discharged to home without services. She was subsequently discharged on | There is remaining vasogenic edema at the site of surgery, with interval removal of a mass, and remaining mass effect on the ipsilateral frontal of the lateral ventricle. FINDINGS: The patient is status post left frontotemporal craniotomy, the previously described left sphenoid mass lesion has been resected. FINDINGS: The patient is status post left craniotomy, with expected post- surgical changes in the area with minimal blood products and pneumocephalus at the surgical site, with a small amount of hyperdense material, in the extra- axial space in the expected range. IMPRESSION: Expected postsurgical changes at the site of left craniotomy with remaining vasogenic edema and stable mass effect. The focal area of restricted diffusion is identified at the posterior capsuloputaminal area, which is worrisome for acute ischemic change, residual blood products are present at the surgical bed. The focal area of restricted diffusion is identified at the posterior capsuloputaminal area, which is worrisome for acute ischemic change, residual blood products are present at the surgical bed. embolization for left sphenoid meningioma surgery pr Contrast: OPTIRAY Amt: 171 FINAL REPORT (Cont) and supraclinoid portions of the ICA. Left internal carotid arteriogram showed normal cervical, petrous, cavernous and supraclinoid portions of the ICA with some mild blush to tumor area through the dorsal meningeal artery branch of meningohypophyseal (posterior trunk) arising from the cavernous portion of internal carotid artery. On the diffusion-weighted sequences, there is evidence of restricted diffusion at the surgical site, likely consistent with blood products At the left capsuloputaminal region, there is a focal area of restricted diffusion with low signal in the corresponding ADC map, which is worrisome for an acute ischemic change (9:13, 8:13). The orbits are unremarkable, the (Over) 9:19 AM MR HEAD W & W/O CONTRAST Clip # Reason: please evaluate for residual mass; must be completed within Admitting Diagnosis: BRAIN TUMOR/SDA Contrast: MAGNEVIST Amt: 18 FINAL REPORT (Cont) paranasal sinuses and the mastoid air cells are grossly normal. FINAL REPORT STUDY: MRI of the head with and without contrast. Status post left frontotemporal craniotomy and mass lesion resection at the sphenoidal . After the administration of gadolinium contrast, there is evidence of mild-to- moderate pattern of enhancement at the surgical site without evidence of residual mass lesion. After injection of local anesthetic into the right femoral area, the right common femoral artery was accessed using micropuncture set. Left vertebral artery arteriogram showed normal distal portion of the left vertebral artery, with reflux into the distal right vertebral artery. embolization for left sphenoid meningioma surgery pr Contrast: OPTIRAY Amt: 171 ********************************* CPT Codes ******************************** * SEL CATH 3RD ORDER SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER * * EXT CAROTID BILAT CAROTID/CERVICAL UNILAT * * CAROTID/CEREBRAL BILAT VERT/CAROTID A-GRAM * **************************************************************************** MEDICAL CONDITION: 50 year old woman with left sphenoid meningioma REASON FOR THIS EXAMINATION: Angio ? Visualized paranasal sinuses and mastoid air cells are normally aerated. After the administration of intravenous gadolinium contrast material, the T1-weighted images were repeated in axial T1, sagittal MP-RAGE and multiplanar reconstructions. Slightly hyperdense material and subcutaneous air is seen in the overlying skin at the site of craniotomy. COMPARISON: Prior head CT without contrast dated , and prior MRI of the head dated . TASKS PERFORMED: Diagnostic cerebral angio with right common carotid arteriogram, right external carotid arteriogram, left internal carotid arteriogram, left external carotid arteriogram, left vertebral arteriogram, and right common femoral arteriogram. Left external carotid arteriogram showed normal external carotid artery. Residual blood products are identified at the surgical bed and also persistent vasogenic edema. COMPARISON: Compared to CT head from . After acquisition of the appropriate imaging, the catheter and sheath were withdrawn and the site of the puncture was closed using 6 French Angio-Seal closure device. Right external carotid artery arteriogram showed a normal vessel and its branches. REASON FOR EXAM: Angio with possible embolization for the meningioma, preop. The above-mentioned vessels were selectively catheterized and arteriograms were performed from those locations. Preprocedure timeout was performed documenting the nature of the procedure, the patient's identity using two independent verifies. | 5 | [
{
"category": "ECG",
"chartdate": "2175-12-12 00:00:00.000",
"description": "Report",
"row_id": 246034,
"text": "Sinus bradycardia with non-diagnostic repolarization abnormalities. No\nprevious tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-12-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1106132,
"text": " 12:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for post-op bleeding. must be completed with\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with s/p left crani\n REASON FOR THIS EXAMINATION:\n please evaluate for post-op bleeding. must be completed within 4 hrs\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf 2:44 AM\n Expected post surgical changes. Stable shift of midline structures.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old woman with status post left craniotomy, evaluate for\n postoperative bleeding.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n COMPARISON: Compared to CT head from .\n\n FINDINGS: The patient is status post left craniotomy, with expected post-\n surgical changes in the area with minimal blood products and pneumocephalus at\n the surgical site, with a small amount of hyperdense material, in the extra-\n axial space in the expected range. Slightly hyperdense material and\n subcutaneous air is seen in the overlying skin at the site of craniotomy.\n There is remaining vasogenic edema at the site of surgery, with interval\n removal of a mass, and remaining mass effect on the ipsilateral frontal \n of the lateral ventricle. There is a stable rightward shift of normally\n midline structures, approximately 5 mm and slight medial displacement of the\n uncus, stable. No hydrocephalus is appreciated. Visualized paranasal sinuses\n and mastoid air cells are normally aerated.\n\n IMPRESSION: Expected postsurgical changes at the site of left craniotomy with\n remaining vasogenic edema and stable mass effect. Interval removal of mass in\n the left frontotemporal region.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-12-14 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1106202,
"text": " 9:19 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for residual mass; must be completed within\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with s/p left crani for mass\n REASON FOR THIS EXAMINATION:\n please evaluate for residual mass; must be completed within 36 hts\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:21 PM\n The patient is status post left craniotomy, again significant vasogenic edema\n is redemonstrated. The focal area of restricted diffusion is identified at\n the posterior capsuloputaminal area, which is worrisome for acute ischemic\n change, residual blood products are present at the surgical bed.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: MRI of the head with and without contrast.\n\n CLINICAL INDICATION: 50-year-old woman with prior left craniotomy, evaluate\n for residual mass.\n\n COMPARISON: Prior head CT without contrast dated , and prior\n MRI of the head dated .\n\n TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained,\n axial FLAIR, axial T2, axial magnetic susceptibility. Axial diffusion-\n weighted sequences. After the administration of intravenous gadolinium\n contrast material, the T1-weighted images were repeated in axial T1, sagittal\n MP-RAGE and multiplanar reconstructions.\n\n FINDINGS: The patient is status post left frontotemporal craniotomy, the\n previously described left sphenoid mass lesion has been resected. Residual\n blood products are identified at the surgical bed and also persistent\n vasogenic edema. On the diffusion-weighted sequences, there is evidence of\n restricted diffusion at the surgical site, likely consistent with blood\n products At the left capsuloputaminal region, there is a focal area of\n restricted diffusion with low signal in the corresponding ADC map, which is\n worrisome for an acute ischemic change (9:13, 8:13). On the left frontal\n convexity, there is a punctate area of high signal intensity on the diffusion-\n weighted sequence (9:21), which is too small to characterize and is not\n visualized on the corresponding ADC; however, the possibility of a small area\n of ischemia cannot be completely ruled out. A focal area of restricted\n diffusion is also identified at the right parietal lobe (9:16). There is\n persistent effacement of the sulci at the convexity on the left cerebral\n hemisphere.\n\n After the administration of gadolinium contrast, there is evidence of mild-to-\n moderate pattern of enhancement at the surgical site without evidence of\n residual mass lesion. Continuous followup is recommended until the complete\n resolution of the residual blood products. The orbits are unremarkable, the\n (Over)\n\n 9:19 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for residual mass; must be completed within\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n paranasal sinuses and the mastoid air cells are grossly normal.\n\n IMPRESSION:\n 1. Status post left frontotemporal craniotomy and mass lesion resection at\n the sphenoidal . Residual blood products are identified at the surgical\n bed without evidence of significant enhancement to suggest residual mass\n lesion.\n\n Focal areas of restricted diffusion are identified at the left\n capsuloputaminal region and right parietal lobe, which are highly suspicious\n for ischemic changes with low signal in the corresponding ADC sequences.\n Please correlate clinically. A small focal area of restricted diffusion is\n also identified at the right frontal convexity, measuring approximately 5 mm\n in size (9:21), which is not visualized in the corresponding ADC map; however,\n the possibility of a small ischemic focus is a consideration.\n\n These findings were communicated to Dr. at 13:56 hours on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-12-14 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1106203,
"text": ", M. NSURG PACU 9:19 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for residual mass; must be completed within\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with s/p left crani for mass\n REASON FOR THIS EXAMINATION:\n please evaluate for residual mass; must be completed within 36 hts\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n The patient is status post left craniotomy, again significant vasogenic edema\n is redemonstrated. The focal area of restricted diffusion is identified at\n the posterior capsuloputaminal area, which is worrisome for acute ischemic\n change, residual blood products are present at the surgical bed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-12-12 00:00:00.000",
"description": "SEL CATH 3RD ORDER THOR",
"row_id": 1105907,
"text": " 5:30 PM\n CAROT/CEREB Clip # \n Reason: Angio ? embolization for left sphenoid meningioma surgery pr\n Contrast: OPTIRAY Amt: 171\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 * EXT CAROTID BILAT CAROTID/CERVICAL UNILAT *\n * CAROTID/CEREBRAL BILAT VERT/CAROTID A-GRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old woman with left sphenoid meningioma\n REASON FOR THIS EXAMINATION:\n Angio ? embolization for left sphenoid meningioma surgery prep\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: This is a 50-year-old woman with left sphenoid meningioma.\n\n REASON FOR EXAM: Angio with possible embolization for the meningioma, preop.\n\n TASKS PERFORMED: Diagnostic cerebral angio with right common carotid\n arteriogram, right external carotid arteriogram, left internal carotid\n arteriogram, left external carotid arteriogram, left vertebral arteriogram,\n and right common femoral arteriogram.\n\n ANESTHESIA: The patient received general anesthesia during the time of the\n procedure, during which her hemodynamic parameters were continuously monitored\n and remained stable.\n\n DETAILS OF THE PROCEDURE: Informed consent was obtained from the patient\n after explaining risks, benefits, indication and alternative management. The\n patient was brought to the neurointerventional suite and placed in supine\n position on the biplane fluoroscopic table. General anesthesia was induced\n and patient was intubated and her hemodynamic parameters were continuously\n monitored. Both groins were prepped and draped in normal sterile fashion.\n Preprocedure timeout was performed documenting the nature of the procedure,\n the patient's identity using two independent verifies. After injection of\n local anesthetic into the right femoral area, the right common femoral artery\n was accessed using micropuncture set. Using Seldinger technique, a 6 French\n Terumo sheath was placed successfully in the right common femoral artery.\n Through the sheath, a 5 French 2 catheter was inserted with the aid\n 0.038 angled Glidewire. The above-mentioned vessels were selectively\n catheterized and arteriograms were performed from those locations. After\n acquisition of the appropriate imaging, the catheter and sheath were withdrawn\n and the site of the puncture was closed using 6 French Angio-Seal closure\n device. The procedure was uneventful and patient tolerated the procedure well\n without immediate complication. The patient was sent to the PACU with post-\n procedure orders.\n\n FINDINGS:\n Right common carotid arteriogram showed normal cervical, petrous, cavernous\n (Over)\n\n 5:30 PM\n CAROT/CEREB Clip # \n Reason: Angio ? embolization for left sphenoid meningioma surgery pr\n Contrast: OPTIRAY Amt: 171\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n and supraclinoid portions of the ICA. ACA and MCA seen normally.\n\n Right external carotid artery arteriogram showed a normal vessel and its\n branches. There was no significant supply to the tumor.\n\n Left internal carotid arteriogram showed normal cervical, petrous, cavernous\n and supraclinoid portions of the ICA with some mild blush to tumor area\n through the dorsal meningeal artery branch of meningohypophyseal (posterior\n trunk) arising from the cavernous portion of internal carotid artery. However\n this branch appears to be very small with mininimal tumor blush. Both the MCA\n and ACA were seen with normal branches.\n\n Left external carotid arteriogram showed normal external carotid artery. All\n branches were seen. There was no supply to the tumor seen from the external\n carotid artery.\n\n Left vertebral artery arteriogram showed normal distal portion of the left\n vertebral artery, with reflux into the distal right vertebral artery. Normal\n caliber basilar was seen. AICA, superior cerebellar arteries, and both PCAs\n were well visualized. PICAs arising from both vertebrals were seen.\n\n Right common femoral arteriogram showed no evidence of contrast extravasation,\n dissection, or pseudoaneurysm.\n\n IMPRESSION: Diagnostic cerebral angiogram was done for possible embolization\n of the left sphenoid meningioma, however, no supply was found coming from the\n left external carotid artery. There was some supply to the tumor coming\n through small branches from the meningohypophyseal trunk of the left\n internal carotid \"cavernous segment\". Those findings were discussed with Dr.\n and no embolization was done.\n\n"
}
] |
29,539 | 135,048 | The patient is a 71 y.o.m. with metastatic melanoma on chemotherapy who presents with hemoptysis. # Hemoptysis - CTA concerning for widespread metastatic disease and encasement of pulmonary vein leading to hemoptysis and obstruction of RLL bronchus leading to postobstructive PNA. Recently received a prescription for antibiotics for the PNA, upon review of records it appears he completed a 10 day course of levaquin. The differential for his hemoptysis is most likely pulmonary related to bleeding from his mets, especially in light of recent chemo trial where increased frequency of bleeding has been seen and with bronch showing clot in the airway. Also on ddx is nasal polyp. Pt reports having epistaxis and difficulty breathing in the past for which he was evaluated by ENT at , last time 6 months ago, found to have large nasal polyp. Patient underwent bronchoscopy that revealed no evidence of active bleed and old blood in RLL. Patient's hemoptysis significantly improved during his admission. On last day of admission, the patient had about two tablespoons of total hemoptysis in 24 hours. The patient was repeatedly instructed of warning signs to immediately return to the emergency room. # PNA - Appears to have post obstructive PNA based on CT scan. Slight fever with mild leukocytosis. Likely immunosuppressed given recent chemotherapy (although may be placebo pill). Patient discharged to complete 7 day course of antibiotics. # H/O DVT - Occurred approximately one month ago and received lovenox, but no longer anticoagulated for unclear reasons. This was confirmed with . The patient is no longer on anti-coagulation. # Anemia ?????? Patient's hct did not drop significantly during his admission. # HTN - Continue outpatient meds. | -Re-check Hct since Hct drop seems disproportionate to amount of recent hemoptysis (Update: now 28.1) -continue cough suppression, antibiotics (Zosyn started for improved anerobic coverage) -ENT eval -has had prior sinus congestion/epistaxis and nasal polyps) -If brisk bleed, IR/angio #Metastatic melanoma: obtain records from doctors : Glycemic Control: Lines: Indwelling Port (PortaCath) - 06:09 AM 20 Gauge - 06:12 AM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition : Transfer to floor Total time spent: 35 minutes - Hold on anticoagulation in setting of hemoptysis - Obtain records from - Pneumatic compression boots # Anemia Unclear baseline. Hemoptysis Assessment: Pt w/ 1 wk hx of hemoptysis as above. Hemoptysis Assessment: Pt w/ 1 wk hx of hemoptysis as above. Hemoptysis Assessment: Pt w/ 1 wk hx of hemoptysis as above. Hemoptysis Assessment: Pt w/ 1 wk hx of hemoptysis as above. PET-CT recent showed pulmonary nodules/small lesions in intestine. PET-CT recent showed pulmonary nodules/small lesions in intestine. PET-CT recent showed pulmonary nodules/small lesions in intestine. PET-CT recent showed pulmonary nodules/small lesions in intestine. - Monitor Cr s/p dye load during CTA - Replete lytes prn # Comm - Patient ICU Care Nutrition: Glycemic Control: Lines: Indwelling Port (PortaCath) - 06:09 AM 20 Gauge - 06:12 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: with metastatic melanoma and HTN who presents with hemoptysis. - Consider transfer to when bed is available for continuity of care - NC as needed - Hold on anticoagulation for DVT # PNA - Appears to have post obstructive PNA based on CT scan. Also with post obstructive PNA, RLL Assessment and Plan 71 yr old male with metastatic melanoma admitted with hemoptysis. TECHNIQUE: MDCT acquired axial imaging of the chest was performed before and after administration of intravenous contrast via non-gated chest pain CTA protocol. Demographics Attending MD: Admit diagnosis: HEMOPTYSIS Code status: Full code Height: 6 Inch Admission weight: 83 kg Daily weight: Allergies/Reactions: No Known Drug Allergies Precautions: PMH: CV-PMH: Additional history: Lung CA (melanoma) on chemotherapy s/p rt lymph node biopsy s/p herniorrhaphy Surgery / Procedure and date: Latest Vital Signs and I/O Non-invasive BP: S:126 D:74 Temperature: 98.4 Arterial BP: S: D: Respiratory rate: 30 insp/min Heart Rate: 92 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: None O2 saturation: 94% % O2 flow: 2 L/min FiO2 set: 24h total in: 830 mL 24h total out: 1,675 mL Pertinent Lab Results: Sodium: 134 mEq/L 04:36 AM Potassium: 4.2 mEq/L 04:36 AM Chloride: 103 mEq/L 04:36 AM CO2: 23 mEq/L 04:36 AM BUN: 15 mg/dL 04:36 AM Creatinine: 0.8 mg/dL 04:36 AM Glucose: 129 mg/dL 04:36 AM Hematocrit: 27.7 % 03:46 PM Valuables / Signature Patient valuables: Glasses Other valuables: Clothes: Sent home with: Wife / : No money / Cash / Credit cards sent home with: Jewelry: Transferred from: 407 Transferred to: 11R Date & time of Transfer: -Re-check Hct since Hct drop seems disproportionate to amount of recent hemoptysis -continue cough suppression, antibiotics (Zosyn started for improved anerobic coverage) -ENT eval (has had prior sinus congestion/epistaxis and nassal polyps) -If brisk bleed, IR/angio #Metastatic melanoma: obtain records from doctors : Glycemic Control: Lines: Indwelling Port (PortaCath) - 06:09 AM 20 Gauge - 06:12 AM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition :; could go to floor if Hct unchanged Total time spent: 35 minutes Called primary oncologist at and left message, Got bronched for hemoptysis, clot seen and removed, no active bleeding, presumed one of masses bleeding parenchymally. - Hold on anticoagulation in setting of hemoptysis - Obtain records from - Pneumatic compression boots # Anemia Unclear baseline. - Hold on anticoagulation in setting of hemoptysis - Obtain records from - Pneumatic compression boots # Anemia Unclear baseline. - Monitor Cr s/p dye load during CTA - Replete lytes prn # Comm - Patient ICU Care Nutrition: NPO for now until decision re: bronch made Glycemic Control: Lines: PIV Indwelling Port (PortaCath) - 06:09 AM 20 Gauge - 06:12 AM Prophylaxis: DVT: Boots Stress ulcer: VAP: Comments: Communication: ICU consent signed Comments: Code status: Full code Disposition: ICU Got bronched for hemoptysis, clot seen and removed, no active bleeding, presumed one of masses bleeding parenchymally. *Hemoptysis:concerning for airway source, Plan bronchoscopy ICU Care Nutrition: Glycemic Control: Lines / Intubation: Indwelling Port (PortaCath) - 06:09 AM 20 Gauge - 06:12 AM Comments: Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Total time spent: # Comm - Patient ICU Care Nutrition: NPO for now until decision re: bronch made Glycemic Control: Lines: PIV Indwelling Port (PortaCath) - 06:09 AM 20 Gauge - 06:12 AM Prophylaxis: DVT: Boots Stress ulcer: VAP: Comments: Communication: ICU consent signed Comments: Code status: Full code Disposition: ICU Assessment and Plan 71 yr old male with metastatic melanoma admitted with hemoptysis ICU Care Nutrition: Glycemic Control: Lines / Intubation: Indwelling Port (PortaCath) - 06:09 AM 20 Gauge - 06:12 AM Comments: Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Total time spent: | 23 | [
{
"category": "Radiology",
"chartdate": "2173-05-23 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1009878,
"text": " 3:19 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: HEMOPTYSIS\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with met lung ca, hemoptysis\n REASON FOR THIS EXAMINATION:\n eval PE, acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd SUN 4:03 AM\n No pulmonary embolism. Innumerable large metastatic foci. Large mass in RLL\n occludes the RLL bronchus, with airspace opacity seen throughout RLL\n concerning for postobstructive pneumonia. Small right pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old male with metastatic lung cancer, and hemoptysis. Please\n evaluate for PE or other acute process.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT acquired axial imaging of the chest was performed before and\n after administration of intravenous contrast via non-gated chest pain CTA\n protocol. Multiplanar reformatted images were obtained and reviewed.\n\n CTA CHEST: There is no pulmonary embolism. Thoracic aorta is normal in\n caliber and contour throughout.\n\n There are innumerable large bilateral pulmonary nodules and masses, consistent\n with widespread metastatic disease. The largest dominant mass in the medial\n aspect of the superior segment of the right lower lobe measures roughly 7 x 5\n cm, and is situated medially, directly adjacent to the mediastinum. This mass\n encases and nearly occludes the right inferior pulmonary vein, and abuts but\n does not definitely invade the left atrium. Mass also abuts, but does not\n definitely invade the esophagus. This mass, and a large adjacent satellite\n mass measuring roughly 5 x 5 cm appear to encase and occlude the right lower\n lobe segmental bronchus, and there is extensive airspace opacity seen\n throughout the right lower lobe, which slightly bulges the major fissure\n anteriorly. There is also peribronchovascular and interstitial thickening in\n the right lower lobe most consistent with peribronchovascular spread of tumor.\n There is a small associated right pleural effusion.\n\n There is no left pleural effusion. There is no pericardial effusion. There\n is no pneumothorax. There is a moderate hiatal hernia.\n\n Visualized portions of the upper abdomen are unremarkable, except to note\n multiple calcified gallstones within the gallbladder lumen.\n\n OSSEOUS STRUCTURES: No suspicious lesions are seen. There is no fracture.\n\n IMPRESSION:\n\n (Over)\n\n 3:19 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: HEMOPTYSIS\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. No pulmonary embolism.\n\n 2. Innumerable large bilateral pulmonary nodules and masses, consistent with\n widespread metastatic disease. Dominant right hilar mass encases and\n significantly narrows the right inferior pulmonary vein. Mass also narrows\n and likely occludes the right lower lobe segmental bronchus, with resultant\n extensive airspace opacity throughout the right lower lobe, most consistent\n with postobstructive pneumonia. Interstitial and peribronchovascular opacity\n is most consistent with lymphangitic tumor spread. Small associated right\n pleural effusion.\n\n 3. Cholelithiasis.\n\n\n\n\n"
},
{
"category": "Physician ",
"chartdate": "2173-05-23 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 323313,
"text": "Chief Complaint: hemoptyis\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 71 year old male with 1 wk hemoptysis. Initially scant hemoptysis then\n worsening, bright red *10-14 cc) and pleurisy.\n Went to oncologist a few days ago. CXR: pneumonia. Prescribed 10 days\n of an unknown antibiotic starting Wednesday. Hemoptysis did not\n improve-- went to over the weekend.\n Known hx of DVT on a month of lovenox\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, ICU housestaff; outside records\n unavailable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n protonix, colace, MVI, lisinopril\n Past medical history:\n Family history:\n Social History:\n All medical care from and \n Metastatic melanoma: lesion on UE. : recurrence with bony mets and\n left flank lesion s/p XRT/removal. PET-CT recent showed pulmonary\n nodules/small lesions in intestine. Got chemo. PET/MRI for unknown\n clinical trial, started 2 wks ago on an unknown experimental vs placebo\n drug.\n Umbilical hernia repair\n HTN\n Hypercholesterolemia\n non cont\n Occupation: married with 4 children\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal\n Allergy / Immunology: No(t) Immunocompromised\n Flowsheet Data as of 09:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.7\nC (98\n HR: 81 (81 - 106) bpm\n BP: 104/58(70) {104/49(64) - 138/71(88)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 6 Inch\n Total In:\n PO:\n TF:\n IVF:\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 -250 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\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 Respiratory / Chest: few rales right side\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: PT / PTT / INR:INR 1.1\n Fluid analysis / Other labs: troponin <0.01\n Imaging: CT (reviewed): negative for PE. Extensive pulmonary nodules-\n random distribution, very smooth margins/hilar LAD with encasement of\n pulmonary vein. Also with post obstructive PNA.\n Assessment and Plan\n 71 yr old male with metastatic melanoma admitted with hemoptysis. CT\n results show large and innumerable smooth pulmonary\n nodules.\n *Hemoptysis: underwent FOB this am which showed some blood but no\n active bleeding and no endobronchial source of bleeding. Given chest CT\n findings and medical history, concerning for parenchymal bleed from\n melanoma met. Also, some possibility of bleeding being precipitated by\n patient\ns experimental oncologic med which was started 2 weeks ago.\n -Continue to monitor\n -Continue antibiotics and add scheduled codeine for cough suppression\n -If begins bleeding briskly will arrange IR/angiography to localize\n source/site of bleed\n -Obtain records from oncologist re: new experimental med\n *Metastatic melanoma: Pt reports his last PET scan was 2 wks ago. Time\n course of CT findings unclear, though presumably present 2 wks ago.\n Will get further information from outside records\n *Anemia: could represent acute blood loss. Check serial hcts, type and\n cross\n *DVT: s/p IVC filter. No anticoagulation.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Indwelling Port (PortaCath) - 06:09 AM\n 20 Gauge - 06:12 AM\n Comments:\n Prophylaxis:\n DVT: boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Pt is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2173-05-23 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 323314,
"text": "Chief Complaint: hemoptyis\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 71 year old male with 1 wk hemoptysis. Initially scant hemoptysis then\n worsening, bright red *10-14 cc) and pleurisy.\n Went to oncologist a few days ago. CXR: pneumonia. Prescribed 10 days\n of an unknown antibiotic starting Wednesday. Hemoptysis did not\n improve-- went to over the weekend.\n Known hx of DVT on a month of lovenox\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, ICU housestaff; outside records\n unavailable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n protonix, colace, MVI, lisinopril\n Past medical history:\n Family history:\n Social History:\n All medical care from and \n Metastatic melanoma: lesion on UE. : recurrence with bony mets and\n left flank lesion s/p XRT/removal. PET-CT recent showed pulmonary\n nodules/small lesions in intestine. Got chemo. PET/MRI for unknown\n clinical trial, started 2 wks ago on an unknown experimental vs placebo\n drug.\n Umbilical hernia repair\n HTN\n Hypercholesterolemia\n non cont\n Occupation: married with 4 children\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal\n Allergy / Immunology: No(t) Immunocompromised\n Flowsheet Data as of 09:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.7\nC (98\n HR: 81 (81 - 106) bpm\n BP: 104/58(70) {104/49(64) - 138/71(88)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 6 Inch\n Total In:\n PO:\n TF:\n IVF:\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 -250 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\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 Respiratory / Chest: few rales right side\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: PT / PTT / INR:INR 1.1\n Fluid analysis / Other labs: troponin <0.01\n Imaging: CT (reviewed): negative for PE. Extensive pulmonary nodules-\n random distribution, very smooth margins/hilar LAD with encasement of\n pulmonary vein. Also with post obstructive PNA, RLL\n Assessment and Plan\n 71 yr old male with metastatic melanoma admitted with hemoptysis. CT\n results show large and innumerable smooth pulmonary\n nodules.\n *Hemoptysis: underwent FOB this am which showed some blood but no\n active bleeding and no endobronchial source of bleeding. Given chest CT\n findings and medical history, concerning for parenchymal bleed from\n melanoma met. Also, some possibility of bleeding being precipitated by\n patient\ns experimental oncologic med which was started 2 weeks ago.\n -Continue to monitor\n -Continue antibiotics (add anerobic coverage given post-obstructive\n ppicture) and add scheduled codeine for cough suppression\n -If begins bleeding briskly will arrange IR/angiography to localize\n source/site of bleed\n -Obtain records from oncologist re: new experimental med\n *Metastatic melanoma: Pt reports his last PET scan was 2 wks ago. Time\n course of CT findings unclear, though presumably present 2 wks ago.\n Will get further information from outside records\n *Anemia: could represent acute blood loss. Check serial hcts, type and\n cross\n *DVT: s/p IVC filter. No anticoagulation.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Indwelling Port (PortaCath) - 06:09 AM\n 20 Gauge - 06:12 AM\n Comments:\n Prophylaxis:\n DVT: boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Pt is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2173-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 323297,
"text": "This is a 71 yr male w/ hx metastatic melanoma w/ mets to lung. Pt\n presented to OSH w/ hemoptysis X 1 wk, and reports increasing frequency\n and amounts of hemoptysis, w increasing DOE despite being on abx since\n Wednesday. Pt reports previous CT showed 2 small lung nodules; however,\n CT w/ current event showed innumberable large metastatic focci w/ a\n large RLL mass. Pt was transferred to MICU for monitoring of\n respiratory and hemodynamic status; however, pt has remained clinically\n stable.\n"
},
{
"category": "Nursing",
"chartdate": "2173-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 323300,
"text": "This is a 71 yr male w/ hx metastatic melanoma w/ mets to lung. Pt\n presented to OSH w/ hemoptysis X 1 wk, and reports increasing frequency\n and amounts of hemoptysis, w increasing DOE despite being on abx since\n Wednesday. Pt reports previous CT showed 2 small lung nodules; however,\n CT w/ current event showed innumberable large metastatic focci w/ a\n large RLL mass. Pt was transferred to MICU for monitoring of\n respiratory and hemodynamic status; however, pt has remained clinically\n stable.\n Hemoptysis\n Assessment:\n Pt w/ 1 wk hx of hemoptysis as above. Pt continues w/ frequent cough\n productive for small amounts bright red bloody sputum.\n Action:\n Monitoring respiratory and hemodynamic status closely. Following hct.\n Adminisering guiefenisin w/ codeine, and benzonatate as ordered. Bronch\n done by IPMD this am.\n Response:\n Pt remains free of s/s respiratory distress t/o shift. SpO2 remains\n 95-99% on 2L via NC, except brief 30min period post bronch during which\n pt received 10L via FM. Pt denies SOB t/o shift. Hct remains stable. Pt\n expectorated a total of ~50ml of bright red blood t/o shift. Bronch\n showed no source of active bleeding.\n Plan:\n Continue to monitor hemodynamic and respiratory status closely.\n Continue anti-tussives as ordered. Increase activity as tolerated.\n Anticipate c/o to floor if pt remains stable.\n"
},
{
"category": "Nursing",
"chartdate": "2173-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 323417,
"text": "This is a 71 yr male w/ hx metastatic melanoma w/ mets to lung. Pt\n presented to OSH w/ hemoptysis X 1 wk, and reports increasing frequency\n and amounts of hemoptysis, w increasing DOE despite being on abx since\n Wednesday. Pt reports previous CT showed 2 small lung nodules; however,\n CT w/ current event showed innumerable large metastatic focci w/ a\n large RLL mass. Pt was transferred to MICU for monitoring of\n respiratory and hemodynamic status; however, pt has remained clinically\n stable. Bronched on , Bronchoscopy showed no source of active\n bleeding.\n Hemoptysis\n Assessment:\n Pt w/ 1 wk hx of hemoptysis as above. Pt continues w/ frequent cough\n productive for small amounts bright red bloody sputum. During the night\n shift, spiked fever to 100.3.\n Action:\n Monitoring respiratory and hemodynamic status closely. Following hct.\n Adminisering guiefenisin w/ codeine, and benzonatate as ordered. Bronch\n done by IPMD on am. Received Tylenol and started on Zosyn as\n ordered, urine cx, sputum cx, and 2 sets of blood cx sent.\n Response:\n Pt remains free of s/s respiratory distress t/o shift. SpO2 remains\n above 95% on 2L via NC. Pt denies SOB t/o shift. Hct remains stable,\n about 30. Pt expectorated small amounts of bright red blood t/o shift,\n Temp decreased to 98.2 orally.\n Plan:\n Continue to monitor hemodynamic and respiratory status closely.\n Continue anti-tussives as ordered. Increase activity as tolerated, pt\n likes to sit on the chair most of the time. Follow up on cxs, continue\n antibiotics as ordered.\n Pt is called out to floor. Report has been given to 11R RN; however,\n receiving MD has been unable to take sign-out per MICU team. Plan to\n transfer pt to floor once MD sign-out given and transfer orders in\n place.\n"
},
{
"category": "Nursing",
"chartdate": "2173-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 323406,
"text": "This is a 71 yr male w/ hx metastatic melanoma w/ mets to lung. Pt\n presented to OSH w/ hemoptysis X 1 wk, and reports increasing frequency\n and amounts of hemoptysis, w increasing DOE despite being on abx since\n Wednesday. Pt reports previous CT showed 2 small lung nodules; however,\n CT w/ current event showed innumerable large metastatic focci w/ a\n large RLL mass. Pt was transferred to MICU for monitoring of\n respiratory and hemodynamic status; however, pt has remained clinically\n stable. Bronched on , Bronchoscopy showed no source of active\n bleeding.\n Hemoptysis\n Assessment:\n Pt w/ 1 wk hx of hemoptysis as above. Pt continues w/ frequent cough\n productive for small amounts bright red bloody sputum. During the night\n shift, spiked fever to 100.3.\n Action:\n Monitoring respiratory and hemodynamic status closely. Following hct.\n Adminisering guiefenisin w/ codeine, and benzonatate as ordered. Bronch\n done by IPMD on am. Received Tylenol and started on Zosyn as\n ordered, urine cx, sputum cx, and 2 sets of blood cx sent.\n Response:\n Pt remains free of s/s respiratory distress t/o shift. SpO2 remains\n above 95% on 2L via NC. Pt denies SOB t/o shift. Hct remains stable,\n about 30. Pt expectorated small amounts of bright red blood t/o shift,\n Temp decreased to 98.2 orally.\n Plan:\n Continue to monitor hemodynamic and respiratory status closely.\n Continue anti-tussives as ordered. Increase activity as tolerated, pt\n likes to sit on the chair most of the time. Follow up on cxs, continue\n antibiotics as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2173-05-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 323388,
"text": "Chief Complaint: hemoptysis\n I saw and examined the patient, and was physically present with the \n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 71 yo male with metastatic melanoma admitted with non massive\n hemoptysis\n 24 Hour Events:\n * admission\n *FOB: clot (removed); no airway source of bleeding\n *Broadened antibiotic coverage\n This am: small (5-10cc) amount of hemoptysis, but decreasing over past\n day\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other medications:\n Fentanyl - 11:40 AM\n Midazolam (Versed) - 11:40 AM\n Other medications:\n Protonix, colace, MVI, lisinopril 5 mg qd, tessalon perles,\n guif/codeine q6h\n Changes to medical and family history:\n OV: hemoptysis? epistaxis\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.1\nC (97\n HR: 78 (76 - 110) bpm\n BP: 103/67(75) {80/25(34) - 146/96(101)} mmHg\n RR: 14 (14 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 6 Inch\n Total In:\n 400 mL\n 350 mL\n PO:\n 300 mL\n 250 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 825 mL\n 975 mL\n Urine:\n 825 mL\n 975 mL\n NG:\n Stool:\n Drains:\n Balance:\n -425 mL\n -625 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Thin,\n No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: No(t) Resonant : ), (Breath Sounds: No(t) Clear : ,\n Crackles : few rales at bases, Diminished: at bases)\n Abdominal: Soft, Non-tender, No(t) Distended, No(t) Tender: , No(t)\n Obese\n Extremities: No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 9.1 g/dL\n 235 K/uL\n 129 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 103 mEq/L\n 134 mEq/L\n 26.0 %\n 10.5 K/uL\n [image002.jpg]\n 10:32 AM\n 04:00 PM\n 11:50 PM\n 04:36 AM\n WBC\n 10.5\n Hct\n 29.2\n 31.0\n 30.0\n 26.0\n Plt\n 235\n Cr\n 0.8\n Glucose\n 129\n Other labs: Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 71 yo male with met melanoma with non massive hemoptysis\n #Hemoptysis-Volume of hemoptysis appears to be decreasing. Diff dx\n includes parenchymal bleed from lung met, drug reaction, contribution\n from RLL Pna.\n -Re-check Hct since Hct drop seems disproportionate to amount of recent\n hemoptysis (Update: now 28.1)\n -continue cough suppression, antibiotics (Zosyn started for improved\n anerobic coverage)\n -ENT eval -has had prior sinus congestion/epistaxis and nasal polyps)\n -If brisk bleed, IR/angio\n #Metastatic melanoma: obtain records from doctors\n \n :\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 06:09 AM\n 20 Gauge - 06:12 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2173-05-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 323409,
"text": "This is a 71 yr male w/ hx metastatic melanoma w/ mets to lung. Pt\n presented to OSH w/ hemoptysis X 1 wk, and reports increasing frequency\n and amounts of hemoptysis, w increasing DOE despite being on abx since\n Wednesday. Pt reports previous CT showed 2 small lung nodules; however,\n CT w/ current event showed innumerable large metastatic focci w/ a\n large RLL mass. Pt was transferred to MICU for monitoring of\n respiratory and hemodynamic status; however, pt has remained clinically\n stable. Bronched on , Bronchoscopy showed no source of active\n bleeding.\n Hemoptysis\n Assessment:\n Pt w/ 1 wk hx of hemoptysis as above. Pt continues w/ frequent cough\n productive for small amounts bright red bloody sputum. During the night\n shift, spiked fever to 100.3.\n Action:\n Monitoring respiratory and hemodynamic status closely. Following hct.\n Adminisering guiefenisin w/ codeine, and benzonatate as ordered. Bronch\n done by IPMD on am. Received Tylenol and started on Zosyn as\n ordered, urine cx, sputum cx, and 2 sets of blood cx sent. FiO2 weaned\n to RA.\n Response:\n Pt remains free of s/s respiratory distress t/o shift. Remains afebrile\n SpO2 remains above 95% on RA. Pt denies SOB t/o shift. Hct remains\n stable. Pt expectorated small amounts of bright red blood t/o shift,\n Temp decreased to 98.2 orally.\n Plan:\n Continue to monitor hemodynamic and respiratory status closely.\n Continue anti-tussives as ordered. Increase activity as tolerated, pt\n likes to sit on the chair most of the time. Follow up on cxs, continue\n antibiotics as ordered.\n Demographics\n Attending MD:\n Admit diagnosis:\n HEMOPTYSIS\n Code status:\n Full code\n Height:\n 6 Inch\n Admission weight:\n 83 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Lung CA (melanoma) on chemotherapy\n s/p rt lymph node biopsy\n s/p herniorrhaphy\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:126\n D:74\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 30 insp/min\n Heart Rate:\n 92 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 830 mL\n 24h total out:\n 1,675 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 04:36 AM\n Potassium:\n 4.2 mEq/L\n 04:36 AM\n Chloride:\n 103 mEq/L\n 04:36 AM\n CO2:\n 23 mEq/L\n 04:36 AM\n BUN:\n 15 mg/dL\n 04:36 AM\n Creatinine:\n 0.8 mg/dL\n 04:36 AM\n Glucose:\n 129 mg/dL\n 04:36 AM\n Hematocrit:\n 27.7 %\n 03:46 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Sent home with: Wife\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 407\n Transferred to: 11R\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2173-05-23 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 323288,
"text": "Chief Complaint: hemoptyis\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 71 year old male with 1 wk hemoptysis. Initially scant hemoptysis then\n worsening, bright red *10-14 cc) and pleurisy.\n Went to oncologist a few days ago. CXR: pneumonia. Prescribed 10 days\n of an unknown antibiotic starting Wednesday. Hemoptysis did not\n improve-- went to over the weekend.\n Known hx of DVT on a month of lovenox\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, ICU housestaff; outside records\n unavailable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n protonix, colace, MVI, lisinopril\n Past medical history:\n Family history:\n Social History:\n All medical care from and \n Metastatic melanoma: lesion on UE. : recurrence with bony mets and\n left flank lesion s/p XRT/removal. PET-CT recent showed pulmonary\n nodules/small lesions in intestine. Got chemo. PET/MRI for unknown\n clinical trial, started 2 wks ago on an unknown experimental vs placebo\n drug.\n Umbilical hernia repair\n HTN\n Hypercholesterolemia\n non cont\n Occupation: married with 4 children\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal\n Allergy / Immunology: No(t) Immunocompromised\n Flowsheet Data as of 09:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.7\nC (98\n HR: 81 (81 - 106) bpm\n BP: 104/58(70) {104/49(64) - 138/71(88)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 6 Inch\n Total In:\n PO:\n TF:\n IVF:\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 -250 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\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 Respiratory / Chest: few rales right side\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: PT / PTT / INR:INR 1.1\n Fluid analysis / Other labs: troponin <0.01\n Imaging: CT (reviewed): negative for PE. Extensive pulmonary nodules-\n random distribution, very smooth margins/hilar LAD with encasement of\n pulmonary vein. Also with post obstructive PNA.\n Assessment and Plan\n 71 yr old male with metastatic melanoma admitted with hemoptysis. CT\n results show large and innumerable smooth pulmonary\n nodules.\n *Hemoptysis: underwent FOB this am which showed some blood but no\n active bleeding and no endobronchial source of bleeding. Given chest CT\n findings and medical history, concerning for parenchymal bleed from\n melanoma met. Also, some possibility of bleeding being precipitated by\n patient\ns experimental oncologic med which was started 2 weeks ago.\n -Continue to monitor\n -Continue antibiotics for potential post-obstructive and add scheduled\n codeine for cough suppression\n -If begins bleeding briskly will arrange IR/angiography to localize\n source/site of bleed\n -Obtain records from oncologist re: new experimental med\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Indwelling Port (PortaCath) - 06:09 AM\n 20 Gauge - 06:12 AM\n Comments:\n Prophylaxis:\n DVT: boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Pt is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2173-05-23 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 323289,
"text": "Chief Complaint: hemoptyis\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 71 year old male with 1 wk hemoptysis. Initially scant hemoptysis then\n worsening, bright red *10-14 cc) and pleurisy.\n Went to oncologist a few days ago. CXR: pneumonia. Prescribed 10 days\n of an unknown antibiotic starting Wednesday. Hemoptysis did not\n improve-- went to over the weekend.\n Known hx of DVT on a month of lovenox\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, ICU housestaff; outside records\n unavailable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n protonix, colace, MVI, lisinopril\n Past medical history:\n Family history:\n Social History:\n All medical care from and \n Metastatic melanoma: lesion on UE. : recurrence with bony mets and\n left flank lesion s/p XRT/removal. PET-CT recent showed pulmonary\n nodules/small lesions in intestine. Got chemo. PET/MRI for unknown\n clinical trial, started 2 wks ago on an unknown experimental vs placebo\n drug.\n Umbilical hernia repair\n HTN\n Hypercholesterolemia\n non cont\n Occupation: married with 4 children\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal\n Allergy / Immunology: No(t) Immunocompromised\n Flowsheet Data as of 09:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.7\nC (98\n HR: 81 (81 - 106) bpm\n BP: 104/58(70) {104/49(64) - 138/71(88)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 6 Inch\n Total In:\n PO:\n TF:\n IVF:\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 -250 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\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 Respiratory / Chest: few rales right side\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: PT / PTT / INR:INR 1.1\n Fluid analysis / Other labs: troponin <0.01\n Imaging: CT (reviewed): negative for PE. Extensive pulmonary nodules-\n random distribution, very smooth margins/hilar LAD with encasement of\n pulmonary vein. Also with post obstructive PNA.\n Assessment and Plan\n 71 yr old male with metastatic melanoma admitted with hemoptysis. CT\n results show large and innumerable smooth pulmonary\n nodules.\n *Hemoptysis: underwent FOB this am which showed some blood but no\n active bleeding and no endobronchial source of bleeding. Given chest CT\n findings and medical history, concerning for parenchymal bleed from\n melanoma met. Also, some possibility of bleeding being precipitated by\n patient\ns experimental oncologic med which was started 2 weeks ago.\n -Continue to monitor\n -Continue antibiotics and add scheduled codeine for cough suppression\n -If begins bleeding briskly will arrange IR/angiography to localize\n source/site of bleed\n -Obtain records from oncologist re: new experimental med\n *Metastatic melanoma: Pt reports his last PET scan was 2 wks ago. Time\n course of CT findings unclear, though presumably present 2 wks ago.\n Will get further information from outside records\n *Anemia: could represent acute blood loss. Check serial hcts, type and\n cross\n *DVT: s/p IVC filter. No anticoagulation.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Indwelling Port (PortaCath) - 06:09 AM\n 20 Gauge - 06:12 AM\n Comments:\n Prophylaxis:\n DVT: boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Pt is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2173-05-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 323350,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 12:02 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 11:40 AM\n Midazolam (Versed) - 11:40 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 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.8\nC (98.2\n HR: 78 (76 - 110) bpm\n BP: 95/52(61) {80/25(34) - 147/96(101)} mmHg\n RR: 16 (14 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 6 Inch\n Total In:\n 400 mL\n 350 mL\n PO:\n 300 mL\n 250 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 825 mL\n 700 mL\n Urine:\n 825 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -425 mL\n -350 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 235 K/uL\n 9.1 g/dL\n 129 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 103 mEq/L\n 134 mEq/L\n 26.0 %\n 10.5 K/uL\n [image002.jpg]\n 10:32 AM\n 04:00 PM\n 11:50 PM\n 04:36 AM\n WBC\n 10.5\n Hct\n 29.2\n 31.0\n 30.0\n 26.0\n Plt\n 235\n Cr\n 0.8\n Glucose\n 129\n Other labs: Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n The patient is a 71 y.o.m. with metastatic melanoma and HTN who\n presents with hemoptysis.\n # Hemoptysis - CTA concerning for widespread metastatic disease and\n encasement of pulmonary vein leading to hemoptysis and obstruction of\n RLL bronchus leading to postobstructive PNA. Recently received a\n prescription for antibiotics for the PNA, but it is unclear what this\n particular antibiotic is. Hemoptysis does not appear to be large\n enough quantity to cause hypoxia or acute blood loss anemia, but HCT\n 29 and concerning and warrants observation.\n - Monitor HCT Q8H\n - Consider bronchoscopy\n - Obtain OSH records from to evaluate if CT shows true\n progression of disease (Dr is oncologist). Presumably the\n patient is known to have metastatic melanoma, which is why he is\n enrolled in a clinical trial at , but per the patient his\n lung disease was minimal and stable based on recent PET scan and MRI\n prior to initiating the clinical trial. Concern is for marked\n progression of disease.\n - Consider transfer to when bed is available for continuity\n of care\n - NC as needed\n - Hold on anticoagulation for DVT\n # PNA - Appears to have post obstructive PNA based on CT scan. No\n fevers or leukocytosis. Likely immunosuppressed given recent\n chemotherapy (although may be placebo pill).\n - Levofloxacin for now\n - Sputum culture\n # H/O DVT - Occurred approximately one month ago and received lovenox,\n but no longer anticoagulated for unclear reasons.\n - Hold on anticoagulation in setting of hemoptysis\n - Obtain records from \n - Pneumatic compression boots\n # Anemia\n Unclear baseline. Unlikely to be all due to acute blood loss\n anemia given good respiratory status.\n - Obtain baseline HCT from OSH\n - Trend HCT\n - Guaiac stools, iron studies\n # HTN - Normotensive.\n - Continue lisinopril - will need to confirm dose with wife\n # FEN - Electrolytes and kidney function normal.\n - Monitor Cr s/p dye load during CTA\n - Replete lytes prn\n # Comm - Patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 06:09 AM\n 20 Gauge - 06:12 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": "2173-05-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 323351,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 12:02 PM\n Got farber records, in chart...looks like CT is unchanged from one in\n . Called primary oncologist at and left message,\n Got bronched for hemoptysis, clot seen and removed, no active bleeding,\n presumed one of masses bleeding parenchymally.\n Aggressive cough suppression\n Continued levaquin, pt spiked to 100.3, pan cultured, started zosyn for\n post obstructive PNA, needs approval\n Advanced diet\n Hct was stable overnight, increasing to 30, however did decrease this\n am to ~26.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 11:40 AM\n Midazolam (Versed) - 11:40 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 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.8\nC (98.2\n HR: 78 (76 - 110) bpm\n BP: 95/52(61) {80/25(34) - 147/96(101)} mmHg\n RR: 16 (14 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 6 Inch\n Total In:\n 400 mL\n 350 mL\n PO:\n 300 mL\n 250 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 825 mL\n 700 mL\n Urine:\n 825 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -425 mL\n -350 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 235 K/uL\n 9.1 g/dL\n 129 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 103 mEq/L\n 134 mEq/L\n 26.0 %\n 10.5 K/uL\n [image002.jpg]\n 10:32 AM\n 04:00 PM\n 11:50 PM\n 04:36 AM\n WBC\n 10.5\n Hct\n 29.2\n 31.0\n 30.0\n 26.0\n Plt\n 235\n Cr\n 0.8\n Glucose\n 129\n Other labs: Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n The patient is a 71 y.o.m. with metastatic melanoma and HTN who\n presents with hemoptysis.\n # Hemoptysis - CTA concerning for widespread metastatic disease and\n encasement of pulmonary vein leading to hemoptysis and obstruction of\n RLL bronchus leading to postobstructive PNA. Recently received a\n prescription for antibiotics for the PNA, but it is unclear what this\n particular antibiotic is. Hemoptysis does not appear to be large\n enough quantity to cause hypoxia or acute blood loss anemia, but HCT\n 29 and concerning and warrants observation.\n - Monitor HCT Q8H\n - Consider bronchoscopy\n - Obtain OSH records from to evaluate if CT shows true\n progression of disease (Dr is oncologist). Presumably the\n patient is known to have metastatic melanoma, which is why he is\n enrolled in a clinical trial at , but per the patient his\n lung disease was minimal and stable based on recent PET scan and MRI\n prior to initiating the clinical trial. Concern is for marked\n progression of disease.\n - Consider transfer to when bed is available for continuity\n of care\n - NC as needed\n - Hold on anticoagulation for DVT\n # PNA - Appears to have post obstructive PNA based on CT scan. No\n fevers or leukocytosis. Likely immunosuppressed given recent\n chemotherapy (although may be placebo pill).\n - Levofloxacin for now\n - Sputum culture\n # H/O DVT - Occurred approximately one month ago and received lovenox,\n but no longer anticoagulated for unclear reasons.\n - Hold on anticoagulation in setting of hemoptysis\n - Obtain records from \n - Pneumatic compression boots\n # Anemia\n Unclear baseline. Unlikely to be all due to acute blood loss\n anemia given good respiratory status.\n - Obtain baseline HCT from OSH\n - Trend HCT\n - Guaiac stools, iron studies\n # HTN - Normotensive.\n - Continue lisinopril - will need to confirm dose with wife\n # FEN - Electrolytes and kidney function normal.\n - Monitor Cr s/p dye load during CTA\n - Replete lytes prn\n # Comm - Patient\n ICU Care\n Nutrition: NPO for now until decision re: bronch made\n Glycemic Control:\n Lines: PIV\n Indwelling Port (PortaCath) - 06:09 AM\n 20 Gauge - 06:12 AM\n Prophylaxis:\n DVT: Boots\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": "2173-05-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 323369,
"text": "Chief Complaint: hemoptysis\n I saw and examined the patient, and was physically present with the \n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 71 yo male with metastatic melanoma admitted with non massive\n hemoptysis\n 24 Hour Events:\n * admission\n *FOB: clot (removed); no airway source of bleeding\n *Broadened antibiotic coverage\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other medications:\n Fentanyl - 11:40 AM\n Midazolam (Versed) - 11:40 AM\n Other medications:\n Protonix, colace, MVI, lisinopril 5 mg qd, tessalon perles,\n guif/codeine q6h\n Changes to medical and family history:\n OV: hemoptysis? epistaxis\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 36.1\nC (97\n HR: 78 (76 - 110) bpm\n BP: 103/67(75) {80/25(34) - 146/96(101)} mmHg\n RR: 14 (14 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 6 Inch\n Total In:\n 400 mL\n 350 mL\n PO:\n 300 mL\n 250 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 825 mL\n 975 mL\n Urine:\n 825 mL\n 975 mL\n NG:\n Stool:\n Drains:\n Balance:\n -425 mL\n -625 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Thin,\n No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: No(t) Resonant : ), (Breath Sounds: No(t) Clear : ,\n Crackles : few rales at bases, Diminished: at bases)\n Abdominal: Soft, Non-tender, No(t) Distended, No(t) Tender: , No(t)\n Obese\n Extremities: No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Not assessed, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 9.1 g/dL\n 235 K/uL\n 129 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 103 mEq/L\n 134 mEq/L\n 26.0 %\n 10.5 K/uL\n [image002.jpg]\n 10:32 AM\n 04:00 PM\n 11:50 PM\n 04:36 AM\n WBC\n 10.5\n Hct\n 29.2\n 31.0\n 30.0\n 26.0\n Plt\n 235\n Cr\n 0.8\n Glucose\n 129\n Other labs: Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 71 yo male with met melanoma with non massive hemoptysis\n #Hemoptysis-Volume of hemoptysis appears to be decreasing. Diff dx\n includes parenchymal bleed from lung met, drug reaction, contribution\n from RLL Pna.\n -Re-check Hct since Hct drop seems disproportionate to amount of recent\n hemoptysis\n -continue cough suppression, antibiotics (Zosyn started for improved\n anerobic coverage)\n -ENT eval (has had prior sinus congestion/epistaxis and nassal polyps)\n -If brisk bleed, IR/angio\n #Metastatic melanoma: obtain records from doctors\n \n :\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 06:09 AM\n 20 Gauge - 06:12 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :; could go to floor if Hct unchanged\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2173-05-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 323375,
"text": "This is a 71 yr male w/ hx metastatic melanoma w/ mets to lung. Pt\n presented to OSH w/ hemoptysis X 1 wk, and reports increasing frequency\n and amounts of hemoptysis, w increasing DOE despite being on abx since\n Wednesday. Pt reports previous CT showed 2 small lung nodules; however,\n CT w/ current event showed innumerable large metastatic focci w/ a\n large RLL mass. Pt was transferred to MICU for monitoring of\n respiratory and hemodynamic status; however, pt has remained clinically\n stable. Bronched on , Bronchoscopy showed no source of active\n bleeding.\n Hemoptysis\n Assessment:\n Pt w/ 1 wk hx of hemoptysis as above. Pt continues w/ frequent cough\n productive for small amounts bright red bloody sputum. During the night\n shift, spiked fever to 100.3.\n Action:\n Monitoring respiratory and hemodynamic status closely. Following hct.\n Adminisering guiefenisin w/ codeine, and benzonatate as ordered. Bronch\n done by IPMD on am. Received Tylenol and started on Zosyn as\n ordered, urine cx, sputum cx, and 2 sets of blood cx sent.\n Response:\n Pt remains free of s/s respiratory distress t/o shift. SpO2 remains\n above 95% on 2L via NC. Pt denies SOB t/o shift. Hct remains stable,\n about 30. Pt expectorated small amounts of bright red blood t/o shift,\n Temp decreased to 98.2 orally.\n Plan:\n Continue to monitor hemodynamic and respiratory status closely.\n Continue anti-tussives as ordered. Increase activity as tolerated, pt\n likes to sit on the chair most of the time. Follow up on cxs, continue\n antibiotics as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2173-05-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 323376,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 12:02 PM\n Got some records, in chart...looks like CT is unchanged from one\n in . Called primary oncologist at and left message.\n Got bronched for hemoptysis, clot seen and removed, no active bleeding,\n presumed one of masses bleeding parenchymally.\n Aggressive cough suppression\n Continued levaquin, pt spiked to 100.3, pan cultured, started zosyn for\n post obstructive PNA.\n Advanced diet\n Hct was stable overnight, increasing to 30, however did decrease this\n am to ~26.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 11:40 AM\n Midazolam (Versed) - 11:40 AM\n Other medications:\n Lisinopril\n Protonix\n Tesselon Perles\n Guaifenesin codeine\n Tylenol\n Senna\n Colace\n MVI\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt reports less cough, improved chest wall pain.\n States previously had nasal polyp bleed with epistaxis, this blood\n seems to be coming up from chest. No blood when clearing nasal\n passages.\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: 37.9\nC (100.3\n Tcurrent: 36.8\nC (98.2\n HR: 78 (76 - 110) bpm\n BP: 95/52(61) {80/25(34) - 147/96(101)} mmHg\n RR: 16 (14 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 6 Inch\n Total In:\n 400 mL\n 350 mL\n PO:\n 300 mL\n 250 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 825 mL\n 700 mL\n Urine:\n 825 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -425 mL\n -350 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Diminished: decreased BS at right base, No(t) Absent : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: 1+, left leg larger than right\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 235 K/uL\n 9.1 g/dL\n 129 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 103 mEq/L\n 134 mEq/L\n 26.0 %\n 10.5 K/uL\n [image002.jpg]\n 10:32 AM\n 04:00 PM\n 11:50 PM\n 04:36 AM\n WBC\n 10.5\n Hct\n 29.2\n 31.0\n 30.0\n 26.0\n Plt\n 235\n Cr\n 0.8\n Glucose\n 129\n Other labs: Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.0 mg/dL\n Micro: sputum cancelled, OP floral contamination\n Urine and blood cultures pending from \n \n CT Chest :\n IMPRESSION:\n 1. No pulmonary embolism.\n 2. Innumerable large bilateral pulmonary nodules and masses, consistent\n with\n widespread metastatic disease. Dominant right hilar mass encases and\n significantly narrows the right inferior pulmonary vein. Mass also\n narrows\n and likely occludes the right lower lobe segmental bronchus, with\n resultant\n extensive airspace opacity throughout the right lower lobe, most\n consistent\n with postobstructive pneumonia. Interstitial and peribronchovascular\n opacity\n is most consistent with lymphangitic tumor spread. Small associated\n right\n pleural effusion.\n 3. Cholelithiasis.\n Assessment and Plan\n The patient is a 71 y.o.m. with metastatic melanoma and HTN who\n presents with hemoptysis.\n # Hemoptysis - CTA concerning for widespread metastatic disease and\n encasement of pulmonary vein leading to hemoptysis and obstruction of\n RLL bronchus leading to postobstructive PNA. Recently received a\n prescription for antibiotics for the PNA, upon review of records it\n appears he completed a 10 day course of levaquin. The differential for\n his hemoptysis is most likely pulmonary related to bleeding from his\n mets, especially in light of recent chemo trial where increased\n frequency of bleeding has been seen and with bronch showing clot in the\n airway. Also on ddx is nasal polyp. Pt reports having epistaxis and\n difficulty breathing in the past for which he was evaluated by ENT at\n , last time 6 months ago, found to have large nasal polyp.\n - Monitor HCT , repeat this morning\ns Hct as given pt\ns decreasing\n hemoptysis and clinical stability is difficulty to believe he lost 4\n Hct points.\n -touch base with primary team\n -Prn supplemental 02\n - Hold on anticoagulation for DVT\n -Aggressive cough suppression\n -Plan to sent to IR for possible emolization if re-bleeds.\n # PNA - Appears to have post obstructive PNA based on CT scan. Slight\n fever overnight with mild leukocytosis. Likely immunosuppressed given\n recent chemotherapy (although may be placebo pill).\n - Switched to zosyn from levaquin for anaerobic coverage of\n post-obstructive PNA.\n - Sputum culture, follow up\n - Tylenol for fevers\n # H/O DVT - Occurred approximately one month ago and received lovenox,\n but no longer anticoagulated for unclear reasons.\n - Hold on anticoagulation in setting of hemoptysis\n - Obtain records from \n - Pneumatic compression boots\n # Anemia\n Unclear baseline. Unlikely to be all due to acute blood loss\n anemia given good respiratory status.\n - Obtain baseline HCT from OSH\n - Trend HCT\n - Guaiac stools, iron studies show pt to be iron deficient, consider\n initiating repletion.\n # HTN - Normotensive.\n - Continue lisinopril at home dose\n # FEN - Electrolytes and kidney function normal.\n - Replete lytes prn\n -regular diet\n # Comm - Patient\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines: PIV\n Indwelling Port (PortaCath) - 06:09 AM\n 20 Gauge - 06:12 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Callout to floor today.\n"
},
{
"category": "Nursing",
"chartdate": "2173-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 323228,
"text": "This is a 71 yo male pt admitted through ED from OSH with bright red\n hemoptysis, known to have lung CA, s/p first cycle of chemotherapy. In\n ED, hemodynamically stable, V/S 98.9, 99 NSR, 127/55, Sat 99% on 2 L\n NC, chest CT done revealed no PE. Innumerable large metastatic foci,\n large mass in RLL occludes the RLL bronchus, with airspace opacity seen\n throughout RLL, concerning for post-obstructive PNA, small Rt pleural\n effusion, admitted to for further observation and management.\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2173-05-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 323340,
"text": "This is a 71 yr male w/ hx metastatic melanoma w/ mets to lung. Pt\n presented to OSH w/ hemoptysis X 1 wk, and reports increasing frequency\n and amounts of hemoptysis, w increasing DOE despite being on abx since\n Wednesday. Pt reports previous CT showed 2 small lung nodules; however,\n CT w/ current event showed innumberable large metastatic focci w/ a\n large RLL mass. Pt was transferred to MICU for monitoring of\n respiratory and hemodynamic status; however, pt has remained clinically\n stable. Bronched on , Bronchoscopy showed no source of active\n bleeding.\n Hemoptysis\n Assessment:\n Pt w/ 1 wk hx of hemoptysis as above. Pt continues w/ frequent cough\n productive for small amounts bright red bloody sputum. During the night\n shift, spiked fever to 100.3.\n Action:\n Monitoring respiratory and hemodynamic status closely. Following hct.\n Adminisering guiefenisin w/ codeine, and benzonatate as ordered. Bronch\n done by IPMD on am. Received Tylenol and started on Zosyn as\n ordered, urine cx, sputum cx, and 2 sets of blood cx sent.\n Response:\n Pt remains free of s/s respiratory distress t/o shift. SpO2 remains\n above 95% on 2L via NC. Pt denies SOB t/o shift. Hct remains stable,\n about 30. Pt expectorated small amounts of bright red blood t/o shift,\n Temp decreased to 98.2 orally.\n Plan:\n Continue to monitor hemodynamic and respiratory status closely.\n Continue anti-tussives as ordered. Increase activity as tolerated, pt\n likes to sit on the chair most of the time. Follow up on cxs, continue\n antibiotics as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2173-05-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 323256,
"text": "Chief Complaint: Hemoptysis\n HPI:\n The patient is a healthy 71 y.o.m. with metastatic melanoma who gets\n all of his care at and who presents with hemoptysis.\n History is obtained as best as possible from the patient's recollection\n of events and medical history as we have no records in our system. He\n developed hemoptysis 1 week ago, intially only in the a.m., <1 tsp, but\n increased in frequency over the week. Also with increasing DOE when\n climbing stairs (normally able to do this without difficulty) over the\n last week and developed right flank pain with coughing. No orthopnea\n or PND, although has been sleeping upright in a chair for the last 6\n months due to sinus congestion. Went to his oncologist Dr. \n on Wednesday and a CXR was done which showed a pneumonia per the\n patient, and he was given 10 days of an antibiotic, although he does\n not know which one. Denies fevers, chills, nausea, emesis or\n hematemesis. Has LE edema, L>R due to recently diagnosed DVT - treated\n with lovenox but not on coumadin. Presented to for\n hemoptysis, no beds at , and transferred to for\n evaluation.\n In the ED vitals were 98.9, 100, 115/55, 27, 99% RA. CTA done and was\n negative for PE but showed many large bilateral pulmonary nodules and\n masses c/w widespread metastatic disease with a dominant right hilar\n mass encasing and narrowing the right inferior pulmonary vein and\n likely occluding the right lower lobe segmental bronchus with\n resultant extensive airspace opacity throughout the right lower lobe,\n most consistent with postobstructive pneumonia. He is admitted to the\n ICU for observation and possible bronchoscopy.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lisinopril - unknown dose\n MVI\n Past medical history:\n Family history:\n Social History:\n # Melanoma - diagnosed in in left upper arm. Resected with LN\n dissection and free of disease until when found to have bony\n disease in left shoulder and lump on L flank. Underwent XRT for\n shoulder and resection of left flank lesion that was found to be\n melanoma. At some point had PET showing 1cm lung nodules bilaterally,\n and two small lesions in his intestine. Treated with 'standard chemo'\n and steroids and responded to treatment. Most recently enrolled in\n trial with new study drug - received first dose ?2 weeks ago last Wed\n with next dose due this coming up Wed. Had MRI and repeat PET prior to\n enrollement.\n # Umbilical hernia s/p repair \n # HTN\n # Hypercholesteremia - diet controlled\n Longevity in family.\n Occupation: Retired\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, Nasal polyps that\n bled in the past, but not currently\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, due to steroids with chemo\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Allergy / Immunology: Immunocompromised\n Pain: No pain / appears comfortable\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: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 101 (101 - 106) bpm\n BP: 130/69(84) {130/69(84) - 138/71(88)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 6 Inch\n Total In:\n PO:\n TF:\n IVF:\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 -250 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Diminished: decreased BS at right base, No(t) Absent : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: 1+, left leg larger than right\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 279\n 126\n 0.9\n 22\n 23\n 103\n 4.4\n 134\n 29.7\n 9.7\n [image002.jpg]\n Other labs: PT / PTT / INR://1.1, CK / CKMB / Troponin-T:56/ND/<0.01\n Imaging: There are innumerable large bilateral pulmonary nodules and\n masses, consistent with widespread metastatic disease. The largest\n dominant mass in the medial aspect of the superior segment of the right\n lower lobe measures roughly 7 x 5 cm, and is situated medially,\n directly adjacent to the mediastinum. This mass encases and nearly\n occludes the right inferior pulmonary vein, and abuts but does not\n definitely invade the left atrium. Mass also abuts, but does not\n definitely invade the esophagus. This mass, and a large adjacent\n satellite\n mass measuring roughly 5 x 5 cm appear to encase and occlude the right\n lower lobe segmental bronchus, and there is extensive airspace opacity\n seen throughout the right lower lobe, which slightly bulges the major\n fissure\n anteriorly. There is a small associated right pleural effusion.\n No pulmonary embolism.\n Cholelithiasis\n Assessment and Plan\n The patient is a 71 y.o.m. with metastatic melanoma and HTN who\n presents with hemoptysis.\n .\n # Hemoptysis - CTA concerning for widespread metastatic disease and\n encasement of pulmonary vein leading to hemoptysis and obstruction of\n RLL bronchus leading to postobstructive PNA. Recently received a\n prescription for antibiotics for the PNA, but it is unclear what this\n particular antibiotic is. Hemoptysis does not appear to be large\n enough quantity to cause hypoxia or acute blood loss anemia, but HCT\n 29 and concerning and warrants observation.\n - Monitor HCT Q8H\n - Consider bronchoscopy\n - Obtain OSH records from to evaluate if CT shows true\n progression of disease (Dr is oncologist). Presumably the\n patient is known to have metastatic melanoma, which is why he is\n enrolled in a clinical trial at , but per the patient his\n lung disease was minimal and stable based on recent PET scan and MRI\n prior to initiating the clinical trial. Concern is for marked\n progression of disease.\n - Consider transfer to when bed is available for continuity\n of care\n - NC as needed\n - Hold on anticoagulation for DVT\n .\n # PNA - Appears to have post obstructive PNA based on CT scan. No\n fevers or leukocytosis. Likely immunosuppressed given recent\n chemotherapy (although may be placebo pill).\n - Levofloxacin for now\n - Sputum culture\n .\n # H/O DVT - Occurred approximately one month ago and received lovenox,\n but no longer anticoagulated for unclear reasons.\n - Hold on anticoagulation in setting of hemoptysis\n - Obtain records from \n - Pneumatic compression boots\n .\n # Anemia\n Unclear baseline. Unlikely to be all due to acute blood loss\n anemia given good respiratory status.\n - Obtain baseline HCT from OSH\n - Trend HCT\n - Guaiac stools, iron studies\n .\n # HTN - Normotensive.\n - Continue lisinopril - will need to confirm dose with wife\n .\n # FEN - Electrolytes and kidney function normal.\n - Monitor Cr s/p dye load during CTA\n - Replete lytes prn\n .\n # Comm - Patient\n ICU Care\n Nutrition: NPO for now until decision re: bronch made\n Glycemic Control:\n Lines: PIV\n Indwelling Port (PortaCath) - 06:09 AM\n 20 Gauge - 06:12 AM\n Prophylaxis:\n DVT: Boots\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": "2173-05-23 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 323257,
"text": "Chief Complaint: hemoptyis\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 71 year old male with 1 wk hemoptysis. Initially scant hemoptysis then\n worsening, bright red *10-14 cc) and pleurisy.\n Went to oncologist a few days ago. CXR: pneumonia. Prescribed 10 days\n of an unknown antibiotic starting Wednesday. Hemoptysis did not\n improve-- went to over the weekend.\n Known hx of DVT on a month of lovenox\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, ICU housestaff; outside records\n unavailable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n protonix, colace, MVI, lisinopril\n Past medical history:\n Family history:\n Social History:\n All medical care from and \n Metastatic melanoma: lesion on UE. : recurrence with bony mets and\n left flank lesion s/p XRT/removal. PET-CT recent showed pulmonary\n nodules/small lesions in intestine. Got chemo. PET/MRI for unknown\n clinical trial, started 2 wks ago on an unknown experimental vs placebo\n drug.\n Umbilical hernia repair\n HTN\n Hypercholesterolemia\n non cont\n Occupation: married with 4 children\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal\n Allergy / Immunology: No(t) Immunocompromised\n Flowsheet Data as of 09:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.7\nC (98\n HR: 81 (81 - 106) bpm\n BP: 104/58(70) {104/49(64) - 138/71(88)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 6 Inch\n Total In:\n PO:\n TF:\n IVF:\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 -250 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\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 Respiratory / Chest: few rales right side\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: PT / PTT / INR:INR 1.1\n Fluid analysis / Other labs: troponin <0.01\n Imaging: CT (reviewed): negative for PE. Extensive pulmonary\n nodules/hilar LAD with encasement of pulmonary vein. Also with post\n obstructive PNA.\n Assessment and Plan\n 71 yr old male with metastatic melanoma admitted with hemoptysis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Indwelling Port (PortaCath) - 06:09 AM\n 20 Gauge - 06:12 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": "2173-05-23 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 323259,
"text": "Chief Complaint: hemoptyis\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 71 year old male with 1 wk hemoptysis. Initially scant hemoptysis then\n worsening, bright red *10-14 cc) and pleurisy.\n Went to oncologist a few days ago. CXR: pneumonia. Prescribed 10 days\n of an unknown antibiotic starting Wednesday. Hemoptysis did not\n improve-- went to over the weekend.\n Known hx of DVT on a month of lovenox\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, ICU housestaff; outside records\n unavailable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n protonix, colace, MVI, lisinopril\n Past medical history:\n Family history:\n Social History:\n All medical care from and \n Metastatic melanoma: lesion on UE. : recurrence with bony mets and\n left flank lesion s/p XRT/removal. PET-CT recent showed pulmonary\n nodules/small lesions in intestine. Got chemo. PET/MRI for unknown\n clinical trial, started 2 wks ago on an unknown experimental vs placebo\n drug.\n Umbilical hernia repair\n HTN\n Hypercholesterolemia\n non cont\n Occupation: married with 4 children\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal\n Allergy / Immunology: No(t) Immunocompromised\n Flowsheet Data as of 09:53 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.7\nC (98\n HR: 81 (81 - 106) bpm\n BP: 104/58(70) {104/49(64) - 138/71(88)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 6 Inch\n Total In:\n PO:\n TF:\n IVF:\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 -250 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\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 Respiratory / Chest: few rales right side\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: PT / PTT / INR:INR 1.1\n Fluid analysis / Other labs: troponin <0.01\n Imaging: CT (reviewed): negative for PE. Extensive pulmonary\n nodules/hilar LAD with encasement of pulmonary vein. Also with post\n obstructive PNA.\n Assessment and Plan\n 71 yr old male with metastatic melanoma admitted with hemoptysis. CT\n results show large and innumerable smooth pulmonary\n nodules.\n *Hemoptysis:concerning for airway source, Plan bronchoscopy\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Indwelling Port (PortaCath) - 06:09 AM\n 20 Gauge - 06:12 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": "Nursing",
"chartdate": "2173-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 323237,
"text": "This is a 71 yo male pt admitted through ED from OSH with bright red\n hemoptysis, known to have lung CA, s/p first cycle of chemotherapy. In\n ED, hemodynamically stable, V/S 98.9, 99 NSR, 127/55, Sat 99% on 2 L\n NC, chest CT done revealed no PE. Innumerable large metastatic foci,\n large mass in RLL occludes the RLL bronchus, with airspace opacity seen\n throughout RLL, concerning for post-obstructive PNA, small Rt pleural\n effusion, admitted to for further observation and management.\n Pneumonia, other\n Assessment:\n Alert, oriented x3, hemodynamically very stable, ambulated from\n stretcher to bed, c/o Rt rib cage pain only when coughing, spitting\n fresh blood hemoptysis, moderate amount, T 100 orally, edematous feet\n Rt more than left, with portocath that is not accessed. NO BP or\n injections in Rt arm due to surgery (lymph node biopsy) per pt.\n Action:\n Stable, pain tolerated, and only occurs when coughing, self-relieved\n Response:\n No complaints, pt is stable\n Plan:\n Monitor for s/s of PNA, send sputum for cx, f/u on cx, trat with\n antibiotics accordingly, no orders yet.\n"
},
{
"category": "Nursing",
"chartdate": "2173-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 323342,
"text": "This is a 71 yr male w/ hx metastatic melanoma w/ mets to lung. Pt\n presented to OSH w/ hemoptysis X 1 wk, and reports increasing frequency\n and amounts of hemoptysis, w increasing DOE despite being on abx since\n Wednesday. Pt reports previous CT showed 2 small lung nodules; however,\n CT w/ current event showed innumberable large metastatic focci w/ a\n large RLL mass. Pt was transferred to MICU for monitoring of\n respiratory and hemodynamic status; however, pt has remained clinically\n stable.\n Hemoptysis and PNA\n Assessment:\n Pt continues w/ frequent cough productively with small amounts of\n bright red bloody sputum. During the night shift, spiked fever to\n 100.3. Hct dropped from 30 at midnight to 26 with am labs (0500).\n Action:\n Monitoring respiratory and hemodynamic status closely. Following hct\n checking Q 8 hours. Adminisering guiefenisin w/ codeine, and\n benzonatate as ordered. Received Tylenol and started on Zosyn as\n ordered (received 2 doses so far), urine cx, sputum cx, and 2 sets of\n blood cx sent.\n Response:\n Pt remains free of s/s respiratory distress t/o shift. SpO2 remains\n above 95% on 2L via NC. Pt denies SOB t/o shift. Hct remains stable,\n about 30. Pt expectorated small amounts of bright red blood t/o shift,\n Temp decreased to 98.2 orally.\n Plan:\n Continue to monitor hemodynamic and respiratory status closely.\n Continue anti-tussives as ordered. Increase activity as tolerated, pt\n likes to sit on the chair most of the time. Follow up on cxs, continue\n antibiotics as ordered. Continue monitoring serial Hct and transfuse\n with PRBCs as ordered. If remains hemodynamically stable, consider\n calling him out to a regular floor.\n"
}
] |
74,793 | 181,257 | Admitted same day to surgery and underwent coronary artery bypass graft surgery. See operative report for further details. He recieved cefazolin for perioperative antibiotics. Post operatively he was transferred to the intensive care unit for post operative management. In the first twenty four hours he was weaned from sedation, awoke neurologically intact, and was extubated without complications. He continued to progress and on post operative day one was transferred to the floor for the remainder of his care. Physical therapy worked with him on strength and mobility. He continued to progress and was ready for discharge to home on post operative day 4. All follow up appointments were advised. | Endocrine: RISS, BG well conrolled. IMPRESSION: Right IJ catheter terminating in the mid SVC. 1^st degree AVB confirmed. 1^st degree AVB confirmed. 1^st degree AVB confirmed. Nausea this am, responded well to 1x zofran. Nausea this am, responded well to 1x zofran. Nausea this am, responded well to 1x zofran. ez intub, chest closure 15:46. or uneventful- rad aline dampened once off pump - placed fem aline. ez intub, chest closure 15:46. or uneventful- rad aline dampened once off pump - placed fem aline. Pneumococcal Vac Polyvalent 24. Pos top period- pt on neo transiently, co 2.2- dipped to 1.9- tx with volume. Pt warm, ct with min drainage even post turn. The aortic valve area calcluates to 1.95 cm2 bythe continuty equation, suggesting borderline mild aortic stenosis. Right internal jugular catheter is again demonstrated terminating in the lower superior vena cava. Hypotensive overnight on phenylephrine gtt, which was weaned to off. Clinical correlation is suggested.Since the previous tracing of right bundle-branch block is now present. Phenylephrine 23. IMPRESSION: AP chest compared to pre-operative study on : Increased caliber of the cardiomediastinal silhouette is essentially normal post-operative appearance. Chlorhexidine Gluconate 0.12% Oral Rinse 9. PATIENT/TEST INFORMATION:Indication: Intraop CABG evaluate wall motion, valves, aortic contoursHeight: (in) 69Weight (lb): 205BSA (m2): 2.09 m2BP (mm Hg): 116/58HR (bpm): 60Status: InpatientDate/Time: at 12:40Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2Dimages. to cvicu- intubated, swan, aline rad/fem- on propfol/neo- 2 a wires- 2 v wires, 2 med CT, 1 L Pl. to cvicu- intubated, swan, aline rad/fem- on propfol/neo- 2 a wires- 2 v wires, 2 med CT, 1 L Pl. Chest tubes dcd this am. Chest tubes dcd this am. Chest tubes dcd this am. Lg diuresis from morning lasix dose. Lg diuresis from morning lasix dose. Lg diuresis from morning lasix dose. Ranitidine 28. Milk of Magnesia 18. Coronary artery bypass graft (CABG) Assessment: Pt immed post op- CABG x 4- or uneventful. There is a minimally increased gradient consistent withminimal aortic valve stenosis. Pt assisted OOB. Pt assisted OOB. Pt assisted OOB. Docusate Sodium 11. Morphine Sulfate 19. Pt to cvicu intub, swan, aline did require an additional fem aline due to dampening- post pump- pt found to be in a slow ventricular rhythm- came out to CVICU AV paced. pt hr- post- ventricular- rate 40's no p evident- pt to cvicu av paced. pt hr- post- ventricular- rate 40's no p evident- pt to cvicu av paced. CVICU HPI: s/p CABG X4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA) PMHx: HTN, Glaucoma, remote ureter stone removed Current medications: 1. Sodium Chloride 0.9% Flush 29. Latest Vital Signs and I/O Non-invasive BP: S:105 D:57 Temperature: 97.1 Arterial BP: S:107 D:55 Respiratory rate: 17 insp/min Heart Rate: 89 bpm Heart rhythm: 1st AV (First degree AV Block) O2 delivery device: Nasal cannula O2 saturation: 95% % O2 flow: 4 L/min FiO2 set: 24h total in: 1,577 mL 24h total out: 1,835 mL Pacer Data Temporary pacemaker type: Epicardial Wires Temporary pacemaker mode: Ventricular Demand Temporary pacemaker rate: 35 bpm Temporary atrial sensitivity: No Temporary ventricular sensitivity: Yes Temporary ventricular sensitivity threshold: 1.5 mV Temporary ventricular sensitivity setting: 0.8 mV Temporary ventricular stimulation threshold : 12 mA Temporary ventricular stimulation setting : 20 mA Temporary pacemaker wire condition: Attached-Pacer Temporary pacemaker wires atrial: 2 Temporary pacemaker wires ventricular: 2 Pertinent Lab Results: Sodium: 141 mEq/L 02:14 AM Potassium: 3.8 mEq/L 08:52 AM Chloride: 111 mEq/L 02:14 AM CO2: 25 mEq/L 02:14 AM BUN: 18 mg/dL 02:14 AM Creatinine: 0.8 mg/dL 02:14 AM Glucose: 95 mg/dL 08:52 AM Hematocrit: 30.8 % 02:14 AM Finger Stick Glucose: 122 01:00 PM Additional pertinent labs: K+ was repleted this am Lines / Tubes / Drains: foley cath, 2a/2v epicardial wires, R IJ TLC change over wire , 22g piv Valuables / Signature Patient valuables: None Other valuables: none Clothes: in central locker Wallet / Money: No money / wallet Cash Amount: 0 Credit Cards: 0 Cash / Credit cards sent home with: 0 Jewelry: none Transferred from: cvicu 796 Transferred to: 6 Date & time of Transfer: 1700 Metoclopramide 17. Cardiovascular: Aspirin, Statins, HD stable. SINGLE FRONTAL CHEST RADIOGRAPH: A right IJ catheter terminates in the mid SVC in appropriate position. Propofol 26. Ranitidine 27. ivp lasix started this am. ivp lasix started this am. | 18 | [
{
"category": "Nursing",
"chartdate": "2136-03-21 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 526971,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n POD #1 from CABG x4. Conduction disorders post-op night requiring\n Epicardial wire pacing. Received patient in Junct tach this am. No\n gtts. Filling pressures wnl & CI greater than 2.\n Action:\n Pt was left in intrinsic rhythm as perfusion was adequate. As morning\n progressed P waves became visible in T waves. 12 lead ecg obtained this\n am. 1^st degree AVB confirmed. Beta blockers held today. Swan & aline\n dc\nd. ivp lasix started this am. Lytes checked & repleted. Clear\n liquids started. Pt assisted OOB. Chest tubes dc\nd this am. Post\n removal CXR reviewed by NP. Poor peripheral access. IV RN only able to\n place 22g. IJ Cortis changed over wire to TLC.\n Response:\n PR interval 0.29 this am, improved to 0.21 this afternoon. Lg diuresis\n from morning lasix dose. Nausea this am, responded well to 1x zofran.\n Plan:\n Transfer to 6. Continue to progress per pathway. Ambulation &\n Physical therapy consult needed. Advance diet.\n Last pain med 1 tab of percocet at 1430 for pain, follow up pain\n .\n"
},
{
"category": "Nursing",
"chartdate": "2136-03-21 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 526975,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n POD #1 from CABG x4. Conduction disorders post-op night requiring\n Epicardial wire pacing. Received patient in Junct tach this am. No\n gtts. Filling pressures wnl & CI greater than 2.\n Action:\n Pt was left in intrinsic rhythm as perfusion was adequate. As morning\n progressed P waves became visible in T waves. 12 lead ecg obtained this\n am. 1^st degree AVB confirmed. Beta blockers held today. Swan & aline\n dc\nd. ivp lasix started this am. Lytes checked & repleted. Clear\n liquids started. Pt assisted OOB. Chest tubes dc\nd this am. Post\n removal CXR reviewed by NP. Poor peripheral access. IV RN only able to\n place 22g. IJ Cortis changed over wire to TLC.\n Response:\n PR interval 0.29 this am, improved to 0.21 this afternoon. Lg diuresis\n from morning lasix dose. Nausea this am, responded well to 1x zofran.\n Plan:\n Transfer to 6. Continue to progress per pathway. Ambulation &\n Physical therapy consult needed. Advance diet.\n Last pain med 1 tab of percocet at 1430 for pain, follow up pain\n .\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 69 Inch\n Admission weight:\n 90 kg\n Daily weight:\n 98.4 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: CAD, Hypertension\n Additional history: glaucoma,\n ureter stone removal\n Surgery / Procedure and date: - CABG X 4-lima- lad, SVG-DIAG,\n OM and PDA, BPT-101, x-cl 87min. ez intub, chest closure 15:46. or\n uneventful- rad aline dampened once off pump - placed fem aline. pt hr-\n post- ventricular- rate 40's no p evident- pt to cvicu av paced. echo\n pre- and post 45-50% EF, cefazolin intra-op. to cvicu- intubated, swan,\n aline rad/fem- on propfol/neo- 2 a wires- 2 v wires, 2 med CT, 1 L Pl.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:114\n D:65\n Temperature:\n 97.1\n Arterial BP:\n S:107\n D:55\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n 1st AV (First degree AV Block)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 1,577 mL\n 24h total out:\n 1,820 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 02:14 AM\n Potassium:\n 3.8 mEq/L\n 08:52 AM\n Chloride:\n 111 mEq/L\n 02:14 AM\n CO2:\n 25 mEq/L\n 02:14 AM\n BUN:\n 18 mg/dL\n 02:14 AM\n Creatinine:\n 0.8 mg/dL\n 02:14 AM\n Glucose:\n 95 mg/dL\n 08:52 AM\n Hematocrit:\n 30.8 %\n 02:14 AM\n Finger Stick Glucose:\n 122\n 01:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n foley cath, 2a/2v epicardial wires to pacer box, 22g piv, TLC R IJ\n Valuables / Signature\n Patient valuables: None\n Other valuables: None\n Clothes: in lockers\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: none\n Transferred from: cvicu 796\n Transferred to: 609\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Respiratory ",
"chartdate": "2136-03-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 526752,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Pt received from or placed on vent as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2136-03-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 526920,
"text": "CVICU\n HPI:\n 76 yo M POD # 1 from CABG X4 (LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA),\n complicated by heart block which improved overnight with 1st-degree AV\n block today.\n Chief complaint:\n PMHx:\n PMH: HTN, Glaucoma, remote ureter stone removed\n :Toprol XL 25 mg daily (to be increased to 50 mg) Travoprost 0.004%\n 1 gtt OS q HS, ASA 81 mg daily\n Allergies:NKDA\n Current medications:\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:33 PM\n PA CATHETER - START 04:35 PM\n ARTERIAL LINE - START 04:35 PM\n CORDIS/INTRODUCER - START 04:35 PM\n ARTERIAL LINE - START 04:45 PM\n dampened!!\n EXTUBATION - At 07:45 PM\n INVASIVE VENTILATION - STOP 07:45 PM\n ARTERIAL LINE - STOP 09:31 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 08:30 AM\n Infusions:\n Other ICU medications:\n Insulin - Regular - 06:00 PM\n Morphine Sulfate - 01:02 AM\n Metoprolol - 03:30 AM\n Furosemide (Lasix) - 06:38 AM\n Other medications:\n Flowsheet Data as of 11:45 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: 94 (74 - 132) bpm\n BP: 118/58(77) {80/49(59) - 137/78(99)} mmHg\n RR: 25 (11 - 25) insp/min\n SPO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 69 Inch\n CVP: 5 (0 - 13) mmHg\n PAP: (27 mmHg) / (13 mmHg)\n CO/CI (Thermodilution): (5.88 L/min) / (2.9 L/min/m2)\n SVR: 952 dynes*sec/cm5\n SV: 62 mL\n SVI: 30 mL/m2\n Total In:\n 7,103 mL\n 1,548 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,503 mL\n 1,548 mL\n Blood products:\n 600 mL\n Total out:\n 1,690 mL\n 1,570 mL\n Urine:\n 770 mL\n 1,410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,413 mL\n -22 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 462 (462 - 5,056) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 7 cmH2O\n Plateau: 15 cmH2O\n Compliance: 60 cmH2O/mL\n SPO2: 95%\n ABG: 7.44/42/99./25/0\n Ve: 7.5 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: Diminshed), (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 (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 151 K/uL\n 10.7 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.8 %\n 11.7 K/uL\n [image002.jpg]\n 04:49 PM\n 04:52 PM\n 05:00 PM\n 06:00 PM\n 07:00 PM\n 07:41 PM\n 11:19 PM\n 11:30 PM\n 02:14 AM\n 08:52 AM\n WBC\n 11.7\n 11.7\n Hct\n 31.3\n 32.0\n 30.8\n Plt\n 152\n 151\n Creatinine\n 0.7\n 0.8\n TCO2\n 25\n 22\n 26\n Glucose\n 129\n 128\n 135\n 130\n 112\n 117\n 89\n 95\n Other labs: PT / PTT / INR:22.0/58.7/2.1, Fibrinogen:208 mg/dL, Lactic\n Acid:2.0 mmol/L\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 76 yo M POD # 1 from CABG X4\n (LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA), complicated by heart block which\n improved overnight with 1st-degree AV block today.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Pain well controlled\n with percocet and morphine PRN.\n Cardiovascular: Aspirin, Statins, HD stable. Started statin today. Hold\n off on b-blocker today. Monitor AV block, which seems to improve.\n Hypotensive overnight on phenylephrine gtt, which was weaned to off.\n Pulmonary: IS, OOB --> bed\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Regular diet, Advance diet as tolerated\n Renal: Foley, Adequate UO, Diurese 2 L today.\n Hematology: Serial Hct, Post-op anemia. Monitor for now. No need for\n PRBC transfusion.\n Endocrine: RISS, BG well conrolled. Insulin drip weaned to off. On RISS\n with adequate BG control. Goal < 150\n Infectious Disease: No evidence of infection. Periop cefazolin\n Lines / Tubes / Drains: Foley, Pacing wires, CT d/c'd this morning with\n no evidence of pneumothorax\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery, P.T.\n Billing Diagnosis: Arrhythmia, Post-op hypotension, Post-op\n complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 04:35 PM\n 18 Gauge - 04:35 PM\n Arterial Line - 04:45 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: Transfer to floor\n Total time spent: 20 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2136-03-21 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 526922,
"text": "CVICU\n HPI:\n s/p CABG X4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)\n PMHx:\n HTN, Glaucoma, remote ureter stone removed\n Current medications:\n 1. 2. 250 mL D5W 3. Acetaminophen 4. Aspirin EC 5. Aspirin 6. Calcium\n Gluconate 7. CefazoLIN\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9. Dextrose 50% 10.\n Docusate Sodium 11. Docusate Sodium (Liquid)\n 12. Furosemide 13. Glycopyrrolate 14. Insulin 15. Magnesium Sulfate 16.\n Metoclopramide 17. Milk of Magnesia\n 18. Morphine Sulfate 19. Neostigmine 20. Nitroglycerin 21.\n Oxycodone-Acetaminophen 22. Phenylephrine\n 23. Pneumococcal Vac Polyvalent 24. Potassium Chloride 25. Propofol 26.\n Ranitidine 27. Ranitidine\n 28. Sodium Chloride 0.9% Flush 29. Travoprost\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:33 PM\n PA CATHETER - START 04:35 PM\n ARTERIAL LINE - START 04:35 PM\n CORDIS/INTRODUCER - START 04:35 PM\n ARTERIAL LINE - START 04:45 PM\n dampened!!\n EXTUBATION - At 07:45 PM\n INVASIVE VENTILATION - STOP 07:45 PM\n ARTERIAL LINE - STOP 09:31 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 08:30 AM\n Other ICU medications:\n Insulin - Regular - 06:00 PM\n Morphine Sulfate - 01:02 AM\n Metoprolol - 03:30 AM\n Furosemide (Lasix) - 06:38 AM\n Flowsheet Data as of 11:46 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: 94 (74 - 132) bpm\n BP: 118/58(77) {80/49(59) - 137/78(99)} mmHg\n RR: 25 (11 - 25) insp/min\n SPO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 69 Inch\n CVP: 5 (0 - 13) mmHg\n PAP: (27 mmHg) / (13 mmHg)\n CO/CI (Thermodilution): (5.88 L/min) / (2.9 L/min/m2)\n SVR: 898 dynes*sec/cm5\n SV: 63 mL\n SVI: 30 mL/m2\n Total In:\n 7,103 mL\n 1,546 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,503 mL\n 1,546 mL\n Blood products:\n 600 mL\n Total out:\n 1,690 mL\n 1,570 mL\n Urine:\n 770 mL\n 1,410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,413 mL\n -24 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 462 (462 - 5,056) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 7 cmH2O\n Plateau: 15 cmH2O\n Compliance: 60 cmH2O/mL\n SPO2: 95%\n ABG: 7.44/42/99./25/0\n Ve: 7.5 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: left base), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 151 K/uL\n 10.7 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.8 %\n 11.7 K/uL\n [image002.jpg]\n 04:49 PM\n 04:52 PM\n 05:00 PM\n 06:00 PM\n 07:00 PM\n 07:41 PM\n 11:19 PM\n 11:30 PM\n 02:14 AM\n 08:52 AM\n WBC\n 11.7\n 11.7\n Hct\n 31.3\n 32.0\n 30.8\n Plt\n 152\n 151\n Creatinine\n 0.7\n 0.8\n TCO2\n 25\n 22\n 26\n Glucose\n 129\n 128\n 135\n 130\n 112\n 117\n 89\n 95\n Other labs: PT / PTT / INR:22.0/58.7/2.1, Fibrinogen:208 mg/dL, Lactic\n Acid:2.0 mmol/L\n Imaging: CXR : mod left effusion, improving\n Microbiology: NGTD\n ECG: 1st degree AVB\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: s/p CABG X4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)\n extubated awaiting transfer to the floor\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, on percocet\n Cardiovascular: Aspirin, 1st degree AV block, holding beta-blockade\n until AV node recovers. Started statin today.\n Pulmonary: IS, Discontinue chest tube(s), OOB to chair, ambulate\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Oliguria overnight which responded to lasix. Diurese\n with goal of .5 liters negative overnight.\n Hematology: stable post-operative anemia\n Endocrine: RISS, Lantus (R), On insulin gtt overnight transitioned to\n lantus and sliding scale with adequate glucose control. Glucose\n goal<150\n Infectious Disease: NGTD\n Lines / Tubes / Drains: 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, Lantus (R) protocol\n Lines:\n Cordis/Introducer - 04:35 PM\n 18 Gauge - 04:35 PM\n Arterial Line - 04:45 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: Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2136-03-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 526801,
"text": "76 yo male- presented with chest tightness assoc with SOB while\n shoveling-and c/o dyspnea while quickly walking- + ETT (ekg\n changes)-fixed septal and inferior wall defects, ant wall hypokinesis-\n EF-47%. Cath done - 3 vessel dx(100% LAD, LCX-50%, 100% RCA prox.-\n calculated EF 50% (mild left vent systolic dysfunction)\n - CABG X 4-lima- lad, SVG-, and PDA, EZI\n Coronary artery bypass graft (CABG)\n Assessment:\n Neuro: Intact, MAE with adequate strength, oriented with no confusion\n CV: 2A2V wires with, A sensed and V paced, no ventricular rhythm\n underlying with only P waves, BP soft with dampened arterial line,\n 80\ns-low 100\ns on Neo, palpable pedal pulses with generalized edema,\n 2CT to wall suction, no leak with serosanguineous drainage\n Resp: LSCTA, 4 liters NC, RR 14-18, no respiratory distress, weak non\n productive cough\n GI: +BS, no difficulty swallowing, +gag\n GU: Patent foley draining concentrated clear yellow urine\n Endo: On insulin gtt, non DM\n Pain: incisional pain\n Action:\n CV: Titrated Neo for appropriate BP, checked pacer, correlated cuff\n pressures\n Resp: Weaned O2 as tolerated, encouraged IS and CDB\n GU: 500cc LR bolus\ns given for low HUO\n Endo: BS every hour\n Pain: Morphine and percocet for pain\n Response:\n CV: VSS BP low 100\ns, pacer #####, cuff correlates, art line\n D/C\nd######\n Resp: Continues with weak non-productive cough\n Endo: Weaned from insulin gtt per protocol, off at 7am\n GU: HUO picked up, adequate\n Pain: Good pain relief with percocet and 2mg of morphine\n Plan:\n Continue to monitor and transfer to the floor today??\n"
},
{
"category": "Nursing",
"chartdate": "2136-03-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 526788,
"text": "76 yo male- presented with chest tightness assoc with SOB while\n shoveling-and c/o dyspnea while quickly walking- + ETT (ekg\n changes)-fixed septal and inferior wall defects, ant wall hypokinesis-\n EF-47%. Cath done - 3 vessel dx(100% LAD, LCX-50%, 100% RCA prox.-\n calculated EF 50% (mild left vent systolic dysfunction)\n - CABG X 4-lima- lad, SVG-, and PDA, EZI\n Coronary artery bypass graft (CABG)\n Assessment:\n Neuro: Intact, MAE with adequate strength, oriented with no confusion\n CV: 2A2V wires with, A sensed and V paced, no ventricular rhythm\n underlying with only P waves, BP soft with dampened arterial line,\n 80\ns-low 100\ns on Neo, palpable pedal pulses with generalized edema,\n 2CT to wall suction, no leak with serosanguineous drainage\n Resp: LSCTA, 4 liters NC, RR 14-18, no respiratory distress, weak non\n productive cough\n GI: +BS, no difficulty swallowing, +gag\n GU: Patent foley draining adequate amounts of clear yellow urine\n Endo: On insulin gtt, non DM\n Pain: incisional pain\n Action:\n CV: Titrated Neo for appropriate BP, checked pacer,\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2136-03-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 526782,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n Pt immed post op- CABG x 4- or uneventful. Pt to cvicu intub, swan,\n aline did require an additional fem aline due to dampening- post pump-\n pt found to be in a slow ventricular rhythm- came out to CVICU AV\n paced.\n Pos top period- pt on neo transiently, co 2.2- dipped to 1.9- tx with\n volume. Pt warm, ct with min drainage even post turn. CO adeq. u/o\n excellent. Glu up to 137- insulin drip started\n Action:\n Pt reversed, weaned from propofol.\n Response:\n ACTION\n Awake, mae, lifts head off bed-\n Pt extubated. Off all drips-except insulin\n Plan:\n NP 4L-provide pain relief as needed, encourage db&c. monitor VS as\n ordered and Ct drainage.\n Follow pathway\n"
},
{
"category": "Nursing",
"chartdate": "2136-03-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 526789,
"text": "76 yo male- presented with chest tightness assoc with SOB while\n shoveling-and c/o dyspnea while quickly walking- + ETT (ekg\n changes)-fixed septal and inferior wall defects, ant wall hypokinesis-\n EF-47%. Cath done - 3 vessel dx(100% LAD, LCX-50%, 100% RCA prox.-\n calculated EF 50% (mild left vent systolic dysfunction)\n - CABG X 4-lima- lad, SVG-, and PDA, EZI\n Coronary artery bypass graft (CABG)\n Assessment:\n Neuro: Intact, MAE with adequate strength, oriented with no confusion\n CV: 2A2V wires with, A sensed and V paced, no ventricular rhythm\n underlying with only P waves, BP soft with dampened arterial line,\n 80\ns-low 100\ns on Neo, palpable pedal pulses with generalized edema,\n 2CT to wall suction, no leak with serosanguineous drainage\n Resp: LSCTA, 4 liters NC, RR 14-18, no respiratory distress, weak non\n productive cough\n GI: +BS, no difficulty swallowing, +gag\n GU: Patent foley draining adequate amounts of clear yellow urine\n Endo: On insulin gtt, non DM\n Pain: incisional pain\n Action:\n CV: Titrated Neo for appropriate BP, checked pacer, correlated cuff\n pressures\n Resp: Weaned O2 as tolerated, encouraged IS and CDB\n Endo: BS every hour\n Pain: Morphine and percocet for pain\n Response:\n CV: VSS BP low 100\ns, pacer #####, cuff correlates, art line\n D/C\nd######\n Resp: Continues with weak non-productive cough\n Endo: Weaned from insulin gtt per protocol, off at 7am\n Pain: Good pain relief with percocet and 2mg of morphine\n Plan:\n Continue to monitor and transfer to the floor today??\n"
},
{
"category": "Nursing",
"chartdate": "2136-03-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 526820,
"text": "76 yo male- presented with chest tightness assoc with SOB while\n shoveling-and c/o dyspnea while quickly walking- + ETT (ekg\n changes)-fixed septal and inferior wall defects, ant wall hypokinesis-\n EF-47%. Cath done - 3 vessel dx(100% LAD, LCX-50%, 100% RCA prox.-\n calculated EF 50% (mild left vent systolic dysfunction)\n - CABG X 4-lima- lad, SVG-, and PDA, EZI\n Coronary artery bypass graft (CABG)\n Assessment:\n Neuro: Intact, MAE with adequate strength, oriented with no confusion\n CV: 2A2V wires with, A sensed and V paced, no ventricular rhythm\n underlying with only P waves, BP soft with dampened arterial line,\n 80\ns-low 100\ns on Neo, palpable pedal pulses with generalized edema,\n 2CT to wall suction, no leak with serosanguineous drainage\n Resp: LSCTA, 4 liters NC, RR 14-18, no respiratory distress, weak non\n productive cough\n GI: +BS, no difficulty swallowing, +gag\n GU: Patent foley draining concentrated clear yellow urine\n Endo: On insulin gtt, non DM\n Pain: incisional pain\n Action:\n CV: Titrated Neo for appropriate BP, checked pacer, correlated cuff\n pressures\n Resp: Weaned O2 as tolerated, encouraged IS and CDB\n GU: 500cc LR bolus\ns given for low HUO\n Endo: BS every hour\n Pain: Morphine and percocet for pain\n Response:\n CV: HR converted to ST/AF?? Rate of 140, SBP 130-140\ns, team made\n aware, 12 lead EKG obtained, 5mg IVP lopressor and 2grams of mag given,\n pacer remains on DDD, cuff correlates, art line D/C\nd######\n Resp: Continues with weak non-productive cough\n Endo: Weaned from insulin gtt per protocol, off at 7am\n GU: HUO picked up, adequate\n Pain: Good pain relief with percocet and 2mg of morphine\n Plan:\n Continue to monitor and transfer to the floor today??\n"
},
{
"category": "Nursing",
"chartdate": "2136-03-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 526824,
"text": "76 yo male- presented with chest tightness assoc with SOB while\n shoveling-and c/o dyspnea while quickly walking- + ETT (ekg\n changes)-fixed septal and inferior wall defects, ant wall hypokinesis-\n EF-47%. Cath done - 3 vessel dx(100% LAD, LCX-50%, 100% RCA prox.-\n calculated EF 50% (mild left vent systolic dysfunction)\n - CABG X 4-lima- lad, SVG-, and PDA, EZI\n Coronary artery bypass graft (CABG)\n Assessment:\n Neuro: Intact, MAE with adequate strength, oriented with no confusion\n CV: 2A2V wires with, A sensed and V paced, no ventricular rhythm\n underlying with only P waves, BP soft with dampened arterial line,\n 80\ns-low 100\ns on Neo, palpable pedal pulses with generalized edema,\n 2CT to wall suction, no leak with serosanguineous drainage\n Resp: LSCTA, 4 liters NC, RR 14-18, no respiratory distress, weak non\n productive cough\n GI: +BS, no difficulty swallowing, +gag\n GU: Patent foley draining concentrated clear yellow urine\n Endo: On insulin gtt, non DM\n Pain: incisional pain\n Action:\n CV: Titrated Neo for appropriate BP, checked pacer, correlated cuff\n pressures\n Resp: Weaned O2 as tolerated, encouraged IS and CDB\n GU: 500cc LR bolus\ns given for low HUO\n Endo: BS every hour\n Pain: Morphine and percocet for pain\n Response:\n CV: HR converted to ST/AF?? Rate of 140, SBP 130-140\ns, team made\n aware, 12 lead EKG obtained, 5mg IVP lopressor and 2grams of mag given,\n pacer remains on DDD, cuff correlates\n Resp: Continues with weak non-productive cough\n Endo: Weaned from insulin gtt per protocol, off at 7am\n GU: HUO picked up, adequate\n Pain: Good pain relief with percocet and 2mg of morphine\n Plan:\n Continue to monitor and transfer to the floor today??\n"
},
{
"category": "Nursing",
"chartdate": "2136-03-21 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 526986,
"text": "Coronary artery bypass graft (CABG)\n Assessment:\n POD #1 from CABG x4. Conduction disorders post-op night requiring\n Epicardial wire pacing. Received patient in Junct tach this am. No\n gtts. Filling pressures wnl & CI greater than 2.\n Action:\n Pt was left in intrinsic rhythm as perfusion was adequate. As morning\n progressed P waves became visible in T waves. 12 lead ecg obtained this\n am. 1^st degree AVB confirmed. Beta blockers held today. Swan & aline\n dc\nd. ivp lasix started this am. Lytes checked & repleted. Clear\n liquids started. Pt assisted OOB. Chest tubes dc\nd this am. Post\n removal CXR reviewed by NP. Poor peripheral access. IV RN only able to\n place 22g. IJ Cortis changed over wire to TLC.\n Response:\n PR interval 0.29 this am, improved to 0.21 this afternoon. Lg diuresis\n from morning lasix dose. Nausea this am, responded well to 1x zofran.\n Plan:\n Transfer to 6. Continue to progress per pathway. Ambulation &\n Physical therapy consult needed. Advance diet.\n Last pain med 1 tab of percocet at 1430 for pain, follow up pain\n .\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 69 Inch\n Admission weight:\n 90 kg\n Daily weight:\n 98.4 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: CAD, Hypertension\n Additional history: glaucoma,\n ureter stone removal\n Surgery / Procedure and date: - CABG X 4-lima- lad, SVG-DIAG,\n OM and PDA, BPT-101, x-cl 87min. ez intub, chest closure 15:46. or\n uneventful- rad aline dampened once off pump - placed fem aline. pt hr-\n post- ventricular- rate 40's no p evident- pt to cvicu av paced. echo\n pre- and post 45-50% EF, cefazolin intra-op. to cvicu- intubated, swan,\n aline rad/fem- on propfol/neo- 2 a wires- 2 v wires, 2 med CT, 1 L Pl.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:105\n D:57\n Temperature:\n 97.1\n Arterial BP:\n S:107\n D:55\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n 1st AV (First degree AV Block)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 1,577 mL\n 24h total out:\n 1,835 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Ventricular Demand\n Temporary pacemaker rate:\n 35 bpm\n Temporary atrial sensitivity:\n No\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 1.5 mV\n Temporary ventricular sensitivity setting:\n 0.8 mV\n Temporary ventricular stimulation threshold :\n 12 mA\n Temporary ventricular stimulation setting :\n 20 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 141 mEq/L\n 02:14 AM\n Potassium:\n 3.8 mEq/L\n 08:52 AM\n Chloride:\n 111 mEq/L\n 02:14 AM\n CO2:\n 25 mEq/L\n 02:14 AM\n BUN:\n 18 mg/dL\n 02:14 AM\n Creatinine:\n 0.8 mg/dL\n 02:14 AM\n Glucose:\n 95 mg/dL\n 08:52 AM\n Hematocrit:\n 30.8 %\n 02:14 AM\n Finger Stick Glucose:\n 122\n 01:00 PM\n Additional pertinent labs:\n K+ was repleted this am\n Lines / Tubes / Drains:\n foley cath, 2a/2v epicardial wires, R IJ TLC change over wire , 22g\n piv \n Valuables / Signature\n Patient valuables: None\n Other valuables: none\n Clothes: in central locker\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: none\n Transferred from: cvicu 796\n Transferred to: 6\n Date & time of Transfer: 1700\n"
},
{
"category": "Echo",
"chartdate": "2136-03-20 00:00:00.000",
"description": "Report",
"row_id": 90475,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraop CABG evaluate wall motion, valves, aortic contours\nHeight: (in) 69\nWeight (lb): 205\nBSA (m2): 2.09 m2\nBP (mm Hg): 116/58\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 12:40\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness. Mild regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - hypo; basal inferior - hypo; septal apex -\ndyskinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. Mildly\ndilated descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Minimal AS.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications.\n\nConclusions:\nPre Bypass: Left ventricular wall thicknesses are normal. There is mild\nregional left ventricular systolic dysfunction with Basal inferior, mid\nanterior and anteroseptal and apical septal dyskinesis. Right ventricular\nchamber size and free wall motion are normal. The aortic root is mildly\ndilated at the sinus level. The ascending aorta is mildly dilated. The\ndescending thoracic aorta is mildly dilated. The aortic valve leaflets (3) are\nmildly thickened. There is a minimally increased gradient consistent with\nminimal aortic valve stenosis. The aortic valve area calcluates to 1.95 cm2 by\nthe continuty equation, suggesting borderline mild aortic stenosis. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno pericardial effusion.\n\nPost Bypass: Patient is AV paced. Preseved biventricular function. Septum\nappears dyskentic, c/w pacing. Wall motion is otherwise unchanged. Aortic\ncontours intact. Remaing exam is unchanged. All findings discussed with\nsurgeons at the time of the exam.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2136-03-21 00:00:00.000",
"description": "Report",
"row_id": 229190,
"text": "Sinus rhythm with A-V conduction delay. Consider left atrial abnormality.\nRight bundle-branch block. Prior inferior myocardial infarction of\nindeterminate age but may be old. Clinical correlation is suggested.\nSince the previous tracing of right bundle-branch block is now present.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-03-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1126470,
"text": " 3:45 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf, eff\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST DATED \n\n COMPARISON: .\n\n INDICATION: Status post coronary artery bypass surgery.\n\n FINDINGS: Cardiomediastinal contours are stable in the postoperative period.\n Improving atelectasis is present at both lung bases as well as small pleural\n effusions. Right internal jugular catheter is again demonstrated terminating\n in the lower superior vena cava.\n\n IMPRESSION: Improving bibasilar atelectasis. Small bilateral pleural\n effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-03-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1126011,
"text": " 10:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CT d/c\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with s/p AVR\n REASON FOR THIS EXAMINATION:\n s/p CT d/c\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:38 A.M. ON \n\n HISTORY: Status post AVR.\n\n IMPRESSION: AP chest compared to :\n\n No pneumothorax. Small left pleural effusion probably unchanged since removal\n of the left pleural tube. Bibasilar atelectasis, severe on the left, moderate\n on the right, is essentially unchanged. There is no pulmonary edema.\n Postoperative cardiomediastinal silhouette is stable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-03-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1126072,
"text": " 3:55 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p line change left IJ TLC\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n s/p line change left IJ TLC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old man status post CABG, status post line change to left\n IJ.\n\n COMPARISON: Chest radiograph from at 10:00 in the morning.\n\n SINGLE FRONTAL CHEST RADIOGRAPH:\n\n A right IJ catheter terminates in the mid SVC in appropriate position. No\n pneumothorax is present. The lungs have low lung volumes with minimal\n bibasilar atelectasis, improved from before. The cardiac silhouette is mildly\n enlarged. The mediastinal silhouette and hilar contours are normal. There is\n a small left pleural effusion.\n\n IMPRESSION:\n\n Right IJ catheter terminating in the mid SVC. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-03-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1125920,
"text": " 4:56 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact NP # if abnormal-will be i\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p cabg x4\n REASON FOR THIS EXAMINATION:\n postop film-contact NP # if abnormal-will be in CVICU approx 4:45\n PM -please call first\n ______________________________________________________________________________\n WET READ: SBNa TUE 7:34 PM\n Status post CABG with mediastinal drains, pacing leads, swan ganz catheter and\n left chest tube. Left lower lobe opacity likely atelectasis and effusion. ETT\n 6 cm above carina.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST , 5:07 P.M\n\n HISTORY: Status post CABG.\n\n IMPRESSION: AP chest compared to pre-operative study on :\n\n Increased caliber of the cardiomediastinal silhouette is essentially normal\n post-operative appearance. Left lower lobe collapse and subsegmental\n atelectasis in the left upper and right lower lung zones are more extensive\n than commonly seen, and there is at least a small left pleural effusion\n despite the left pleural drain. No pneumothorax. ET tube at the thoracic\n inlet, Swan-Ganz catheter in the right pulmonary artery, and midline drains\n are in standard placements, nasogastric tube should be advanced at least 6 cm\n to move all the side ports into the stomach.\n\n\n"
}
] |
90,165 | 144,543 | 47M with asthma, obstructive sleep apnea, chronic low back pain, recent rib fracure, who presented with subacute history of malaise and exertional dyspnea found to have hyperglycemia, and constellation of findings consistent with multiple myeloma. . # Hypercalcemia: The calcium of 17.7 (ionized 2.13) on admission was thought to be due to an underlying malignant process. He was vigourously hydrated with intravenous fluids and given lasix to maintain a urine output of over 200cc/hr. He was given pamidronate, steroids, and calcitonin in the ICU. His calcium level dropped with this regimen and at time of discharge from the ICU was low-normal. Vitamin D levels were low, PTH low, TSH WNL. He was transferred to the BMT floor and his serum Ca remained in a low to low-normal range. . # Multiple Myeloma/ Plasma cell leukemia: Patient with M-protein in both urine & serum identified as IgG kappa as well as end-organ damage manifested as ARF and anemia, diffuse lytic lesions on CT and hypercalcemia suggested a diagnosis multiple myeloma. Bone marrow biopsy results were positive for myeloma. He was started on Dexamethasone therapy in the ICU on . Patient had a normal serum viscosity and was without signs or symptoms of hyperviscosity syndrome, but a beta-2 microglobulin was 6.8. EBV/CMV/Toxo negative. Patient was treated with Dexamethasone 40 mg IV qd x 4d and then started on Velcade. Skeletal survey was not significant for lucencies, although these were appreciated on his CT chest. He ultimately completed 8 days of Velcade, but peripheral blood demonstrated an increasing number of plasma cells (peak 38% plasma cells). Subsequently, his therapy was switched to a modified hyper-CVAD regimen with Cytoxan/Doxorubicin and Dexamethasone. The patient tolerated cycle 1 of this therapy well and responded appropriately with complete clearing of plasma cells from peripheral blood. Tumor lysis labs were monitored during treatment, and whiel LDH and Uric acid where transiently elevated, the patient never required Rasburicase treatment. Neupogen was initiated 24 hours after completion of chemotherapy at a lower dose of 300 mcg due to profound splenomegaly in this patient. The patient remained afebrile while neutropenic. Oxycontin with Oxycodone PRN for breakthrough pain was initiated prior to discharge. The patient was started on Acyclover, Atovaquone for prophylaxis. At the time of discharge, neutropenia has resolved and neupogen was discontinued. The patient will follow up with Dr. for subsequent treatment of his PCL. . # Lower extremity pain: Prior to discharge, the patient developed lower extremity / hip pain. MRI of thorasic and lumbar spine as well as left hip was performed and revealed significant disk disease and hyperdensity at femoral neck region which could represent an area more suscpetible to pathological fracture. However, there was no clear evidence of cortical interruption or pathologic fractures. In order to evealuate further for pathologic fracture, ORTHO CT of the pevis without contrast was performed and did not reveal any pathologic fractures, however revealed areas of possible cortical interruption in right iliac region and femoral neck, which may be susceptible to pathologic fracture. The patient was informed to abstain from signficant physical activity at this time. . # Dyspnea/Respiratory Distress: Early in the course of his hospitalization, the patient developed an increasing O2 requirement in the setting of known asthma, aggressive fluid therapy, and a new right middle lobe pneumonia with pulmonary edema on CXR and CT chest. For the pneumonia he was initially treated with ceftriaxone and azithromycin, but upon worsening of his respiratory status was empirically switched to cefepime and levofloxacin, ultimately completing a total of 14 days of antibiotics. In the setting of an elevated BNP, aggressive fluid hydration, and signs of overload on CXR, he underwent a repeated echocardiograms that demonstrated acute worsening of the patient's pulmonary artery hypertension with a peak pressure of 60mm Hg. Pulmonology and Cardiology were consulted and felt that his distress was owed to his right-sided heart failure. He received aggressive diuresis with Lasix balanced with his need for IVF's during chemotherapy and his respiratory status improved on this regimen. He was also continued on supplemental O2 with NC/face tent until his oxygen was weaned entirely and he was able to maintain his oxygen saturation on room air. The patient was no longer able to tolerate outpatient CPAP at home settings, so autoset CPAP was employed which resulted in significant improvement in patient's ability to tolerate CPAP therapy. The patient's outpatient CPAP machine was adjusted appropriately at the time of discharge. The patient will follow up with cardiology or pulmonology upon discharge. . # Hyperuricemia: Likely due to rate of cellular proliferation in conjunction with ARF. He was started on allopurinol. He received Rasburicase on . His uric acid levels downtrended following administration of rasburicase and aggressive hydration to WNL, at which time allopurinol was d/ced. His uric acid level normalized, but Allopurinol was restarted during his Cytoxan/Doxorubicin therapy. As there was no evidence of TLS and LDH / Uric Acid trended down, Allopurinol was discontinued prior to discharge. . # ARF: Elevated Cr on admission (baseline Cr 0.6-0.8) that continued to rise initially during hospitalization. This was thought consistent with a tumor lysis/myeloma kidney from multiple myeloma, as evidenced by his hypercalcemia / hyperuricemia. Renal was consulted. He was given rasburicase and aggressive hydration. His urine output remained excellent throughout hospitalization and his Cr following hydration began to downtrend. Given his quantification of Bence- proteins on UPEP and successful improvement, the renal service did not feel that plasmapheresis was indicated. His Cr eventually gradually decreased to a baseline of ~1.0. . # Anemia/Thrombocytopenia: Patient with a low reticulocyte count, elevated haptoglobin & ferritin. As his bone marrow biopsy demonstrated significant marrow infiltration, it was felt likely that this was due to ineffective production rather than destruction. No evidence of TTP or intravascular hemolysis. The patient's hematocrit and platelet counts were monitored and he was transfused as needed throughout admission. The patient had multiple episode of epistaxis during his ICU stay with negligible blood loss that was corrected with Afrin, platelet transfusion, and switching his nasal cannula to humidified O2 via face tent. These values remained stable prior to discharge and the patient had no further episodes of epistaxis. . # Asthma: We continued Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN . | Abnormal septal motion/position consistent with RVpressure/volume overload.AORTA: Normal aortic diameter at the sinus level. Abnormal septalmotion/position.AORTA: Normal aortic diameter at the sinus level. The right ventricularcavity is mildly dilated with borderline normal free wall function. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Frequent ventricular premature beats.Conclusions:The left atrium is moderately dilated. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor apical views.Conclusions:The left atrium is mildly dilated. FINDINGS: Diffuse, patchy irregular infiltrative medullary low T1 signal with associated high T2 signal within the sacrum, pelvis, and femora bilaterally. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is elongated. Borderline normal RV systolicfunction.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Normalregional LV systolic function. No MS. Normal LV inflow pattern for age.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal ascending aortadiameter. Shortness of breath.Height: (in) 72Weight (lb): 260BSA (m2): 2.38 m2BP (mm Hg): 143/57HR (bpm): 98Status: InpatientDate/Time: at 16:16Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. TITLE: Chief Complaint: 24 Hour Events: - spontaneously stabilized on 3L NC - continued to have good UOP (~200 cc/hr) with IVF + lasix - uric acid downtrending s/p rasburicase; trending tumor lysis labs q6h - per BMT, probable plan for Velcade tmrw Allergies: Iodine; Iodine Containing Anaphylaxis; Last dose of Antibiotics: Azithromycin - 11:30 AM Ceftriaxone - 12:00 PM Levofloxacin - 10:00 PM Cefipime - 12:00 AM Infusions: Other ICU medications: Furosemide (Lasix) - 12:00 AM Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 06:59 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since AM Tmax: 36.9C (98.4 Tcurrent: 36.9C (98.4 HR: 76 (76 - 95) bpm BP: 150/76(91) {120/53(71) - 150/76(91)} mmHg RR: 21 (21 - 30) insp/min SpO2: 98% Heart rhythm: SR (Sinus Rhythm) Height: 62 Inch Total In: 2,271 mL 1,100 mL PO: 500 mL TF: IVF: 1,771 mL 1,100 mL Blood products: Total out: 4,110 mL 2,640 mL Urine: 4,110 mL 2,640 mL NG: Stool: Drains: Balance: -1,839 mL -1,540 mL Respiratory support O2 Delivery Device: CPAP mask SpO2: 98% ABG: 7.47/44/209/31/8 Physical Examination GEN: NAD CV: RRR, no murmurs, rubs, gallops PULM: Mild expiratory wheezes throughout with crackles at the bases bilaterally and increased work of breathing ABD: soft, obese, NT/ND, normoactive bowel sounds EXT: warm, well-perfused, 2+ dorsalis pedis pulsations Labs / Radiology 43 K/uL 7.7 g/dL 163 mg/dL 3.5 mg/dL 31 mEq/L 3.6 mEq/L 127 mg/dL 96 mEq/L 140 mEq/L 22.5 % 11.5 K/uL [image002.jpg] 02:29 PM 03:47 AM 05:02 AM 10:42 AM 05:07 PM 10:37 PM 04:55 AM 07:51 PM 10:03 PM 05:25 AM WBC 7.4 10.7 11.5 Hct 24.5 23.4 22.5 Plt 77 59 43 Cr 2.6 3.1 3.4 3.4 3.4 3.6 3.6 3.5 TropT 0.01 TCO2 34 33 Glucose 121 123 169 149 163 Other labs: PT / PTT / INR:14.4/22.8/1.2, CK / CKMB / Troponin-T:104/2/0.01, ALT / AST:95/102, Alk Phos / T Bili:68/0.4, Fibrinogen:641 mg/dL, Lactic Acid:0.8 mmol/L, LDH:2590 IU/L, Ca++:9.9 mg/dL, Mg++:2.2 mg/dL, PO4:6.6 mg/dL CT TORSO: 1. - require HD for calcium, uric acid, possible tumor lysis - Moderate UEos, etiology unclear. - require HD for calcium, uric acid, possible tumor lysis - Moderate UEos, etiology unclear. - require HD for calcium, uric acid, possible tumor lysis - Moderate UEos, etiology unclear. - require HD for calcium, uric acid, possible tumor lysis - Moderate UEos, etiology unclear. - Likely marrow failure - Type and screen up to date, cross match one unit as will likely need blood after IVFs given - Transfuse for H/H < - Guaiac stools. - Likely marrow failure - Type and screen up to date, cross match one unit as will likely need blood after IVFs given - Transfuse for H/H < - Guaiac stools. - Likely marrow failure - Type and screen up to date, cross match one unit as will likely need blood after IVFs given - Transfuse for H/H < - Guaiac stools. Receiving IVF's & Foley in place. CXR doneshows fluid overload.lasix 40mg iv given with good response intermittent nasal CPAP and nasal canula 4L Nebs/ PRN as needed Patient desats to low 80s, on and off CPAP and nasal canula Received total of 120mg lasix and maintance fluid d/ced Response: Appears to be uncomfortable and very tired, RR in high 30s, patient desats to low 80s, SOB, blood gas 7.44/49/72/7, changed to BIPAP mask with improvement in O2 sats Plan: Continue to monitor resp status and continue fluid bolus 300mls/hr for hypercalcemia and monitor CXR and lasix iv accordingly Ineffective Coping Assessment: HCT 26.6 this Am, bone marrow biopsy done yesterday evening, and preliminary report showed a diagnosis of aplastic multiple myeloma. Renal failure, acute (Acute renal failure, ARF) Assessment: BUN/Cr trending upwards, UOP >100cc/hr Action: Response: Plan: Anemia/thrombocytopenia Assessment: AM labs revealing decreased HCT and platelets (pts baseline HCT40s). Renal failure, acute (Acute renal failure, ARF) Assessment: BUN/Cr trending upwards Action: Response: Plan: Anemia, other Assessment: AM labs revealing decreased HCT and platelets (pts baseline HCT40s). # Access: peripherals # Communication: Patient # Code: FULL # Disposition: BMT floor for now INEFFECTIVE COPING HYPERCALCEMIA (HIGH CALCIUM) RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) .H/O ASTHMA ANEMIA, OTHER ICU Care Nutrition: Glycemic Control: Lines: Prophylaxis: DVT: Boots Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: ------ Protected Section ------ MICU ATTENDING ADDENDUM I saw and examined the patient, and was physically present with the ICU team for the key portions of the services provided. - Likely marrow failure - Type and screen up to date, cross match one unit as will likely need blood after IVFs given - Transfuse for H/H < - Guaiac stools. FINAL REPORT CHEST RADIOGRAPH INDICATION: Hypoxia, evaluation for interval changes. - Likely marrow failure - Type and screen up to date, cross match one unit as will likely need blood after IVFs given - Transfuse for H/H < - Guaiac stools. - Likely marrow failure - Type and screen up to date, cross match one unit as will likely need blood after IVFs given - Transfuse for H/H < - Guaiac stools. # Access: peripherals # Communication: Patient # Code: FULL # Disposition: BMT floor for now INEFFECTIVE COPING HYPERCALCEMIA (HIGH CALCIUM) RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) .H/O ASTHMA ANEMIA, OTHER ICU Care Nutrition: Glycemic Control: Lines: Prophylaxis: DVT: Boots Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: | 120 | [
{
"category": "Radiology",
"chartdate": "2136-05-10 00:00:00.000",
"description": "L MR THIGH W&W/O CONTRAST LEFT",
"row_id": 1133621,
"text": " 3:56 PM\n MR THIGH W&W/O CONTRAST LEFT Clip # \n Reason: Please assess for cause of pain\n Admitting Diagnosis: DYSPNEA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with 47 year old man with multiple myeloma / plasma cell\n leukemia s/p chemo now with left hip / thigh pain\n REASON FOR THIS EXAMINATION:\n Please assess for cause of pain\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI THIGHS.\n\n CLINICAL INDICATION: 47-year-old man with multiple myeloma/plasma cell\n leukemia, status post chemotherapy. Now with left hip/thigh pain. Please\n assess for cause of pain.\n\n COMPARISON EXAM: None.\n\n TECHNIQUE: Multiplanar and multisequence MR images were acquired through the\n thighs on a 1.5 Tesla magnet including pre- and post-gadolinium sequences.\n\n FINDINGS:\n\n Diffuse, patchy irregular infiltrative medullary low T1 signal with associated\n high T2 signal within the sacrum, pelvis, and femora bilaterally. There is\n infiltration throughout the acetabulum. There is confluent abnormal signal in\n the left femoral neck (sequence 5, image 8), which to be a region susceptible\n to a pathological fracture. Normal signal extends along the entire left\n femoral diaphysis, with relative decrease of the left distal diaphysis. No\n definite cortical penetration or fracture is evident. No evidence of hip\n effusion. The contralateral femur demonstrates a similar pattern of marrow\n infiltration. Visualized portions of the sacroiliac joints are unremarkable.\n No abnormal intramuscular signal or enhancement. No tendinous injury is seen.\n\n No significant lymphadenopathy. Visualized gastrointestinal tract, urinary\n bladder, seminal vesicles, and prostate are unremarkable. Testicles show no\n gross abnormalities.\n\n IMPRESSION:\n\n Diffuse, marrow infiltration in the pelvis and femurs, consistent with known\n multiple myeloma. While no definite fracture is evident, there is confluent\n abnormal signal in the femoral necks bilaterally, which would be susceptible\n to a pathologic fracture.\n\n (Over)\n\n 3:56 PM\n MR THIGH W&W/O CONTRAST LEFT Clip # \n Reason: Please assess for cause of pain\n Admitting Diagnosis: DYSPNEA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-05-06 00:00:00.000",
"description": "P SKELETAL SURVEY (INCLUD LONG BONES) PORT",
"row_id": 1133022,
"text": " 2:34 PM\n SKELETAL SURVEY (INCLUD LONG BONES) PORT Clip # \n Reason: Please evaluate for lytic lesions\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with plasma cell leukemia\n REASON FOR THIS EXAMINATION:\n Please evaluate for lytic lesions\n ______________________________________________________________________________\n FINAL REPORT\n SKELETAL SURVEY\n\n HISTORY: Plasma cell leukemia, evaluate for lytic lesions.\n\n Images of the skull, spine, pelvis, humeri and femurs were submitted.\n\n Comparison is made with the previous study of . Interval development\n of an ill-defined zone of lucency in the occipital region of the skull in the\n single lateral view of the calvarium which is submitted. In addition, there\n are now multiple small focal areas of decreased density in the vertebral\n bodies. No other osteolytic or osteoblastic lesion is identified. Degenerative\n changes are again demonstrated in the spine.\n\n IMPRESSION: Evidence of osteolytic lesion in the calvarium and probable\n additional small osteolytic lesions in the spine. These might be better\n evaluated by CT.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-05-10 00:00:00.000",
"description": "MR L SPINE W/O CONTRAST",
"row_id": 1133610,
"text": " 3:00 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: Please assess for cause of symptoms\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with multiple myeloma / plasma cell leukemia s/p chemo now with\n left hip / lower extremity pain and parasthesias\n REASON FOR THIS EXAMINATION:\n Please assess for cause of symptoms\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:39 PM\n PFI: MRI of the lumbar spine.\n\n Diffuse bone marrow infiltration is identified at all the vertebral bodies\n including the sacrum and disc degenerative changes are demonstrated consistent\n with posterior disc bulge at L3/L4, causing left side neural foraminal\n narrowing and apparently impinging the exiting nerve root and the left dorsal\n root ganglion. There is also right paracentral disc bulge at L4/L5, causing\n right side neural foraminal narrowing, additionally there is spinal canal\n stenosis at L3/L4, L4/L5 and L5/S1 with shortening of the pedicles and\n articular joint facet hypertrophy. There is no evidence of bone marrow\n expansion or mass effect in the conus medullaris. These findings were\n communicated to Dr. on at 1720 hours.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: MRI of the lumbar spine.\n\n CLINICAL INDICATION: 47-year-old man with multiple myeloma-plasma cell\n leukemia, status post chemotherapy, now with left hip and lower extremity pain\n and also paraesthesias.\n\n COMPARISON: No prior examinations of the lumbar spine are available at the\n time of this interpretation.\n\n TECHNIQUE: Sagittal T1- and T2-weighted sequences were obtained, axial T2-\n weighted images were also performed.\n\n FINDINGS: The signal intensity in the bone marrow is heterogeneous on T2,\n likely consistent with diffuse bone marrow infiltration for multiple myeloma.\n The conus medullaris appears at the level of T12 and is unremarkable with no\n evidence of compression. At T12/L1 and L1/L2 levels, there is no evidence of\n neural foraminal narrowing or central spinal canal stenosis.\n\n At L2/L3 level, demonstrates disc desiccation, mild posterior diffuse disc\n bulge, causing mild bilateral neural foraminal narrowing with no frank\n evidence of nerve root compression.\n\n At L3/L4, there is disc desiccation, left paracentral disc protrusion, causing\n narrowing of the left neural foramen and possibly contacting the exiting nerve\n root and also the left dorsal root ganglion (4:6).\n\n (Over)\n\n 3:00 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: Please assess for cause of symptoms\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n At L4/L5 level, there is disc desiccation, posterior diffuse disc bulge, right\n greater than left, causing right side neural foraminal narrowing and\n apparently impinging the exiting nerve root and also the right dorsal root\n ganglia, additionally there is moderate-to-severe bilateral articular joint\n facet hypertrophy and ligamentum flavum thickening resulting in moderate-to-\n severe spinal canal stenosis (3:12 and 3:9, 4:13).\n\n At L5/S1 level, there is disc desiccation, mild posterior diffuse disc bulge,\n causing mild bilateral neural foraminal narrowing, right greater than left and\n possibly contacting the right S1 nerve root (4:10). The sacrum demonstrates\n diffuse bone marrow infiltration. The visualized aspect of the\n retroperitoneum and vascular structures are unremarkable.\n\n IMPRESSION:\n\n 1. Heterogeneous signal intensity in the bone marrow, likely consistent with\n neoplastic infiltration from multiple myeloma.\n\n 2. Multilevel disc degenerative changes throughout the lumbar spine as\n described in detail above, more significant at L3/L4 and L4/L5 level, causing\n left side neural foraminal narrowing at L3/L4 and right-sided neural foraminal\n narrowing at L4/L5.\n\n 3. Disc desiccation and posterior diffuse disc bulge is also noted at L5/S1,\n apparently contacting the S1 nerve root on the right.\n\n These findings were communicated to Dr. on at\n 17:20 hours.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-05-10 00:00:00.000",
"description": "MR L SPINE W/O CONTRAST",
"row_id": 1133611,
"text": ", E. OMED 7F 3:00 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: Please assess for cause of symptoms\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with multiple myeloma / plasma cell leukemia s/p chemo now with\n left hip / lower extremity pain and parasthesias\n REASON FOR THIS EXAMINATION:\n Please assess for cause of symptoms\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: MRI of the lumbar spine.\n\n Diffuse bone marrow infiltration is identified at all the vertebral bodies\n including the sacrum and disc degenerative changes are demonstrated consistent\n with posterior disc bulge at L3/L4, causing left side neural foraminal\n narrowing and apparently impinging the exiting nerve root and the left dorsal\n root ganglion. There is also right paracentral disc bulge at L4/L5, causing\n right side neural foraminal narrowing, additionally there is spinal canal\n stenosis at L3/L4, L4/L5 and L5/S1 with shortening of the pedicles and\n articular joint facet hypertrophy. There is no evidence of bone marrow\n expansion or mass effect in the conus medullaris. These findings were\n communicated to Dr. on at 1720 hours.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1131141,
"text": " 2:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval infiltrate, effusion\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man w/ multiple myeloma w/ respiratory distress, cough, ronchi on L\n REASON FOR THIS EXAMINATION:\n eval infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Multiple myeloma with respiratory distress.\n\n Comparison is made with prior study .\n\n Mild-to-moderate cardiomegaly is stable. Moderate pulmonary edema is\n unchanged. Persistent denser opacities in the lower lobes bilaterally, right\n greater than left are unchanged, on the right could correspond to pneumonia.\n There is no pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130942,
"text": " 9:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with multiple myeloma with asthma, pulmonary edema, RML PNA\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:29 A.M. \n\n HISTORY: 47-year-old man with multiple myeloma, asthma and pulmonary edema.\n Question pneumonia.\n\n IMPRESSION:\n AP chest compared to :\n\n Generalized pulmonary edema has improved. Greater opacification in the right\n lower lung is consistent with pneumonia, unchanged. Moderate cardiomegaly and\n mediastinal vascular engorgement stable. No pneumothorax or large pleural\n effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-25 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1131314,
"text": " 7:50 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: PULMONARY HYPERTENSION ASSESS FOR DVT\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with pulmonary edema, worsening pulmonary artery hypertension\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 47-year-old man with pulmonary edema, worsening\n pulmonary arterial hypertension. Rule out DVT.\n\n FINDINGS: scale, color Doppler images of the right and left lower\n extremity demonstrate normal compressibility and augmentation of the right and\n left common femoral vein, superficial femoral vein, and popliteal vein\n bilaterally. Incidentally, pulse Doppler images demonstrate triphasic\n waveforms in both lower extremities consistent with increased pressures in the\n right heart.\n\n IMPRESSION: No evidence of DVT. Venous waveforms consistent with right-sided\n heart increased pressures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-05-12 00:00:00.000",
"description": "CT PELVIS ORTHO W/O C",
"row_id": 1133901,
"text": " 10:45 AM\n CT PELVIS ORTHO W/O C Clip # \n Reason: Please assess for pathological fractures\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with multiple myeloma / plasma cell leukemia with left leg pain\n with increased signal in femoral necks b/l on MRI thigh\n REASON FOR THIS EXAMINATION:\n Please assess for pathological fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc SAT 11:37 AM\n Multiple cystic changes within the marrow throughout the pelvic, compatible\n with hx of MM, with no evidence of pathologic fracture.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Multiple myeloma, plasma cell leukemia, left leg pain, increased\n signal on femoral necks on MRI, question path fracture.\n\n TECHNIQUE: Contiguous helical images were obtained from the iliac crest\n through the proximal femur reconstructed using both bone and soft tissue\n algorithm. Coronal and sagittal reformats were also generated.\n\n CT PELVIS, WITHOUT CONTRAST:\n\n There are innumerable lytic lesions throughout all the visualized bones. The\n pelvic girdle is congruent, without SI joint or pubic symphysis diastasis. In\n the pelvis, there are areas where there is focally marked thinning or\n effacement of the cortex, e.g. along the right iliac bone deep surface (series\n 2, image 33). There are also areas of fissure like interruption of the\n cortex.\n\n The hip joints are congruent, without gross effusion. No evidence of\n avascular necrosis. Within the proximal femurs, there is osteoporosis of the\n cortex and small fissure-like lucencies in the cortex. Within the right\n femoral neck (series 2, image 75), there is a focal lytic lesion measuring 4.5\n x 9.1 mm, where there is marked effacement of the cortex.\n\n Limited assessment of pelvic and pelvic girdle soft tissues shows scattered\n vascular calcification, small bilateral fatty inguinal hernias, and scattered\n nonenlarged inguinal lymph nodes. No abnormal soft tissue masses are\n detected.\n\n IMPRESSION:\n\n 1) Innumerable lytic areas throughout the bones of the pelvic girdle and, to a\n lesser extent, in the proximal femurs.\n\n 2) Two specific areas where the lesion thins and interrupts the overlying\n cortex -- one in the right iliac bone and one in the right proximal femoral\n neck posteriorly. Although no conventional fracture is identified, both areas\n are associated with areas of complete cortical interruption. Given the degree\n (Over)\n\n 10:45 AM\n CT PELVIS ORTHO W/O C Clip # \n Reason: Please assess for pathological fractures\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of osteoporosis and absence of overlying cortex, these areas are likely at\n increased risk for pathologic fracture, particularly in the right femoral neck\n lesion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1131767,
"text": " 6:15 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please read for 54cm right basilic PICC.Thanks! #95\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with MM, req. chemo/abx\n REASON FOR THIS EXAMINATION:\n Please read for 54cm right basilic PICC.Thanks! #\n ______________________________________________________________________________\n WET READ: MBue FRI 6:52 PM\n RT PICC TERMINATES MID SVC. NO PTX. NO ADDITIONAL SIG CHANGE. LEFT CPA\n ELIMINATED FROM VIEW.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: Newly placed PICC line over the right upper extremity. The course\n of the line is unremarkable. The tip of the line projects over the mid SVC.\n There is no evidence of complication, notably no pneumothorax. Otherwise, the\n radiograph is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-26 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1131541,
"text": " 1:08 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ? hepatosplenomegaly, varices, size of pulmonary artery comp\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with multiple myeloma, worsening right heart failure\n REASON FOR THIS EXAMINATION:\n ? hepatosplenomegaly, varices, size of pulmonary artery compared to prior\n CONTRAINDICATIONS for IV CONTRAST:\n myeloma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Man with multiple myeloma, worsening right heart failure.\n\n COMPARISON: CT of the torso of .\n\n TECHNIQUE: MDCT images were acquired through the torso without contrast.\n Multiplanar reformations were obtained and reviewed.\n\n CT OF THE CHEST WITHOUT CONTRAST:\n\n The thyroid gland is unremarkable. There is no axillary or mediastinal\n lymphadenopathy present. The heart size is mildly enlarged. The pulmonary\n arteries are normal in size. The airways are patent down to the subsegmental\n level. No pericardial effusions are present. No pleural effusions are\n present either. Both lung shows diffuse perihilar ground-glass opacity\n consistent with pulmonary edema. Two nodules in the right lower lobe and left\n lower lobe (6:49) likely represent rounded atelectasis.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST:\n\n The patient has hepatosplenomegaly but no varices are noted. No worrisome\n lesions are noted, in this non-contrast CT, in the liver or spleen. Both\n adrenals, left kidney, pancreas, and gallbladder are unremarkable. There is a\n nonobstructing stone in the right kidney measuring 6 mm. No evidence of\n hydronephrosis or other complications are noted.\n\n The small and large bowel is unremarkable. There is no abdominal free fluid\n or free air present. There is no abdominal, retroperitoneal or mesenteric\n lymphadenopathy present.\n\n CT OF THE PELVIS WITHOUT CONTRAST:\n\n There are two fat-filled inguinal hernias. There is a Foley catheter within\n the bladder. The prostate, bladder, rectum, and sigmoid colon are\n unremarkable. There is a small amount of pelvic free fluid of uncertain\n significance. No pelvic or inguinal lymphadenopathy is noted.\n\n OSSEOUS STRUCTURES:\n\n The osseous structures show diffuse lytic lesions consistent with multiple\n (Over)\n\n 1:08 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ? hepatosplenomegaly, varices, size of pulmonary artery comp\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n myeloma metastases.\n\n IMPRESSION:\n\n 1. Diffuse multiple myeloma metastases.\n\n 2. Pulmonary edema.\n\n 3. Hepatosplenomegaly without varices.\n\n 4. Normal size of pulmonary artery.\n\n 5. 6 mm non-obstructing renal stone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-26 00:00:00.000",
"description": "CT NECK W/O CONTRAST (EG: PAROTIDS)",
"row_id": 1131542,
"text": " 1:08 PM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: ?mass/plasmacytoma in neck\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with multiple myeloma, worsening right heart failure, and 2\n weeks of weak voice/hoarseness\n REASON FOR THIS EXAMINATION:\n ?mass/plasmacytoma in neck\n CONTRAINDICATIONS for IV CONTRAST:\n myeloma\n ______________________________________________________________________________\n WET READ: 3:37 PM\n Numerous tiny lytic lesions consistent w/ known multiple myeloma. No evidence\n of neck soft tissue mass within limits of non-contrast exam.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male with multiple myeloma and two-week of hoarse voice.\n Evaluate for plasmacytoma in neck.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT helical acquisition was performed through the neck without IV\n contrast. Multiplanar reformations were provided.\n\n CT NECK WITHOUT IV CONTRAST: Extensive osseous findings of multiple myeloma\n are seen, with innumerable tiny punched out lytic lesions seen throughout the\n cervical spine as well as the skull base, the vast majority tiny in size, with\n a few slightly larger foci only measuring up to 6 mm (2:12 in the left\n sphenoid).\n\n No soft tissue mass is seen in the neck to explain hoarse voice. The study is\n somewhat limited due to lack of intravenous contrast. There is no\n prevertebral soft tissue swelling or thickening. The visualized paranasal\n sinuses appear unremarkable except for minimal left maxillary sinus mucosal\n thickening (2:22). There is partial pneumatization of the optic strut on the\n right. There is no cervical lymphadenopathy. The mastoid air cells and\n middle ear cavities appear clear. The cervical spine demonstrates normal\n alignment. However, a disc osteophyte complex is seen at the C5-C6 level\n causing canal narrowing and putting mass effect on the cord (6:29).\n\n The lung apices again demonstrate interstitial septal thickening better\n evaluated on CT torso , possibly related to infection and/or known\n heart failure.\n\n IMPRESSION:\n\n 1. Numerous osseous findings of multiple myeloma include innumerable tiny\n lytic lesions throughout the cervical spine, which gives the bones a somewhat\n mottled appearance.\n\n 2. No evidence of focal plasmacytoma or other soft tissue mass within the\n (Over)\n\n 1:08 PM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: ?mass/plasmacytoma in neck\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n limits of non-contrast examination.\n\n 3. Disc osteophyte complex at the C5-C6 level causes canal narrowing/mass\n effect on the cord.\n\n Results relayed to Dr. 6p .\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130254,
"text": " 7:17 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: infiltrate, edema\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with acute hypoxia\n REASON FOR THIS EXAMINATION:\n infiltrate, edema\n ______________________________________________________________________________\n WET READ: JKSd WED 2:42 AM\n likely worsening pulmonary edema given short interval change. increasing\n opacity at right lung base/middle lobe, worsening edema and/or pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n CXR SINGLE FILM\n\n HISTORY: Acute hypoxemia, edema.\n\n FINDINGS: Heart is enlarged. There is CHF with interstitial and alveolar\n edema. No pleural effusions are seen. No significant change from the film\n done at 02:54 hours the same day.\n\n CONCLUSION: Cardiomegaly with CHF/pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-25 00:00:00.000",
"description": "LUNG SCAN",
"row_id": 1131340,
"text": "LUNG SCAN Clip # \n Reason: 47 YR OLD MAN WITH INCREASING PULMONARY ARTERY HYPERTENSION HEART FAILURE ? NEW PE\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 7.3 mCi Tc-m MAA ();\n 41.9 mCi Tc-99m DTPA Aerosol ();\n HISTORY: Increasing pulmonary arterial hypertension. Heart failure. ? New\n PE.\n\n INTERPRETATION:\n\n Ventilation images obtained with Tc-m aerosol in 8 views demonstrate normal\n ventilation, with minimal clumping in the central airways.\n\n Perfusion images in the same 8 views show normal perfusion.\n\n Chest x-ray from shows moderate pulmonary edema.\n\n SPECT-CT was also performed for improved anatomic correlation. CT images\n demonstrate cardiomegaly, and diffuse ground glass opacity throughout the lungs,\n most consistent with pulmonary edema as seen on radiographs. There is a small\n right pleural effusion and trace left pleural effusion.\n\n Limited noncontrast views of the upper abdominal organs demonstrate apparent\n hepatosplenomegaly, with probable left upper quadrant varices, less likely\n multiple small lymph nodes.\n\n IMPRESSION:\n\n 1. Normal lung perfusion. 2. Moderate pulmonary edema. Cardiomegaly. 3.\n Hepatosplenomegaly, with possible left upper quadrant varices.\n\n Findings discussed via telephone with Dr. at 16:56 on .\n\n\n\n , M.D.\n , M.D. Approved: 3:59 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": "2136-04-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130110,
"text": " 2:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with hypercalcemia, respiratory distress\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypercalcemia and respiratory distress.\n\n FINDINGS: In comparison with study of , there is continued mild\n enlargement of the cardiac silhouette with engorgement of pulmonary vessels\n consistent with increased pulmonary venous pressure. More focal opacification\n is seen at the right base with silhouetting of the right heart border, this is\n suspicious for a right middle lobe pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1129920,
"text": " 9:24 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for fluid overload\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with hypercalcemia receiving large amounts of IVF, now with\n worsening SOB and increased oxygen requirement.\n REASON FOR THIS EXAMINATION:\n eval for fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible fluid overload.\n\n FINDINGS: In comparison with the earlier study of this date, there are again\n areas of increased opacification at the bases, worrisome for aspiration. Mild\n indistinctness of pulmonary vessels could reflect some overhydration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1129815,
"text": " 10:26 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with increased sob and doe and dyspnea at rest\n REASON FOR THIS EXAMINATION:\n r/o infection\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male with increased shortness of breath and dyspnea.\n\n COMPARISON: Chest radiograph .\n\n TWO VIEWS OF THE CHEST: The heart size is upper limits of normal. There is\n no focal consolidation, but interstitial prominence with possible nodular\n component may be indicative of atypical infection. There is no pleural\n effusion or pneumothorax. The bony thorax appears unremarkable.\n\n IMPRESSION: Reticular interstitial prominence with somewhat nodular pattern\n overall suggest atypical or viral infection.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2136-04-24 00:00:00.000",
"description": "Report",
"row_id": 95306,
"text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath. S/P Flash Pulmonary Edema\nHeight: (in) 71\nWeight (lb): 248\nBSA (m2): 2.31 m2\nBP (mm Hg): 104/56\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 16:57\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Increased IVC diameter\n(>2.1cm) with <35% decrease during respiration (estimated RA pressure\n(10-20mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Hyperdynamic\nLVEF >75%. No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. Borderline normal RV\nsystolic function. Abnormal septal motion/position consistent with RV\npressure/volume overload.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. No MS. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Moderate [2+] TR. Severe PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Frequent ventricular premature beats.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThe estimated right atrial pressure is 10-20mmHg. Left ventricular wall\nthicknesses are normal. The left ventricular cavity size is normal. Left\nventricular systolic function is hyperdynamic (EF 80%). The right ventricular\nfree wall is hypertrophied. The right ventricular cavity is dilated with\nborderline normal free wall function. There is abnormal septal motion/position\nconsistent with right ventricular pressure/volume overload. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. There is no mitral valve prolapse. The\ntricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid\nregurgitation is seen. There is severe pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , the pulmonary artery pressure is significantly more elevated (now\nseverely so), and the right ventricle is now dilated with boderline\ncontractile function.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Report",
"row_id": 95307,
"text": "PATIENT/TEST INFORMATION:\nIndication: Murmur. Shortness of breath.\nHeight: (in) 72\nWeight (lb): 260\nBSA (m2): 2.38 m2\nBP (mm Hg): 143/57\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 16:16\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Increased IVC diameter\n(>2.1cm) with <35% decrease during respiration (estimated RA pressure\n(10-20mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Hyperdynamic LVEF\n>75%. Mid-cavitary gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Abnormal septal\nmotion/position.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No valvular AS. The\nincreased transaortic velocity is related to high cardiac output. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. The\nestimated right atrial pressure is 10-20mmHg. Left ventricular wall\nthicknesses and cavity size are normal. Left ventricular systolic function is\nhyperdynamic (EF>75%). A mid-cavitary and outflow tract gradient is identified\nwithout dynamic resting LVOT obstruction (high output state). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. There is abnormal septal motion/position. The aortic valve\nleaflets (3) are mildly thickened. 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.\nTrivial mitral regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: High output stae. Moderate pulmonary hypertension.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2136-05-04 00:00:00.000",
"description": "Report",
"row_id": 95227,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chemotherapy. Right ventricular function. Left ventricular function.\nHeight: (in) 72\nWeight (lb): 237\nBSA (m2): 2.29 m2\nBP (mm Hg): 118/70\nHR (bpm): 60\nStatus: Outpatient\nDate/Time: at 09:38\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: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with <35%\ndecrease during respiration (estimated RA pressure indeterminate).\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic\nfunction.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrial pressure is indeterminate.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\nmildly dilated. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%). The right ventricular\ncavity is mildly dilated with borderline normal free wall function. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. There is no mitral valve prolapse. There is\nmild pulmonary artery systolic hypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the right\nventricular cavity size is smaller, free wall motion is improved, and the\nestimated pulmonary artery systolic pressure is lower.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2136-04-23 00:00:00.000",
"description": "Report",
"row_id": 254776,
"text": "Sinus rhythm. Modest right ventricular conduction delay may be incomplete\nright bundle-branch block. The QTc interval appears borderline prolonged.\nFindings are non-specific. Since the previous tracing of probably no\nsignificant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Report",
"row_id": 254777,
"text": "Sinus rhythm. Incomplete right bundle-branch block. Low T wave amplitude\nis non-specific. Since the previous tracing of sinus tachycardia is\nabsent, ST-T wave abnormalities have decreased and the QTc interval may be\nlonger.\n\n"
},
{
"category": "ECG",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Report",
"row_id": 254986,
"text": "Sinus rhythm with borderline sinus tachycardia. Right bundle-branch block.\nDiffuse primary ST-T wave changes with QTc interval which appears short but it\nis difficult to assess in the presence of the right bundle-branch block.\nClinical correlation is suggested. Since the previous tracing of the same date\nprobably no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Report",
"row_id": 254987,
"text": "Sinus rhythm. The Q-T interval is short. Incomplete right bundle-branch block.\nNon-specific ST-T wave changes. Compared to the previous tracing the\nQRS duration is shorter and the Q-T interval is shorter.\n\n"
},
{
"category": "ECG",
"chartdate": "2136-04-14 00:00:00.000",
"description": "Report",
"row_id": 254988,
"text": "Sinus rhythm. Right bundle-branch block. Non-specific T wave changes.\nCompared to the previous tracing of there is no significant change.\n\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736786,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to have progressive anemia from 44 to 25 and in\n acute renal failure with creatinine 2.2, elevated LFT's, and Ca+ 17.7.\n He was originally admitted to 3 but during fluid resuscitation\n became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward. Pt with recent rib fractures\n related to increased calcium levels. Skeletal survey films of skull,\n long bones and spine showed no obvious lucent lesions and innumerable\n small lytic foci which are consistent with myeloma; also Degenerative\n changes in the spine and Aortic calcification.\n Action:\n completed his calcitonin SC injection, continues on NS @ 150cc/hr and\n PRN IV lasix; tumor lysis labs q6hrs\n Response:\n Calcium trending down. Good U/O. K, MG stable.\n Plan:\n Monitor for signs and symptoms of hypercalcemia / arrhythmias.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr remains elevated but trending down; urine output > 200cc/hr;\n clear, yellow urine via foley; Renal following, renal failure likely\n related to hypercalcemia induced vasoconstriction to renal\n vasculature.\n Action:\n Continues on NS 150cc/hr , no need for IV lasix this shift. Taking po\n fluids/ water.\n Response:\n Cont to diurese well, > 200ml/hour u/o, renal function improving\n Plan:\n Continue lytes check with tumor lysis labs, monitor I/O\n Anemia/thrombocytopenia\n Assessment:\n 2130 Hct 23.1, plts 57. Bone marrow biopsy done . CT done \n consistent of myeloma. ECHO from showing EF >55%; petechia on\n hands and feet steady; BMT following for chemotherapy; received 1 unit\n PRBC and 1 pack of platelets yesterday.\n Action:\n Recheck hct, plt this am. Afrin x 3 days (for nosebleed ), IV\n steroids continues ( last dose today); received chemo valcade,\n next dose 4/17.\n Response:\n no episode of nosebleed noted; Hct 21.1 this am, MD notified. Plts 50.\n Plan:\n transfuse to keep hct >23 and platelet >10 if no s/s of bleeding; next\n chemo on sat (72 hrs after last was given) will add cytoxan as\n second if patient remains to be stable\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on 4L NC while awake, placed on CPAP overnight for sleep apnea\n uses his own machine from home; desats to 84-85% off O2. Tachypneic.\n Lung sounds clear, diminished at bases; occasional non-productive\n cough. Patient anxious, worried during night.\n Action:\n Patient on cpap at MN. Sat 98% with 10L bleed in. Zyprexa for sleep.\n Patient taking ice chips for mouth dryness\n Response:\n O2 sats 95-98% on CPAP. Patient slept 3-4 hours during night.\n Plan:\n Wean O2 as tolerated,\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 736816,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - HIT...negative\n - Renal: if continues to improve, will forego plasmapheresis\n - BMT --> one more night in ICU. Likely call-out in AM\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.6\nC (97.8\n HR: 73 (70 - 81) bpm\n BP: 122/52(67) {108/52(66) - 138/78(86)} mmHg\n RR: 24 (16 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 5,716 mL\n 2,051 mL\n PO:\n 1,560 mL\n 720 mL\n TF:\n IVF:\n 4,156 mL\n 1,331 mL\n Blood products:\n Total out:\n 7,690 mL\n 1,810 mL\n Urine:\n 7,690 mL\n 1,810 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,974 mL\n 241 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 50 K/uL\n 7.4 g/dL\n 159 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 122 mg/dL\n 105 mEq/L\n 141 mEq/L\n 21.1 %\n 8.3 K/uL\n [image002.jpg]\n 10:03 PM\n 05:25 AM\n 09:36 AM\n 03:07 PM\n 10:00 PM\n 04:10 AM\n 09:52 AM\n 03:20 PM\n 09:45 PM\n 05:41 AM\n WBC\n 11.5\n 12.7\n 9.7\n 8.3\n Hct\n 22.5\n 24.5\n 23.7\n 23.1\n 21.1\n Plt\n 43\n 66\n 62\n 55\n 57\n 50\n Cr\n 3.6\n 3.5\n 3.5\n 3.4\n 3.3\n 3.1\n 3.0\n 2.7\n 2.5\n TropT\n 0.01\n Glucose\n 149\n 163\n 166\n 147\n 155\n 174\n 150\n 159\n Other labs: PT / PTT / INR:17.0/23.1/1.5, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:67/88, Alk Phos / T Bili:54/0.3,\n Differential-Neuts:33.0 %, Band:1.0 %, Lymph:51.0 %, Mono:5.0 %,\n Eos:0.0 %, D-dimer:150 ng/mL, Fibrinogen:440 mg/dL, Lactic Acid:0.8\n mmol/L, LDH:2214 IU/L, Ca++:7.1 mg/dL, Mg++:2.3 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 47 yo M with asthma, OSA, chronic low back pain, recent rib fracure,\n who presented with malaise & DOE found to have bony lesions on CT and a\n constellation of hematologic/electrolyte findings consistent with\n multiple myeloma.\n .\n # Dyspnea/Respiratory Distress: Likely pulm edema +/- RML\n pneumonia. Patient also with hyperdynamic heart on TTE (EF 75%),\n elevated BNP to 4232, moderate pulmonary artery hypertension.\n - IVFs + lasix PRN to titrate to UOP 200-300cc/hr\n - Levofloxacin & Cefepime, renally dosed, day \n - O2 to maintain sats >92% using NC\n - CPAP at night at 11cm H2O\n .\n # Multiple Myeloma: Patient with M-protein in both urine & serum\n identified as IgG kappa as well as end-organ dammage manifested as ARF\n and anemia, diffuse lytic lesions on CT and hypercalcemia suggests a\n diagnosis multiple myeloma. Bone marrow biopsy results are positive for\n myeloma, but patient has commenced Dexamethasone therapy as of .\n Normal serum viscosity and patient without signs or symptoms of\n hyperviscosity syndrome, but beta-2 microglobulin was 6.8. EBV/CMV/Toxo\n negative.\n - K/L light chain ratio pending\n - completed 4 day course of dexamethasone\n - Continue IVF's at 150cc NS/hr, titrate to UOP of 200-300cc/hr\n - Oncology following, will guide treatment\n .\n # Hypercalcemia: Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n - Goal urine output 200-300cc/hr\n - Vitamin D levels low\n .\n # Hyperuricemia: Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase .\n - d/ced allopurinol\n - Brisk UOP as above\n - Avoid HCO3 as it will precipitate calcium & phosphate\n - Repeat tumor lysis labs q6h (rasburicase precautions; uric acid level\n must be measured in green top on ice and spun on a cooled centrifuge)\n .\n # Acute renal insufficiency: Cr 3.1, stable/downtrending from\n yesterday. Renal following. Renal failure is likely tubular injury from\n cast nephropathy in conjunction with hypercalcemia, hyperuricemia.\n - f/u renal recs\n - Continuous IVF's/Lasix to preempt further tubular injury\n .\n # Anemia/Thrombocytopenia: Low reticulocyte count, elevated haptoglobin\n & ferritin demonstrating insufficient erythropoeisis. Likely secondary\n to massive marrow infilitration from multiple myeloma. No evidence of\n TTP, ITP, or intravascular hemolysis.\n - Maintain active T&S\n - Transfuse for HCT < 23\n - obtain transfusion goals for platelets from BMT service\n - Guaiac stools\n .\n # Epistaxis: now resolved\n - humidified O2 when possible\n - transfuse platelets prn\n .\n # Asthma: Continue Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, regular\n .\n # Prophylaxis:\n -DVT ppx with pneumoboots/CPAP\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n .\n # Access: peripherals\n # Communication: Patient\n # Code: FULL\n # Disposition: to BMT floor today if respiratory status remains stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 736933,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Subjective:\n Patient reports appetite is fair & declines supplements at this time.\n Reports weight is 250lbs/113.6kg, height as 5\n11.5\n with no weight\n loss. Reports no food allergies\nallergic to iodine in medication only.\n Objectives:\n Diagnosis: Dyspnea\n WT: 113.2kg\n HT: 71.5 inches\n Diet: Regular\n PMH:\n - Asthma - using inhaler more frequently, but with no good effect\n - Costrochondritis recently diagnosed\n - Lower back pain w/ L3-L4 lateral disc protrusion\n - Obesity\n - Nephrolithiasis\n - H/O atypical chest pain\n - Rectal bleeding\n - Hyperlipidemia\n - Sleep apnea, OSA 11cm H20\n - S/P rib fractures x2\n - Depression\n Asssessment/Plan:\n 47 yo male w/ asthma, OSA, chronic low back pain, recent rib fracture\n now with multiple myeloma confirmed by bone marrow biopsy with plan to\n initiate chemo. Will continue to monitor po intake & provide\n supplements PRN. Monitor labs & hydration. Will follow.\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 736159,
"text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Experienced epistaxis last PM, eventually controlled with pressure on\n nares.\n Less dyspneic.\n Mental status clearer.\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Azithromycin - 11:30 AM\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:03 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 (97.2\n HR: 80 (73 - 95) bpm\n BP: 128/65(78) {120/53(72) - 150/76(91)} mmHg\n RR: 20 (20 - 30) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 2,271 mL\n 1,630 mL\n PO:\n 500 mL\n TF:\n IVF:\n 1,771 mL\n 1,630 mL\n Blood products:\n Total out:\n 4,110 mL\n 3,340 mL\n Urine:\n 4,110 mL\n 3,340 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,839 mL\n -1,710 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Face tent\n SpO2: 92%\n ABG: 7.47/44/209/31/8\n PaO2 / FiO2: 261\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube, Dryed blood in nares\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, Rash: petichae on hands/palms, feet/soles, No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.7 g/dL\n 43 K/uL\n 163 mg/dL\n 3.5 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 127 mg/dL\n 96 mEq/L\n 140 mEq/L\n 22.5 %\n 11.5 K/uL\n [image002.jpg]\n 02:29 PM\n 03:47 AM\n 05:02 AM\n 10:42 AM\n 05:07 PM\n 10:37 PM\n 04:55 AM\n 07:51 PM\n 10:03 PM\n 05:25 AM\n WBC\n 7.4\n 10.7\n 11.5\n Hct\n 24.5\n 23.4\n 22.5\n Plt\n 77\n 59\n 43\n Cr\n 2.6\n 3.1\n 3.4\n 3.4\n 3.4\n 3.6\n 3.6\n 3.5\n TropT\n 0.01\n TCO2\n 34\n 33\n Glucose\n 121\n 123\n 169\n 149\n 163\n Other labs: PT / PTT / INR:14.4/22.8/1.2, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:95/102, Alk Phos / T Bili:68/0.4,\n Differential-Neuts:33.0 %, Band:1.0 %, Lymph:51.0 %, Mono:5.0 %,\n Eos:0.0 %, Fibrinogen:641 mg/dL, Lactic Acid:0.8 mmol/L, LDH:2590 IU/L,\n Ca++:9.9 mg/dL, Mg++:2.2 mg/dL, PO4:6.6 mg/dL\n Assessment and Plan\n 47 yom asthma, OSA, chronic low back pain, recent rib fracure now with\n multiple myeloma.\n RESPIRATORY DISTRESS -- CXR and CT consistent with pulmonary edema,\n suspect related to volume resusitation. Underlying asthma, OSA,\n moderate pulmonary HTN. Continue net diuresis. Provide oxygen,\n maintain SaO2 >90%.\n PNEUMONIA -- continue Levofloxacin & Cefepime, renally dosed, day 1 for\n CAP\n ASTHMA -- Continue Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN\n OSA -- CPAP at night at 11cm H20\n MULTIPLE MYELOMA -- Dx confirmed by bone marrow biopsy. Awaiting\n initiating chemotherapy. Continue dexamethasome.\n ALTERED MENTAL STATUS -- improved. Monitor.\n FLUIDS -- Continue IVF's at 150cc NS/hr, titrate to UOP of\n 200-300cc/hr. Use lasix as needed.\n EPISTAXIS -- chronic history, escalation in context of\n thrombocytopenia. If persists or escalated, consider ENT evaluation\n and packing\n THROMBOCYTOPENIA -- related to myeloma. Monitor. WOuld transfuse if\n active bleeding.\n HYPERCALCEMIA -- Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n HYPERURICEMIA -- Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase this PM. Continue\n Allopurinol 100mg daily\n ACUTE RENAL FAILURE -- Cr 3.7 and continuing to rise. Renal following.\n Renal failure is likely tubular injury from cast nephropathy in\n conjunction with hypercalcemia, hyperuricemia.\n ANEMIA -- Low reticulocyte count, elevated haptoglobin & ferritin.\n demonstrating insufficient erythropoeisis. No evidence of TTP or\n intravascular hemolysis. Transfuse for HCT <25. Guaiac stools\n FLUIDS -- IVF as above, replete electrolytes.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-19 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 736668,
"text": "Chief Complaint: Respiratory distress\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 Tolerating net diuresis.\n States overall to feel \"much better\"\n Remains thirsty, requesting water.\n Received PRBC 1 unit.\n Received plts.\n No further nosebleeds.\n Started chemotherapy last PM.\n History obtained from Medical records\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, 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, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:20 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 70 (68 - 85) bpm\n BP: 118/57(70) {109/48(65) - 133/84(89)} mmHg\n RR: 22 (19 - 33) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 6,032 mL\n 2,063 mL\n PO:\n 1,560 mL\n 360 mL\n TF:\n IVF:\n 3,922 mL\n 1,703 mL\n Blood products:\n 550 mL\n Total out:\n 7,340 mL\n 3,610 mL\n Urine:\n 7,340 mL\n 3,610 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,308 mL\n -1,547 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 91%\n ABG: ///26/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice, petichae on palms soles\n resolving\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.9 g/dL\n 55 K/uL\n 174 mg/dL\n 3.1 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 136 mg/dL\n 100 mEq/L\n 141 mEq/L\n 23.7 %\n 9.7 K/uL\n [image002.jpg]\n 10:37 PM\n 04:55 AM\n 07:51 PM\n 10:03 PM\n 05:25 AM\n 09:36 AM\n 03:07 PM\n 10:00 PM\n 04:10 AM\n 09:52 AM\n WBC\n 10.7\n 11.5\n 12.7\n 9.7\n Hct\n 23.4\n 22.5\n 24.5\n 23.7\n Plt\n 59\n 43\n 66\n 62\n 55\n Cr\n 3.4\n 3.6\n 3.6\n 3.5\n 3.5\n 3.4\n 3.3\n 3.1\n TropT\n 0.01\n TCO2\n 33\n Glucose\n 169\n 149\n 163\n 166\n 147\n 155\n 174\n Other labs: PT / PTT / INR:17.1/25.2/1.5, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:67/88, Alk Phos / T Bili:54/0.3,\n Differential-Neuts:33.0 %, Band:1.0 %, Lymph:51.0 %, Mono:5.0 %,\n Eos:0.0 %, D-dimer:150 ng/mL, Fibrinogen:440 mg/dL, Lactic Acid:0.8\n mmol/L, LDH:2214 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:6.4 mg/dL\n Assessment and Plan\n 47 yom asthma, OSA, chronic low back pain, recent rib fracure now with\n multiple myeloma.\n RESPIRATORY DISTRESS -- CXR and CT consistent with pulmonary edema,\n suspect related to volume resusitation. Underlying asthma, OSA,\n moderate pulmonary HTN. Rib fractures likely contributing to limiting\n respiratory efforts. Continue net diuresis. Provide oxygen, maintain\n SaO2 >90%.\n PNEUMONIA -- Possible RLL pneuomonia. Continue Levofloxacin &\n Cefepime, renally dosed.\n ASTHMA -- Continue Albuterol, Fluticasone, & Ipratropium nebs q6H PRN\n OSA\n Nasal CPAP at night at 11cm H20\n MULTIPLE MYELOMA -- Dx confirmed by bone marrow biopsy. Awaiting\n initiating chemotherapy. Continue dexamethasome.\n ALTERED MENTAL STATUS -- improved. Monitor.\n FLUIDS -- Continue IVF's at 150cc NS/hr, titrate to UOP of\n 200-300cc/hr. Use lasix as needed. Restrict PO intake.\n EPISTAXIS -- chronic history, escalation in context of\n thrombocytopenia. If persists or escalated, consider ENT evaluation\n and packing\n THROMBOCYTOPENIA -- related to myeloma. Good response to plts\n transfusion. Monitor. Transfuse <50\n HYPERCALCEMIA -- Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n HYPERURICEMIA -- Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase this PM. Continue\n Allopurinol 100mg daily\n ACUTE RENAL FAILURE -- Cr 3.7 and continuing to rise. Renal following.\n Renal failure is likely tubular injury from cast nephropathy in\n conjunction with hypercalcemia, hyperuricemia.\n ANEMIA -- Low reticulocyte count, elevated haptoglobin & ferritin.\n demonstrating insufficient erythropoeisis. No evidence of TTP or\n intravascular hemolysis. Transfuse for HCT <25. Guaiac stools\n FLUIDS -- IVF as above, replete electrolytes.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 736926,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diagnosis: Dyspnea\n PMH:\n 47 yom asthma, OSA, chronic low back pain, recent rib fracure now with\n multiple myeloma. Gradual clinical improvement\n"
},
{
"category": "Nutrition",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 736928,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Objectives:\n Diagnosis: Dyspnea\n WT: 113.2kg\n HT: 71 inches\n Diet: Regular\n PMH:\n - Asthma - using inhaler more frequently, but with no good effect\n - Costrochondritis recently diagnosed\n - Lower back pain w/ L3-L4 lateral disc protrusion\n - Obesity\n - Nephrolithiasis\n - H/O atypical chest pain\n - Rectal bleeding\n - Hyperlipidemia\n - Sleep apnea, OSA 11cm H20\n - S/P rib fractures x2\n - Depression\n Asssessment/Plan:\n 47 yo male w/ asthma, OSA, chronic low back pain, recent rib fracture\n now with multiple myeloma confirmed by bone marrow biopsy with plan to\n initiate chemo. Will continue to monitor po intake & provide\n supplements PRN. Monitor labs & hydration. Will follow.\n"
},
{
"category": "Respiratory ",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 736954,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 53.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt uses his own nasal mask CPAP at night ; on and off by himself.. No\n Rx\ns were given this shift.\n, RRT 16:00\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 737033,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - HIT...negative\n - Renal: if continues to improve, will forego plasmapheresis\n - BMT --> one more night in ICU. Likely call-out in AM\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.6\nC (97.8\n HR: 73 (70 - 81) bpm\n BP: 122/52(67) {108/52(66) - 138/78(86)} mmHg\n RR: 24 (16 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 5,716 mL\n 2,051 mL\n PO:\n 1,560 mL\n 720 mL\n TF:\n IVF:\n 4,156 mL\n 1,331 mL\n Blood products:\n Total out:\n 7,690 mL\n 1,810 mL\n Urine:\n 7,690 mL\n 1,810 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,974 mL\n 241 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n GEN: NAD\n CV: RRR\n RESP: mildly rhonchorous throughout\n ABD: S, NT/ND\n Labs / Radiology\n 50 K/uL\n 7.4 g/dL\n 159 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 122 mg/dL\n 105 mEq/L\n 141 mEq/L\n 21.1 %\n 8.3 K/uL\n [image002.jpg]\n 10:03 PM\n 05:25 AM\n 09:36 AM\n 03:07 PM\n 10:00 PM\n 04:10 AM\n 09:52 AM\n 03:20 PM\n 09:45 PM\n 05:41 AM\n WBC\n 11.5\n 12.7\n 9.7\n 8.3\n Hct\n 22.5\n 24.5\n 23.7\n 23.1\n 21.1\n Plt\n 43\n 66\n 62\n 55\n 57\n 50\n Cr\n 3.6\n 3.5\n 3.5\n 3.4\n 3.3\n 3.1\n 3.0\n 2.7\n 2.5\n TropT\n 0.01\n Glucose\n 149\n 163\n 166\n 147\n 155\n 174\n 150\n 159\n Other labs: PT / PTT / INR:17.0/23.1/1.5, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:67/88, Alk Phos / T Bili:54/0.3,\n Differential-Neuts:33.0 %, Band:1.0 %, Lymph:51.0 %, Mono:5.0 %,\n Eos:0.0 %, D-dimer:150 ng/mL, Fibrinogen:440 mg/dL, Lactic Acid:0.8\n mmol/L, LDH:2214 IU/L, Ca++:7.1 mg/dL, Mg++:2.3 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 47 yo M with asthma, OSA, chronic low back pain, recent rib fracure,\n who presented with malaise & DOE found to have bony lesions on CT and a\n constellation of hematologic/electrolyte findings consistent with\n multiple myeloma.\n .\n # Dyspnea/Respiratory Distress: Likely pulm edema +/- RML\n pneumonia. Patient also with hyperdynamic heart on TTE (EF 75%),\n elevated BNP to 4232, moderate pulmonary artery hypertension.\n - IVFs + lasix PRN to titrate to UOP 200-300cc/hr\n - Levofloxacin & Cefepime, renally dosed, day \n - O2 to maintain sats >92% using NC\n - CPAP at night at 11cm H2O\n .\n # Multiple Myeloma: Patient with M-protein in both urine & serum\n identified as IgG kappa as well as end-organ dammage manifested as ARF\n and anemia, diffuse lytic lesions on CT and hypercalcemia suggests a\n diagnosis multiple myeloma. Bone marrow biopsy results are positive for\n myeloma, but patient has commenced Dexamethasone therapy as of .\n Normal serum viscosity and patient without signs or symptoms of\n hyperviscosity syndrome, but beta-2 microglobulin was 6.8. EBV/CMV/Toxo\n negative.\n - K/L light chain ratio pending\n - completed 4 day course of dexamethasone\n - Continue IVF's at 150cc NS/hr, titrate to UOP of 200-300cc/hr\n - Oncology following, will guide treatment\n .\n # Hypercalcemia: Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n - Goal urine output 200-300cc/hr\n - Vitamin D levels low\n .\n # Hyperuricemia: Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase .\n - d/ced allopurinol\n - Brisk UOP as above\n - Avoid HCO3 as it will precipitate calcium & phosphate\n - Repeat tumor lysis labs q6h (rasburicase precautions; uric acid level\n must be measured in green top on ice and spun on a cooled centrifuge)\n .\n # Acute renal insufficiency: Cr 3.1, stable/downtrending from\n yesterday. Renal following. Renal failure is likely tubular injury from\n cast nephropathy in conjunction with hypercalcemia, hyperuricemia.\n - f/u renal recs\n - Continuous IVF's/Lasix to preempt further tubular injury\n .\n # Anemia/Thrombocytopenia: Low reticulocyte count, elevated haptoglobin\n & ferritin demonstrating insufficient erythropoeisis. Likely secondary\n to massive marrow infilitration from multiple myeloma. No evidence of\n TTP, ITP, or intravascular hemolysis.\n - Maintain active T&S\n - Transfuse for HCT < 23\n - obtain transfusion goals for platelets from BMT service\n - Guaiac stools\n .\n # Epistaxis: now resolved\n - humidified O2 when possible\n - transfuse platelets prn\n .\n # Asthma: Continue Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, regular\n .\n # Prophylaxis:\n -DVT ppx with pneumoboots/CPAP\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n .\n # Access: peripherals\n # Communication: Patient\n # Code: FULL\n # Disposition: to BMT floor today if respiratory status remains stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 736156,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - spontaneously stabilized on 3L NC\n - continued to have good UOP (~200 cc/hr) with IVF + lasix\n - uric acid downtrending s/p rasburicase; trending tumor lysis labs q6h\n - per BMT, probable plan for Velcade tmrw\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Azithromycin - 11:30 AM\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 76 (76 - 95) bpm\n BP: 150/76(91) {120/53(71) - 150/76(91)} mmHg\n RR: 21 (21 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 2,271 mL\n 1,100 mL\n PO:\n 500 mL\n TF:\n IVF:\n 1,771 mL\n 1,100 mL\n Blood products:\n Total out:\n 4,110 mL\n 2,640 mL\n Urine:\n 4,110 mL\n 2,640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,839 mL\n -1,540 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 98%\n ABG: 7.47/44/209/31/8\n Physical Examination\n GEN: NAD\n CV: RRR, no murmurs, rubs, gallops\n PULM: Mild expiratory wheezes throughout with crackles at the bases\n bilaterally and increased work of breathing\n ABD: soft, obese, NT/ND, normoactive bowel sounds\n EXT: warm, well-perfused, 2+ dorsalis pedis pulsations\n Labs / Radiology\n 43 K/uL\n 7.7 g/dL\n 163 mg/dL\n 3.5 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 127 mg/dL\n 96 mEq/L\n 140 mEq/L\n 22.5 %\n 11.5 K/uL\n [image002.jpg]\n 02:29 PM\n 03:47 AM\n 05:02 AM\n 10:42 AM\n 05:07 PM\n 10:37 PM\n 04:55 AM\n 07:51 PM\n 10:03 PM\n 05:25 AM\n WBC\n 7.4\n 10.7\n 11.5\n Hct\n 24.5\n 23.4\n 22.5\n Plt\n 77\n 59\n 43\n Cr\n 2.6\n 3.1\n 3.4\n 3.4\n 3.4\n 3.6\n 3.6\n 3.5\n TropT\n 0.01\n TCO2\n 34\n 33\n Glucose\n 121\n 123\n 169\n 149\n 163\n Other labs: PT / PTT / INR:14.4/22.8/1.2, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:95/102, Alk Phos / T Bili:68/0.4,\n Fibrinogen:641 mg/dL, Lactic Acid:0.8 mmol/L, LDH:2590 IU/L, Ca++:9.9\n mg/dL, Mg++:2.2 mg/dL, PO4:6.6 mg/dL\n CT TORSO:\n 1. Findings most consistent with multiple myeloma with innumerable\n lucent\n lesions seen throughout all visualized osseous structures.\n 2. Diffuse ground glass and partially nodular opacities throughout both\n lungs\n is a nonspecific finding, though raises concern for an atypical\n infection;\n pulmonary edema alone is felt less likely.\n 3. No lymphadenopathy.\n Assessment and Plan\n 47 yo M with asthma, OSA, chronic low back pain, recent rib fracure,\n who presented with malaise & DOE found to have bony lesions on CT and a\n constellation of hematologic/electrolyte findings consistent with\n multiple myeloma.\n .\n # Dyspnea/Respiratory Distress: Patient with increasing O2 requirement\n in setting of known asthma, fluid therapy, and new right middle lobe\n pneumonia with pulmonary edema. Also with CT chest on with diffuse\n ground glass opacities. Patient also with hyperdynamic heart on TTE\n (EF 75%), elevated BNP to 4232, moderate pulmonary artery hypertension.\n Receiving Lasix with fluids and now on antibiotics.\n - Lasix 80mg \n - IVF's to titrate to UOP 200-300cc/hr\n - Levofloxacin & Cefepime, renally dosed, day \n - O2 to maintain sats >92% using face tent for now\n - CPAP at night at 11cm H2O\n .\n # Multiple Myeloma: Patient with M-protein in both urine & serum\n identified as IgG kappa as well as end-organ dammage manifested as ARF\n and anemia, diffuse lytic lesions on CT and hypercalcemia suggests a\n diagnosis multiple myeloma. Bone marrow biopsy results are positive for\n myeloma, but patient has commenced Dexamethasone therapy as of .\n Normal serum viscosity and patient without signs or symptoms of\n hyperviscosity syndrome, but beta-2 microglobulin was 6.8. EBV/CMV/Toxo\n negative.\n - K/L light chain ratio pending\n - Continue Dexamethasone 40mg IV qday, day \n - Continue IVF's at 150cc NS/hr, titrate to UOP of 200-300cc/hr\n - Continue Lasix 80mg \n - F/U skeletal survey results\n - Oncology following, will guide treatment\n .\n # Hypercalcemia: Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n - Goal urine output 200-300cc/hr\n - Continue IV NS as above\n - Lasix as above\n - Dexamethasone as above\n - q6H labs\n - Vitamin D pending\n - Vitamin D 25 pending\n .\n # Hyperuricemia: Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase .\n - Continue Allopurinol 100mg daily\n - Brisk UOP as above\n - Avoid HCO3 as it will precipitate calcium & phosphate\n - Repeat tumor lysis labs q6h (rasburicase precautions; uric acid level\n must be measured in green top on ice and spun on a cooled centrifuge)\n .\n # Acute renal insufficiency: Cr 3.5, stable/downtrending from\n yesterday. Renal following. Renal failure is likely tubular injury from\n cast nephropathy in conjunction with hypercalcemia, hyperuricemia.\n - f/u renal recs\n - require renal biopsy if function does not improve\n - Continuous IVF's/Lasix to preempt further tubular injury\n .\n # Anemia/Thrombocytopenia: Low reticulocyte count, elevated haptoglobin\n & ferritin demonstrating insufficient erythropoeisis. Likely secondary\n to massive marrow infilitration from multiple myeloma. No evidence of\n TTP, ITP, or intravascular hemolysis.\n - Maintain active T&S\n - Transfuse for HCT <25\n - obtain transfusion goals for platelets from BMT service\n - Guaiac stools\n .\n Epistaxis: baseline problem worsened by thrombocytopenia and dry air of\n Nasal cannula\n - afrin first line, packing if profuse with appropriate antibiotic ppx\n - avoid nasal cannula, CPAP may worsen as well\n .\n # Asthma: Continue Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, regular\n .\n # Prophylaxis:\n -DVT ppx with pneumoboots/CPAP\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n .\n # Access: peripherals\n # Communication: Patient\n # Code: FULL\n # Disposition: to BMT floor today if respiratory status remains stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:00 PM\n 20 Gauge - 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": "2136-04-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 736158,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - spontaneously stabilized on 3L NC\n - continued to have good UOP (~200 cc/hr) with IVF + lasix\n - uric acid downtrending s/p rasburicase; trending tumor lysis labs q6h\n - per BMT, probable plan for Velcade tmrw\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Azithromycin - 11:30 AM\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 76 (76 - 95) bpm\n BP: 150/76(91) {120/53(71) - 150/76(91)} mmHg\n RR: 21 (21 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 2,271 mL\n 1,100 mL\n PO:\n 500 mL\n TF:\n IVF:\n 1,771 mL\n 1,100 mL\n Blood products:\n Total out:\n 4,110 mL\n 2,640 mL\n Urine:\n 4,110 mL\n 2,640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,839 mL\n -1,540 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 98%\n ABG: 7.47/44/209/31/8\n Physical Examination\n GEN: NAD\n CV: RRR, no murmurs, rubs, gallops\n PULM: Mild expiratory wheezes throughout with crackles at the bases\n bilaterally and increased work of breathing\n ABD: soft, obese, NT/ND, normoactive bowel sounds\n EXT: warm, well-perfused, 2+ dorsalis pedis pulsations\n Labs / Radiology\n 43 K/uL\n 7.7 g/dL\n 163 mg/dL\n 3.5 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 127 mg/dL\n 96 mEq/L\n 140 mEq/L\n 22.5 %\n 11.5 K/uL\n [image002.jpg]\n 02:29 PM\n 03:47 AM\n 05:02 AM\n 10:42 AM\n 05:07 PM\n 10:37 PM\n 04:55 AM\n 07:51 PM\n 10:03 PM\n 05:25 AM\n WBC\n 7.4\n 10.7\n 11.5\n Hct\n 24.5\n 23.4\n 22.5\n Plt\n 77\n 59\n 43\n Cr\n 2.6\n 3.1\n 3.4\n 3.4\n 3.4\n 3.6\n 3.6\n 3.5\n TropT\n 0.01\n TCO2\n 34\n 33\n Glucose\n 121\n 123\n 169\n 149\n 163\n Other labs: PT / PTT / INR:14.4/22.8/1.2, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:95/102, Alk Phos / T Bili:68/0.4,\n Fibrinogen:641 mg/dL, Lactic Acid:0.8 mmol/L, LDH:2590 IU/L, Ca++:9.9\n mg/dL, Mg++:2.2 mg/dL, PO4:6.6 mg/dL\n CT TORSO:\n 1. Findings most consistent with multiple myeloma with innumerable\n lucent\n lesions seen throughout all visualized osseous structures.\n 2. Diffuse ground glass and partially nodular opacities throughout both\n lungs\n is a nonspecific finding, though raises concern for an atypical\n infection;\n pulmonary edema alone is felt less likely.\n 3. No lymphadenopathy.\n Assessment and Plan\n 47 yo M with asthma, OSA, chronic low back pain, recent rib fracure,\n who presented with malaise & DOE found to have bony lesions on CT and a\n constellation of hematologic/electrolyte findings consistent with\n multiple myeloma.\n .\n # Dyspnea/Respiratory Distress: Patient with increasing O2 requirement\n in setting of known asthma, fluid therapy, and new right middle lobe\n pneumonia with pulmonary edema. Also with CT chest on with diffuse\n ground glass opacities. Patient also with hyperdynamic heart on TTE\n (EF 75%), elevated BNP to 4232, moderate pulmonary artery hypertension.\n Receiving Lasix with fluids and now on antibiotics.\n - Lasix 80mg \n - IVF's to titrate to UOP 200-300cc/hr\n - Levofloxacin & Cefepime, renally dosed, day \n - O2 to maintain sats >92% using face tent for now\n - CPAP at night at 11cm H2O\n .\n # Multiple Myeloma: Patient with M-protein in both urine & serum\n identified as IgG kappa as well as end-organ dammage manifested as ARF\n and anemia, diffuse lytic lesions on CT and hypercalcemia suggests a\n diagnosis multiple myeloma. Bone marrow biopsy results are positive for\n myeloma, but patient has commenced Dexamethasone therapy as of .\n Normal serum viscosity and patient without signs or symptoms of\n hyperviscosity syndrome, but beta-2 microglobulin was 6.8. EBV/CMV/Toxo\n negative.\n - K/L light chain ratio pending\n - Continue Dexamethasone 40mg IV qday, day \n - Continue IVF's at 150cc NS/hr, titrate to UOP of 200-300cc/hr\n - Continue Lasix 80mg \n - F/U skeletal survey results\n - Oncology following, will guide treatment\n .\n # Hypercalcemia: Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n - Goal urine output 200-300cc/hr\n - Continue IV NS as above\n - Lasix as above\n - Dexamethasone as above\n - q6H labs\n - Vitamin D pending\n - Vitamin D 25 pending\n .\n # Hyperuricemia: Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase .\n - Continue Allopurinol 100mg daily\n - Brisk UOP as above\n - Avoid HCO3 as it will precipitate calcium & phosphate\n - Repeat tumor lysis labs q6h (rasburicase precautions; uric acid level\n must be measured in green top on ice and spun on a cooled centrifuge)\n .\n # Acute renal insufficiency: Cr 3.5, stable/downtrending from\n yesterday. Renal following. Renal failure is likely tubular injury from\n cast nephropathy in conjunction with hypercalcemia, hyperuricemia.\n - f/u renal recs\n - require renal biopsy if function does not improve\n - Continuous IVF's/Lasix to preempt further tubular injury\n .\n # Anemia/Thrombocytopenia: Low reticulocyte count, elevated haptoglobin\n & ferritin demonstrating insufficient erythropoeisis. Likely secondary\n to massive marrow infilitration from multiple myeloma. No evidence of\n TTP, ITP, or intravascular hemolysis.\n - Maintain active T&S\n - Transfuse for HCT <25\n - obtain transfusion goals for platelets from BMT service\n - Guaiac stools\n .\n # Epistaxis: baseline problem worsened by thrombocytopenia and dry air\n of Nasal cannula\n - afrin first line, packing if profuse with appropriate antibiotic ppx\n - avoid nasal cannula, CPAP may worsen as well\n - transfuse plateletes prn\n .\n # Asthma: Continue Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, regular\n .\n # Prophylaxis:\n -DVT ppx with pneumoboots/CPAP\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n .\n # Access: peripherals\n # Communication: Patient\n # Code: FULL\n # Disposition: to BMT floor today if respiratory status remains stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:00 PM\n 20 Gauge - 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": "Nutrition",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 736924,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diagnosis: Dyspnea\n PMH:\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 736090,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - spontaneously stabilized on 3L NC\n - continued to have good UOP (~200 cc/hr) with IVF + lasix\n - uric acid downtrending s/p rasburicase; trending tumor lysis labs q6h\n - per BMT, probable plan for Velcade tmrw\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Azithromycin - 11:30 AM\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 76 (76 - 95) bpm\n BP: 150/76(91) {120/53(71) - 150/76(91)} mmHg\n RR: 21 (21 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 2,271 mL\n 1,100 mL\n PO:\n 500 mL\n TF:\n IVF:\n 1,771 mL\n 1,100 mL\n Blood products:\n Total out:\n 4,110 mL\n 2,640 mL\n Urine:\n 4,110 mL\n 2,640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,839 mL\n -1,540 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 98%\n ABG: 7.47/44/209/31/8\n Physical Examination\n GEN: NAD\n CV: RRR, no murmurs, rubs, gallops\n PULM: Mild expiratory wheezes throughout with crackles at the bases\n bilaterally and increased work of breathing\n ABD: soft, obese, NT/ND, normoactive bowel sounds\n EXT: warm, well-perfused, 2+ dorsalis pedis pulsations\n Labs / Radiology\n 43 K/uL\n 7.7 g/dL\n 163 mg/dL\n 3.5 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 127 mg/dL\n 96 mEq/L\n 140 mEq/L\n 22.5 %\n 11.5 K/uL\n [image002.jpg]\n 02:29 PM\n 03:47 AM\n 05:02 AM\n 10:42 AM\n 05:07 PM\n 10:37 PM\n 04:55 AM\n 07:51 PM\n 10:03 PM\n 05:25 AM\n WBC\n 7.4\n 10.7\n 11.5\n Hct\n 24.5\n 23.4\n 22.5\n Plt\n 77\n 59\n 43\n Cr\n 2.6\n 3.1\n 3.4\n 3.4\n 3.4\n 3.6\n 3.6\n 3.5\n TropT\n 0.01\n TCO2\n 34\n 33\n Glucose\n 121\n 123\n 169\n 149\n 163\n Other labs: PT / PTT / INR:14.4/22.8/1.2, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:95/102, Alk Phos / T Bili:68/0.4,\n Fibrinogen:641 mg/dL, Lactic Acid:0.8 mmol/L, LDH:2590 IU/L, Ca++:9.9\n mg/dL, Mg++:2.2 mg/dL, PO4:6.6 mg/dL\n CT TORSO:\n 1. Findings most consistent with multiple myeloma with innumerable\n lucent\n lesions seen throughout all visualized osseous structures.\n 2. Diffuse ground glass and partially nodular opacities throughout both\n lungs\n is a nonspecific finding, though raises concern for an atypical\n infection;\n pulmonary edema alone is felt less likely.\n 3. No lymphadenopathy.\n Assessment and Plan\n 47 yo M with asthma, OSA, chronic low back pain, recent rib fracure,\n who presented with malaise & DOE found to have bony lesions on CT and a\n constellation of hematologic/electrolyte findings consistent with\n multiple myeloma.\n .\n # Dyspnea/Respiratory Distress: Patient with increasing O2 requirement\n in setting of known asthma, fluid therapy, and new right middle lobe\n pneumonia with pulmonary edema. Also with CT chest on with diffuse\n ground glass opacities. Patient also with hyperdynamic heart on TTE\n (EF 75%), elevated BNP to 4232, moderate pulmonary artery hypertension.\n Receiving Lasix with fluids and now on antibiotics.\n - Lasix 80mg \n - IVF's to titrate to UOP 200-300cc/hr\n - Levofloxacin & Cefepime, renally dosed, day \n - O2 to maintain sats >92%\n - CPAP at night at 11cm H2O\n .\n # Multiple Myeloma: Patient with M-protein in both urine & serum\n identified as IgG kappa as well as end-organ dammage manifested as ARF\n and anemia, diffuse lytic lesions on CT and hypercalcemia suggests a\n diagnosis multiple myeloma. Bone marrow biopsy results are positive for\n myeloma, but patient has commenced Dexamethasone therapy as of .\n Normal serum viscosity and patient without signs or symptoms of\n hyperviscosity syndrome, but beta-2 microglobulin was 6.8. EBV/CMV/Toxo\n negative.\n - K/L light chain ratio pending\n - Continue Dexamethasone 40mg IV qday, day \n - Continue IVF's at 150cc NS/hr, titrate to UOP of 200-300cc/hr\n - Continue Lasix 80mg \n - F/U skeletal survey results\n - Oncology following, will guide treatment\n .\n # Hypercalcemia: Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n - Goal urine output 200-300cc/hr\n - Continue IV NS as above\n - Lasix as above\n - Dexamethasone as above\n - q6H labs\n - Vitamin D pending\n - Vitamin D 25 pending\n .\n # Hyperuricemia: Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase .\n - Continue Allopurinol 100mg daily\n - Brisk UOP as above\n - Avoid HCO3 as it will precipitate calcium & phosphate\n - Repeat tumor lysis labs q6h (rasburicase precautions; uric acid level\n must be measured in green top on ice and spun on a cooled centrifuge)\n .\n # Acute renal insufficiency: Cr 3.5, stable/downtrending from\n yesterday. Renal following. Renal failure is likely tubular injury from\n cast nephropathy in conjunction with hypercalcemia, hyperuricemia.\n - f/u renal recs\n - require renal biopsy if function does not improve\n - Continuous IVF's/Lasix to preempt further tubular injury\n .\n # Anemia/Thrombocytopenia: Low reticulocyte count, elevated haptoglobin\n & ferritin demonstrating insufficient erythropoeisis. Likely secondary\n to massive marrow infilitration from multiple myeloma. No evidence of\n TTP, ITP, or intravascular hemolysis.\n - Maintain active T&S\n - Transfuse for HCT <25\n - obtain transfusion goals for platelets from BMT service\n - Guaiac stools\n .\n # Asthma: Continue Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, regular\n .\n # Prophylaxis:\n -DVT ppx with pneumoboots/CPAP\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n .\n # Access: peripherals\n # Communication: Patient\n # Code: FULL\n # Disposition: to BMT floor today if respiratory status remains stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:00 PM\n 20 Gauge - 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": "2136-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736219,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward. Pt with recent rib fractures\n related to increased calcium levels.\n Action:\n Yesterday pt. completed his calcitonin SC injection, continues on NS @\n 150cc/hr and IV lasixtumor lysis labs q6hrs\n Response:\n Calcium trending down 9.4; . Skeletal survey films of skull, long\n bones and spine showed No obvious lucent lesions and innumerable small\n lytic foci which are consistent with myeloma; also Degenerative changes\n in the spine and Aortic calcification, unusual in someone of this age;\n Plan:\n Monitor for signs and symptoms of hypercalcemia, arrhythmias.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr remain elevated, UOP >200cc/hr, clear, yellow. Renal following\n tubular injury likely related to hypercalcemia induced vasoconstriction\n to renal vasculature.\n Action:\n NS 150cc/hr to flush kidneys, lasix to flush kidney\n Response:\n Continues to maintain good urine output. Tolerating lasix well,\n BUN/Cr remains elevated but kidney function expected to improve over\n time as calcium levels decrease.\n Plan:\n Continue lytes with tumor lysis labs, monitor I/O\ns. Renal team\n suggesting kidney biopsy if no improvement over next few days.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . Pt. continue to have noosebleed. CT done consistent of\n myeloma. ECHO from showing EF >55%.\n Action:\n Afrin x 3 days ( day 1), transfused with 1 unit platelet for\n platelet of 43, IV steroids continues\n Response:\n Plan:\n Continue to monitor HCT and PLTS, monitor for further signs of\n bleeding, continue IV steroids, HCT goal >21\n Uric Acid blood test to be rechecked @ 1000 (this specimen is in a\n green top vial and placed on ice.)\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736294,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward. Pt with recent rib fractures\n related to increased calcium levels.\n Action:\n Yesterday pt. completed his calcitonin SC injection, continues on NS @\n 150cc/hr and IV lasixtumor lysis labs q6hrs; allopurinol dc\n Response:\n Calcium trending down 9.0 this am; Skeletal survey films of skull, long\n bones and spine showed No obvious lucent lesions and innumerable small\n lytic foci which are consistent with myeloma; also Degenerative changes\n in the spine and Aortic calcification, unusual in someone of this age;\n Plan:\n Monitor for signs and symptoms of hypercalcemia, arrhythmias;\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr remain elevated, UOP >200cc/hr, clear, yellow. Renal following\n tubular injury likely related to hypercalcemia induced vasoconstriction\n to renal vasculature.\n Action:\n NS 150cc/hr to flush kidneys, continues to IV lasix to flush kidney ;\n renagel not given\n patient not on reguklar diet\n medical house staff\n aware that this is not started; 12 hr urine collection started at 12\n noon to check presence of protein; lasix dc\n Response:\n Continues to maintain good urine output. BUN/Cr remains elevated but\n kidney function expected to improve over time as calcium levels\n decreases; negative 8L LOS and 2.4 liters since MN\n Plan:\n Continue lytes check with tumor lysis labs, monitor I/O\ns. Renal team\n suggesting kidney biopsy if no improvement over next few days.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . Pt. continue to have noosebleed. CT done consistent of\n myeloma. ECHO from showing EF >55%; petechia on hands and feet\n increasing; BMT following for chemotherapy\n Action:\n Afrin x 3 days ( day 1), transfused with 1 unit platelet for\n platelet of 43, IV steroids continues\n Response:\n Nosebleed slowing down, platelet 66 post transfusion\n Plan:\n Continue to monitor HCT and PLTS, monitor for further signs of\n bleeding, continue IV steroids, HCT goal >21; plan to start\n chemotherapy tonight or tomorrow\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Transferred from BMT floor for increased O2 requirement, placed on CPAP\n overnight for sleep apnea\n uses his own set-up; desatted down to mids\n 80\ns whenever he takes his O2 off; desatted while on 6 liters via nasal\n cannula; lung sounds clear, diminished at bases; occasional\n non-productive cough; Placed on cool aerosol via face tent 100% at\n 0800\n sats improved wgile on cool neb; CXR showed increasing fluid\n overload due to hydration to flush kidney\n Action:\n O2 weaned down to 50% FiO2, flovent dc\n no wheezing noted; PRN\n albuterol and atrovent nebs continues; continues on cefipime and\n levofloxacin IV for RML pneumonia\n Response:\n O2 sats > 92% at 50% FiO2\n Plan:\n Wean O2 as tolerated\n Oriented x 3, denies pain still with weakness but helps with turning.\n BP stable in the 110\ns MAP above 60 mmHg; pedal pulses easily palpable,\n normal sinus rhythm in the 80\ns no PVC\ns noted\n On sips of clear liquids for now, no BM this shift, refused colace\n Patient\ns family stayed most of the day ( patient\ns 3 sons came and\n visited too after school) wife and patient bother\ns very supportive\n with recent diagnosis\n Uric Acid blood test to be rechecked @ 2200( this specimen is in a\n green top vial and placed on ice.) PLEASE CALL STAT LABS WHEN YOU ARE\n ABOUT TO SEND URIC ACID ON A GREEN TOP WITH ICE.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736304,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward. Pt with recent rib fractures\n related to increased calcium levels.\n Action:\n Yesterday pt. completed his calcitonin SC injection, continues on NS @\n 150cc/hr and IV lasixtumor lysis labs q6hrs; allopurinol dc\n Response:\n Calcium trending down 9.0 this am; Skeletal survey films of skull, long\n bones and spine showed No obvious lucent lesions and innumerable small\n lytic foci which are consistent with myeloma; also Degenerative changes\n in the spine and Aortic calcification, unusual in someone of this age;\n Plan:\n Monitor for signs and symptoms of hypercalcemia, arrhythmias;\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr remain elevated, UOP >200cc/hr, clear, yellow. Renal following\n tubular injury likely related to hypercalcemia induced vasoconstriction\n to renal vasculature.\n Action:\n NS 150cc/hr to flush kidneys, continues to IV lasix to flush kidney ;\n renagel not given\n patient not on reguklar diet\n medical house staff\n aware that this is not started; 12 hr urine collection started at 12\n noon to check presence of protein; lasix dc\n Response:\n Continues to maintain good urine output. BUN/Cr remains elevated but\n kidney function expected to improve over time as calcium levels\n decreases; negative 8L LOS and 2.4 liters since MN\n Plan:\n Continue lytes check with tumor lysis labs, monitor I/O\ns. Renal team\n suggesting kidney biopsy if no improvement over next few days.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . Pt. continue to have noosebleed. CT done consistent of\n myeloma. ECHO from showing EF >55%; petechia on hands and feet\n increasing; BMT following for chemotherapy\n Action:\n Afrin x 3 days ( day 1), transfused with 1 unit platelet for\n platelet of 43, IV steroids continues\n Response:\n Nosebleed slowing down, platelet 66 post transfusion\n Plan:\n Continue to monitor HCT and PLTS, monitor for further signs of\n bleeding, continue IV steroids, HCT goal >21; plan to start\n chemotherapy tonight or tomorrow\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Transferred from BMT floor for increased O2 requirement, placed on CPAP\n overnight for sleep apnea\n uses his own set-up; desatted down to mids\n 80\ns whenever he takes his O2 off; desatted while on 6 liters via nasal\n cannula; lung sounds clear, diminished at bases; occasional\n non-productive cough; Placed on cool aerosol via face tent 100% at\n 0800\n sats improved wgile on cool neb; CXR showed increasing fluid\n overload due to hydration to flush kidney\n Action:\n O2 weaned down to 50% FiO2, flovent dc\n no wheezing noted; PRN\n albuterol and atrovent nebs continues; continues on cefipime and\n levofloxacin IV for RML pneumonia\n Response:\n O2 sats > 92% at 50% FiO2\n Plan:\n Wean O2 as tolerated\n Oriented x 3, denies pain still with weakness but helps with turning.\n BP stable in the 110\ns MAP above 60 mmHg; pedal pulses easily palpable,\n normal sinus rhythm in the 80\ns no PVC\ns noted\n On sips of clear liquids for now, no BM this shift, refused colace\n Patient\ns family stayed most of the day ( patient\ns 3 sons came and\n visited too after school) wife and patient bother\ns very supportive\n with recent diagnosis\n Uric Acid blood test to be rechecked @ 2200( this specimen is in a\n green top vial and placed on ice.) PLEASE CALL STAT LABS WHEN YOU ARE\n ABOUT TO SEND URIC ACID ON A GREEN TOP WITH ICE.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736063,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Ineffective Coping\n Assessment:\n Pt\ns wife and brother in to visit pt. Pt has 3 small children at home.\n Action:\n Social work in to see family. Emotional support provided to pt and\n family by staff.\n Response:\n Family and pt seems to be coping appropriately, very supportive family,\n involved in pt\ns care.\n Plan:\n Continue to provide support as needed, SW aware and involved.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward per HS labs, AM labs pending. Pt\n with recent rib fractures related to increased calcium levels.\n Action:\n Yesterday pt. completed his calcitonin salmon SC injection, ordered for\n NS @ 150cc/hr for 1L, and lasix. Skeletal survey films of skull,\n long bones and spine pending. Calcium rechecked, results pending.\n Response:\n Final read of skeletal survey pending. Calcium trending down\n appropriately.\n Plan:\n Monitor for signs and symptoms of hypercalcemia, arrhythmias. Follow\n up skeletal survey results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards, UOP >200cc/hr, clear, yellow. Renal following\n for . Likely related to hypercalcemia induced vasoconstriction to\n renal vasculature.\n Action:\n NS 150cc/hr to flush kidneys, lasix.\n Response:\n Continues to maintain good urine output. Tolerating lasix well, HS\n BUN/Cr continuing to climb however renal unimpressed. Per discussion\n with renal kidney function expected to improve over time and as calcium\n levels decrease.\n Plan:\n Continue to trend BUN/Cr frequently, monitor UOP. Renal team\n suggesting kidney biopsy if no improvement over next few days.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . Pt. had a bloody nose last evening. CT done . ECHO from \n showing EF >55%.\n Action:\n Drop discussed during , team likely related to disease\n process in bone marrow. Team in to evaluate bloody nose, After adding\n humidified O2 and ice pack. Afin nasal spray ordered with desired\n effects reached..\n Response:\n CT results supporting atypical myeloma diagnosis. Started on IV\n steroids.\n Plan:\n Continue to monitor HCT, and PLTS, monitor for further signs of\n bleeding, continue IV steroids, HCT goal >21\n Uric Acid blood test to be rechecked @ 1000 (this specimen is in a\n green top vial and placed on ice.)\n"
},
{
"category": "Respiratory ",
"chartdate": "2136-04-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 736416,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 53.5 None\n Ideal tidal volume: mL/kg\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 Comments: Occasional non productive cough.\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Comments: Received on 70% to 50% face tent. Well tolerated with no c/o\n dyspnea. Placed patient on his own nasal CPAP machine at night, on\n pre-set setting of 11cmH2O. O2 bleed in initially @ 5L, with acceptable\n (90-95%) sats. Later ^ to 10L O2 to correct low sats, due to Pt\n unconsciously mouth breathing.\n Plan\n Next 24-48 hours:\n Reason for continuing current support: Continue nocturnal nasal CPAP,\n adjusting O2\nbleed in\n to maintain Sats within desired range of\n 90-95%. Albuterol & Atrovent prn. Resume humidified O2 via face tent\n on days.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736263,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward. Pt with recent rib fractures\n related to increased calcium levels.\n Action:\n Yesterday pt. completed his calcitonin SC injection, continues on NS @\n 150cc/hr and IV lasixtumor lysis labs q6hrs\n Response:\n Calcium trending down 9.0 this am; Skeletal survey films of skull, long\n bones and spine showed No obvious lucent lesions and innumerable small\n lytic foci which are consistent with myeloma; also Degenerative changes\n in the spine and Aortic calcification, unusual in someone of this age;\n Plan:\n Monitor for signs and symptoms of hypercalcemia, arrhythmias;\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr remain elevated, UOP >200cc/hr, clear, yellow. Renal following\n tubular injury likely related to hypercalcemia induced vasoconstriction\n to renal vasculature.\n Action:\n NS 150cc/hr to flush kidneys, continues to IV lasix to flush kidney ;\n renagel not given\n patient not on reguklar diet\n medical house staff\n aware that this is not started; 12 hr urine collection started at 12\n noon to check presence of protein\n Response:\n Continues to maintain good urine output. Tolerating lasix well,\n BUN/Cr remains elevated but kidney function expected to improve over\n time as calcium levels decreases\n Plan:\n Continue lytes check with tumor lysis labs, monitor I/O\ns. Renal team\n suggesting kidney biopsy if no improvement over next few days.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . Pt. continue to have noosebleed. CT done consistent of\n myeloma. ECHO from showing EF >55%; petechia on hands and feet\n increasing; BMT following for chemotherapy\n Action:\n Afrin x 3 days ( day 1), transfused with 1 unit platelet for\n platelet of 43, IV steroids continues\n Response:\n No further nosebleed noted\n Plan:\n Continue to monitor HCT and PLTS, monitor for further signs of\n bleeding, continue IV steroids, HCT goal >21; plan to start\n chemotherapy tonight or tomorrow\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Transferred from BMT floor for increased O2 requirement, placed on CPAP\n overnight for sleep apnea\n uses his own set-up; desatted down to mids\n 80\ns whenever he takes his O2 off; desatted while on 6 liters via nasal\n cannula; lung sounds clear, diminished at bases; occasional\n non-productive cough; Placed on cool aerosol via face tent 100% at\n 0800\n sats improved wgile on cool neb; CXR showed increasing fluid\n overload due to hydration to flush kidney\n Action:\n O2 weaned down to 50% FiO2, flovent dc\n no wheezing noted; PRN\n albuterol and atrovent nebs continues; continues on cefipime and\n levofloxacin IV for RML pneumonia\n Response:\n O2 sats > 92% at 50% FiO2\n Plan:\n Wean O2 as tolerated\n Oriented x 3, denies pain still with weakness but helps with turning.\n BP stable in the 110\ns MAP above 60 mmHg; pedal pulses easily palpable,\n normal sinus rhythm in the 80\ns no PVC\ns noted\n On sips of clear liquids for now, no BM this shift, refused colace\n Patient\ns family stayed most of the day ( patient\ns 3 sons came and\n visited too after school) wife and patient bother\ns very supportive\n with recent diagnosis\n Uric Acid blood test to be rechecked @ 2200( this specimen is in a\n green top vial and placed on ice.)\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736267,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward. Pt with recent rib fractures\n related to increased calcium levels.\n Action:\n Yesterday pt. completed his calcitonin SC injection, continues on NS @\n 150cc/hr and IV lasixtumor lysis labs q6hrs\n Response:\n Calcium trending down 9.0 this am; Skeletal survey films of skull, long\n bones and spine showed No obvious lucent lesions and innumerable small\n lytic foci which are consistent with myeloma; also Degenerative changes\n in the spine and Aortic calcification, unusual in someone of this age;\n Plan:\n Monitor for signs and symptoms of hypercalcemia, arrhythmias;\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr remain elevated, UOP >200cc/hr, clear, yellow. Renal following\n tubular injury likely related to hypercalcemia induced vasoconstriction\n to renal vasculature.\n Action:\n NS 150cc/hr to flush kidneys, continues to IV lasix to flush kidney ;\n renagel not given\n patient not on reguklar diet\n medical house staff\n aware that this is not started; 12 hr urine collection started at 12\n noon to check presence of protein\n Response:\n Continues to maintain good urine output. Tolerating lasix well,\n BUN/Cr remains elevated but kidney function expected to improve over\n time as calcium levels decreases\n Plan:\n Continue lytes check with tumor lysis labs, monitor I/O\ns. Renal team\n suggesting kidney biopsy if no improvement over next few days.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . Pt. continue to have noosebleed. CT done consistent of\n myeloma. ECHO from showing EF >55%; petechia on hands and feet\n increasing; BMT following for chemotherapy\n Action:\n Afrin x 3 days ( day 1), transfused with 1 unit platelet for\n platelet of 43, IV steroids continues\n Response:\n No further nosebleed noted\n Plan:\n Continue to monitor HCT and PLTS, monitor for further signs of\n bleeding, continue IV steroids, HCT goal >21; plan to start\n chemotherapy tonight or tomorrow\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Transferred from BMT floor for increased O2 requirement, placed on CPAP\n overnight for sleep apnea\n uses his own set-up; desatted down to mids\n 80\ns whenever he takes his O2 off; desatted while on 6 liters via nasal\n cannula; lung sounds clear, diminished at bases; occasional\n non-productive cough; Placed on cool aerosol via face tent 100% at\n 0800\n sats improved wgile on cool neb; CXR showed increasing fluid\n overload due to hydration to flush kidney\n Action:\n O2 weaned down to 50% FiO2, flovent dc\n no wheezing noted; PRN\n albuterol and atrovent nebs continues; continues on cefipime and\n levofloxacin IV for RML pneumonia\n Response:\n O2 sats > 92% at 50% FiO2\n Plan:\n Wean O2 as tolerated\n Oriented x 3, denies pain still with weakness but helps with turning.\n BP stable in the 110\ns MAP above 60 mmHg; pedal pulses easily palpable,\n normal sinus rhythm in the 80\ns no PVC\ns noted\n On sips of clear liquids for now, no BM this shift, refused colace\n Patient\ns family stayed most of the day ( patient\ns 3 sons came and\n visited too after school) wife and patient bother\ns very supportive\n with recent diagnosis\n Uric Acid blood test to be rechecked @ 2200( this specimen is in a\n green top vial and placed on ice.) PLEASE CALL STAT LABS WHEN YOU ARE\n ABOUT TO SEND URIC ACID ON A GREEN TOP WITH ICE.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736276,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward. Pt with recent rib fractures\n related to increased calcium levels.\n Action:\n Yesterday pt. completed his calcitonin SC injection, continues on NS @\n 150cc/hr and IV lasixtumor lysis labs q6hrs\n Response:\n Calcium trending down 9.0 this am; Skeletal survey films of skull, long\n bones and spine showed No obvious lucent lesions and innumerable small\n lytic foci which are consistent with myeloma; also Degenerative changes\n in the spine and Aortic calcification, unusual in someone of this age;\n Plan:\n Monitor for signs and symptoms of hypercalcemia, arrhythmias;\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr remain elevated, UOP >200cc/hr, clear, yellow. Renal following\n tubular injury likely related to hypercalcemia induced vasoconstriction\n to renal vasculature.\n Action:\n NS 150cc/hr to flush kidneys, continues to IV lasix to flush kidney ;\n renagel not given\n patient not on reguklar diet\n medical house staff\n aware that this is not started; 12 hr urine collection started at 12\n noon to check presence of protein\n Response:\n Continues to maintain good urine output. Tolerating lasix well,\n BUN/Cr remains elevated but kidney function expected to improve over\n time as calcium levels decreases; negative 8L LOS and 2.4 liters since\n MN\n Plan:\n Continue lytes check with tumor lysis labs, monitor I/O\ns. Renal team\n suggesting kidney biopsy if no improvement over next few days.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . Pt. continue to have noosebleed. CT done consistent of\n myeloma. ECHO from showing EF >55%; petechia on hands and feet\n increasing; BMT following for chemotherapy\n Action:\n Afrin x 3 days ( day 1), transfused with 1 unit platelet for\n platelet of 43, IV steroids continues\n Response:\n No further nosebleed noted\n Plan:\n Continue to monitor HCT and PLTS, monitor for further signs of\n bleeding, continue IV steroids, HCT goal >21; plan to start\n chemotherapy tonight or tomorrow\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Transferred from BMT floor for increased O2 requirement, placed on CPAP\n overnight for sleep apnea\n uses his own set-up; desatted down to mids\n 80\ns whenever he takes his O2 off; desatted while on 6 liters via nasal\n cannula; lung sounds clear, diminished at bases; occasional\n non-productive cough; Placed on cool aerosol via face tent 100% at\n 0800\n sats improved wgile on cool neb; CXR showed increasing fluid\n overload due to hydration to flush kidney\n Action:\n O2 weaned down to 50% FiO2, flovent dc\n no wheezing noted; PRN\n albuterol and atrovent nebs continues; continues on cefipime and\n levofloxacin IV for RML pneumonia\n Response:\n O2 sats > 92% at 50% FiO2\n Plan:\n Wean O2 as tolerated\n Oriented x 3, denies pain still with weakness but helps with turning.\n BP stable in the 110\ns MAP above 60 mmHg; pedal pulses easily palpable,\n normal sinus rhythm in the 80\ns no PVC\ns noted\n On sips of clear liquids for now, no BM this shift, refused colace\n Patient\ns family stayed most of the day ( patient\ns 3 sons came and\n visited too after school) wife and patient bother\ns very supportive\n with recent diagnosis\n Uric Acid blood test to be rechecked @ 2200( this specimen is in a\n green top vial and placed on ice.) PLEASE CALL STAT LABS WHEN YOU ARE\n ABOUT TO SEND URIC ACID ON A GREEN TOP WITH ICE.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736277,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward. Pt with recent rib fractures\n related to increased calcium levels.\n Action:\n Yesterday pt. completed his calcitonin SC injection, continues on NS @\n 150cc/hr and IV lasixtumor lysis labs q6hrs\n Response:\n Calcium trending down 9.0 this am; Skeletal survey films of skull, long\n bones and spine showed No obvious lucent lesions and innumerable small\n lytic foci which are consistent with myeloma; also Degenerative changes\n in the spine and Aortic calcification, unusual in someone of this age;\n Plan:\n Monitor for signs and symptoms of hypercalcemia, arrhythmias;\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr remain elevated, UOP >200cc/hr, clear, yellow. Renal following\n tubular injury likely related to hypercalcemia induced vasoconstriction\n to renal vasculature.\n Action:\n NS 150cc/hr to flush kidneys, continues to IV lasix to flush kidney ;\n renagel not given\n patient not on reguklar diet\n medical house staff\n aware that this is not started; 12 hr urine collection started at 12\n noon to check presence of protein\n Response:\n Continues to maintain good urine output. Tolerating lasix well,\n BUN/Cr remains elevated but kidney function expected to improve over\n time as calcium levels decreases; negative 8L LOS and 2.4 liters since\n MN\n Plan:\n Continue lytes check with tumor lysis labs, monitor I/O\ns. Renal team\n suggesting kidney biopsy if no improvement over next few days.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . Pt. continue to have noosebleed. CT done consistent of\n myeloma. ECHO from showing EF >55%; petechia on hands and feet\n increasing; BMT following for chemotherapy\n Action:\n Afrin x 3 days ( day 1), transfused with 1 unit platelet for\n platelet of 43, IV steroids continues\n Response:\n Nosebleed slowing down, platelet 66 post transfusion\n Plan:\n Continue to monitor HCT and PLTS, monitor for further signs of\n bleeding, continue IV steroids, HCT goal >21; plan to start\n chemotherapy tonight or tomorrow\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Transferred from BMT floor for increased O2 requirement, placed on CPAP\n overnight for sleep apnea\n uses his own set-up; desatted down to mids\n 80\ns whenever he takes his O2 off; desatted while on 6 liters via nasal\n cannula; lung sounds clear, diminished at bases; occasional\n non-productive cough; Placed on cool aerosol via face tent 100% at\n 0800\n sats improved wgile on cool neb; CXR showed increasing fluid\n overload due to hydration to flush kidney\n Action:\n O2 weaned down to 50% FiO2, flovent dc\n no wheezing noted; PRN\n albuterol and atrovent nebs continues; continues on cefipime and\n levofloxacin IV for RML pneumonia\n Response:\n O2 sats > 92% at 50% FiO2\n Plan:\n Wean O2 as tolerated\n Oriented x 3, denies pain still with weakness but helps with turning.\n BP stable in the 110\ns MAP above 60 mmHg; pedal pulses easily palpable,\n normal sinus rhythm in the 80\ns no PVC\ns noted\n On sips of clear liquids for now, no BM this shift, refused colace\n Patient\ns family stayed most of the day ( patient\ns 3 sons came and\n visited too after school) wife and patient bother\ns very supportive\n with recent diagnosis\n Uric Acid blood test to be rechecked @ 2200( this specimen is in a\n green top vial and placed on ice.) PLEASE CALL STAT LABS WHEN YOU ARE\n ABOUT TO SEND URIC ACID ON A GREEN TOP WITH ICE.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736705,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to have progressive anemia from 44 to 25 and in\n acute renal failure with creatinine 2.2, elevated LFT's, and Ca+ 17.7.\n He was originally admitted to 3 but during fluid resuscitation\n became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward. Pt with recent rib fractures\n related to increased calcium levels. Skeletal survey films of skull,\n long bones and spine showed no obvious lucent lesions and innumerable\n small lytic foci which are consistent with myeloma; also Degenerative\n changes in the spine and Aortic calcification.\n Action:\n completed his calcitonin SC injection, continues on NS @ 150cc/hr and\n PRN IV lasix; tumor lysis labs q6hrs\n Response:\n Calcium trending down. Good U/O. K, MG stable.\n Plan:\n Monitor for signs and symptoms of hypercalcemia / arrhythmias.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr remains elevated but trending down; urine output > 200cc/hr;\n clear, yellow urine via foley; Renal following, renal failure likely\n related to hypercalcemia induced vasoconstriction to renal\n vasculature.\n Action:\n Continues on NS 150cc/hr , no need for IV lasix this shift. Taking po\n fluids/ water.\n Response:\n Cont to diurese well, > 200ml/hour u/o. negative 8L LOS and 1.6 liters\n since MN, renal function improving\n Plan:\n Continue lytes check with tumor lysis labs, monitor I/O\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . Pt. had nosebleed yesterday. CT done consistent of myeloma.\n ECHO from showing EF >55%; petechia on hands and feet steady; BMT\n following for chemotherapy; received 1 unit PRBC and 1 pack of\n platelets\n Action:\n Afrin x 3 days ( day 2), IV steroids continues ( last dose today);\n received chemo valcade last night\n Response:\n no episode of nosebleed noted\n Plan:\n transfuse to keep hct >23 and platelet >10 if no s/s of bleeding; next\n chemo on sat (72 hrs after last was given) will add cytoxan as\n second if patient remains to be stable\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on 4L NC while awake, placed on CPAP overnight for sleep apnea\n uses his own machine from home; desats to 84-85% off O2. Tachypneic.\n Lung sounds clear, diminished at bases; occasional non-productive\n cough. Patient anxious, worried during night.\n Action:\n Patient on cpap at MN. Sat 98% with 10L bleed in. Zyprexa for sleep\n Response:\n O2 sats 95-98% on CPAP.\n Plan:\n Wean O2 as tolerated\n"
},
{
"category": "Respiratory ",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 736759,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 53.5 None\n Ideal tidal volume: mL/kg\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: /\n Comments: Non productive cough\n Comments: Received on continuous 4L nasal cannula, weaned down from\n 70-50% face tent previous day. Rested overnight on Pt's own nasal CPAP\n machine, preset @ 11cmH2O. O2 \"bleed in\" titrated to meet sat goal of\n 90-95%. Well tolerated by patient. Albuterol/Atrovent prn, not needed\n tonight.\n Plan\n Next 24-48 hours:\n Reason for continuing current support: Continue present respiratory\n care plan, as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-15 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 735361,
"text": "Chief Complaint: Malaise\n HPI:\n 47M with a history of obesity, asthma, chronic low back pain, 2 recent\n rib fractures, and a recent dental abscess who presented to the ED for\n malaise. He had been seen by his pulmonologist recently who diagnosed\n the second of his 2 rib fractures and he was started on Aleve. Both\n fractures occured with incidental trauma - (first with bumping his\n couch, second with coughing). He reports that he has been feeling\n unwell for a month or so, but has been severely fatigued for the past 2\n weeks. Over the past 2 weeks he also has had progressive exertional\n dyspnea with significant decrease in his exercise tolerance. Mild\n subjective fevers at home, no weigh gain or weight loss, night sweats,\n or chills. complains of total body pain but no focal pain in back or\n other areas. He called his PCP with complaint DOE for the past 3 days\n and was called in to the ED.\n .\n In the ED his initial vital signs were 98.4 85 129/98 and 97% on RA. He\n was found to have progressive anemia from H/H 14.9/44.9 a year ago to\n 9.0/25.7 with almost no change in MCV with new thrombocytopenia to 101\n and an abnormal differential with a WBC of 8.7. He also had new \n with creatinine of 2.2. Given an initial concern for TTP, Tbili and LDH\n were added. The Tbili came back WNL but his LDH was elevated to 764.\n He was also noted to have a new murmur on exam. BCx were taken for\n possible endocarditis. Cardiology was consulted for TTE but this was\n deferred. He was admitted to for further management.\n .\n On the floor he was lethargic and ill appearing. Given his\n constellation of anemia, thrombocytopenia, and abnormal differential\n with multiple myeloid forms, his smear was reviewed and uric acid,\n LFTs, Ca, Mg, and Pi were added to his labs. His uric acid came back at\n 12.9 and his calcium came back at 17.7. An ionized calcium was then\n sent, a second PIV was placed, and IVF were started. Coags and\n fibrinogen were also sent, which were WNL.\n .\n Patient tolerated IV fluids with some increase in his O2 requirement to\n 2L-4L NC. Triggered this AM for somnolence and altered mental status.\n Heme-Onc consulted for concern for new myeloma diagnosis vs. TTP.\n Requesting unit transfer for close monitoring of his volume status and\n for nursing concern.\n .\n ROS low grade temps at home, marked new dyspnea with exertion.\n .\n Patient admitted from: \n History obtained from Patient, Family / Medical records\n Allergies:\n Iodine; Iodine Containing\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 Past Medical History:\n - Asthma - using inhaler more frequently, but with no good effect\n - Costrochondritis recently diagnosed\n - Lower back pain w/ L3-L4 lateral disc protrusion\n - Obesity\n - Nephrolithiasis\n - H/O atypical chest pain\n - Rectal bleeding\n - Hyperlipidemia\n - Sleep apnea, OSA 11cm H20\n - S/P rib fractures x2\n - Depression\n .\n Home Medications:\n - ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - \n puffs(s) by mouth every four (4) to six (6) hours as needed for\n cough/wheezing\n - BUDESONIDE [PULMICORT FLEXHALER] - 180 mcg/Actuation (160 mcg\n delivered) Aerosol Powdr Breath Activated - 2 (Two) puffs(s)\n inhaled twice a day\n - BUPROPION HCL [BUDEPRION SR] - 150 mg Tablet Sustained Release -\n 1 Tablet(s) by mouth once a day in the morning; increase to 150\n mg twice daily by day 4 if tolerated --> not taking\n - NAPROXEN SODIUM [ALEVE] - 220 mg Tablet - 1 to 2 Tablet(s) by\n mouth twice a day with food as needed for chest pain\n .\n Allergies:\n - Iodine --> Choking sensation\n - Mother: CAD and DM\n - Father: DM\n - No history of cancer or sarcoidosis\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives in with his wife. They have three sons. She is a\n plastic surgeon who trained at .\n - Tobacco: Denies\n - etOH: Denies\n - Illicits: Denies\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: diffuse body aches\n Flowsheet Data as of 10:51 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 85 (85 - 85) bpm\n RR: 23 (23 - 23) insp/min\n SpO2: 96%\n Total In:\n PO:\n TF:\n IVF:\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 -250 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), radiates to axilla, posterior chest, III/VI\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n very scattered at bases, Diminished: )\n Abdominal: Soft, Tender: RUQ, , Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not\n assessed, somewhat drowsy\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Notable for Hct 26, Plt 101, Uric Acid 13,\n Calcium 18, Cr 2.2,\n Peripheral smear: Normocytic RBC with anisocytosis, many teardrops,\n some cigar forms, no schistocytes, no acanthocytes or echinocytes.\n Possibly roleaux formation, but uncertain. Platlets are somewhat\n reduced in number and there are some large platlets. No obvious blasts\n in the main portion of the smear or the feathered edge. Several large\n mononuclear cells ? atypical lymphocytes, many bands, metamyelocytes,\n and myelocytes. Many monocytes.\n Imaging: - CXR: No acute process on admission.\n Microbiology: Blood Cultures Pending\n ECG: New RBBB.\n Assessment and Plan\n 47M with a history asthma, recent dental infection, recent rib\n fracures, now presents with progressive malaise in setting of\n hypercalcemia, renal failure, hyperuricemia, and abnormal differential\n which is highly suggestive of a new malignancy diagnosis. Would favor\n multiple myeloma as most likely, although lymphoma/leukemia are in\n differential. Altered mental status, renal failure and\n thrombocytopenia c/w TTP but no schistocytes on smear excluding dx.\n Overall constellation of symptoms is likely explained by severe\n hypercalcemia.\n .\n # Hypercalcemia: Likely malignant given the degree of hypercalcemia.\n Admission calcium is 17.7 with an ionized calcium of 2.13. Not on HCTZ,\n not taking vitamin D, and not taking calcium. Sarcoidosis is also\n within the differential but does not explain the hematologic\n abnormalities.\n - Continue IV normal saline at 200cc/hr until 2Liters given\n - Furosemide dosing q6 hours (await repeat labs, but anticipate can\n start as intravascularly replete).\n - Place foley for accurate Is and Os\n - Zoledronate 4mg IV once (Pamidronate associated with FSGS so opt for\n zoledronate).\n - Calcitonin -> can be dosed , one dose given this AM.\n - Trend calcium Q6H for now\n - Malignancy work up as below\n - TSH pending\n - Parathyroid Hormone pending for endocrine cause of his hypercalcemia\n - Vitamin D pending\n - Vitamin D 25 pending\n - Heme-Onc consult\n - Renal Consult\n - ACE Level\n .\n # Respiratory Status/volume: Increasing O2 requirement in setting of\n volume resuscitation. Likely pulmonary edema. Potentially underlying\n valvular disease given murmur on exam. Lasix as needed. Got 20mg IV\n lasix on floor -> unclear what was to that dose, but lasix naive.\n Goal to keep I/O even.\n - lasix q6hours\n - CXR now\n - Echo, f/u blood cultures\n .\n # Hyperuricemia: Likely due to cell turn over given elevated LDH, in\n setting of dehydration. Complicated by and likely contributing to\n .\n - Start allopurinol 100mg daily\n - serum pH remains alkalemic so will defer bicarbonate infusion.\n - trend pH\n .\n # Acute kidney injury: Likely combination of hypercalcemia,\n hyperuricemia as a component of tumor lysis, and poor POs.\n - Renal consult in AM.\n - require HD for calcium, uric acid, possible tumor lysis\n - Moderate UEos, etiology unclear. Stopping all nonessential meds\n .\n # Likely cancer diagnosis:\n - Heme onc consult for BM biopsy, hold steroids until biopsy performed.\n - PSA pending\n - skeletal survey if can be done as portable\n - ESR and CRP are elevated\n - SPEP pending for ?MM\n - UPEP pending for ?MM\n - Serum free light chains pending\n - B2uGlobulin pending\n - No steroids to avoid complicating possible diagnosis\n - EBV Antibody Panel, CMV IgG/IgM Antibody Panel, and Toxoplasma\n IgG/IgM Antibody Panel pending given atypical lymphocytes on smear all\n ordered\n .\n # Anemia: Likely due to a bone marrow process. No evidence of TTP or\n intravascular hemolysis. Elevated haptoglobin and ferritin.\n - Likely marrow failure\n - Type and screen up to date, cross match one unit as will likely need\n blood after IVFs given\n - Transfuse for H/H < \n - Guaiac stools.\n .\n # Asthma:\n - Albuterol and ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, NPO for now, but ADAT\n # Prophylaxis:\n -DVT ppx with SC heparin\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n # Access: peripherals\n # Communication: Patient\n # Code: full\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-15 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 735367,
"text": "Chief Complaint: Malaise\n HPI:\n 47M with a history of obesity, asthma, chronic low back pain, 2 recent\n rib fractures, and a recent dental abscess who presented to the ED for\n malaise. He had been seen by his pulmonologist recently who diagnosed\n the second of his 2 rib fractures and he was started on Aleve. Both\n fractures occured with incidental trauma - (first with bumping his\n couch, second with coughing). He reports that he has been feeling\n unwell for a month or so, but has been severely fatigued for the past 2\n weeks. Over the past 2 weeks he also has had progressive exertional\n dyspnea with significant decrease in his exercise tolerance. Mild\n subjective fevers at home, no weigh gain or weight loss, night sweats,\n or chills. complains of total body pain but no focal pain in back or\n other areas. He called his PCP with complaint DOE for the past 3 days\n and was called in to the ED.\n .\n In the ED his initial vital signs were 98.4 85 129/98 and 97% on RA. He\n was found to have progressive anemia from H/H 14.9/44.9 a year ago to\n 9.0/25.7 with almost no change in MCV with new thrombocytopenia to 101\n and an abnormal differential with a WBC of 8.7. He also had new \n with creatinine of 2.2. Given an initial concern for TTP, Tbili and LDH\n were added. The Tbili came back WNL but his LDH was elevated to 764.\n He was also noted to have a new murmur on exam. BCx were taken for\n possible endocarditis. Cardiology was consulted for TTE but this was\n deferred. He was admitted to for further management.\n .\n On the floor he was lethargic and ill appearing. Given his\n constellation of anemia, thrombocytopenia, and abnormal differential\n with multiple myeloid forms, his smear was reviewed and uric acid,\n LFTs, Ca, Mg, and Pi were added to his labs. His uric acid came back at\n 12.9 and his calcium came back at 17.7. An ionized calcium was then\n sent, a second PIV was placed, and IVF were started. Coags and\n fibrinogen were also sent, which were WNL.\n .\n Patient tolerated IV fluids with some increase in his O2 requirement to\n 2L-4L NC. Triggered this AM for somnolence and altered mental status.\n Heme-Onc consulted for concern for new myeloma diagnosis vs. TTP.\n Requesting unit transfer for close monitoring of his volume status and\n for nursing concern.\n .\n ROS low grade temps at home, marked new dyspnea with exertion.\n .\n Patient admitted from: \n History obtained from Patient, Family / Medical records\n Allergies:\n Iodine; Iodine Containing\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 Past Medical History:\n - Asthma - using inhaler more frequently, but with no good effect\n - Costrochondritis recently diagnosed\n - Lower back pain w/ L3-L4 lateral disc protrusion\n - Obesity\n - Nephrolithiasis\n - H/O atypical chest pain\n - Rectal bleeding\n - Hyperlipidemia\n - Sleep apnea, OSA 11cm H20\n - S/P rib fractures x2\n - Depression\n .\n Home Medications:\n - ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - \n puffs(s) by mouth every four (4) to six (6) hours as needed for\n cough/wheezing\n - BUDESONIDE [PULMICORT FLEXHALER] - 180 mcg/Actuation (160 mcg\n delivered) Aerosol Powdr Breath Activated - 2 (Two) puffs(s)\n inhaled twice a day\n - BUPROPION HCL [BUDEPRION SR] - 150 mg Tablet Sustained Release -\n 1 Tablet(s) by mouth once a day in the morning; increase to 150\n mg twice daily by day 4 if tolerated --> not taking\n - NAPROXEN SODIUM [ALEVE] - 220 mg Tablet - 1 to 2 Tablet(s) by\n mouth twice a day with food as needed for chest pain\n .\n Allergies:\n - Iodine --> Choking sensation\n - Mother: CAD and DM\n - Father: DM\n - No history of cancer or sarcoidosis\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives in with his wife. They have three sons. She is a\n plastic surgeon who trained at .\n - Tobacco: Denies\n - etOH: Denies\n - Illicits: Denies\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: diffuse body aches\n Flowsheet Data as of 10:51 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 85 (85 - 85) bpm\n RR: 23 (23 - 23) insp/min\n SpO2: 96%\n Total In:\n PO:\n TF:\n IVF:\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 -250 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), radiates to axilla, posterior chest, III/VI\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n very scattered at bases, Diminished: )\n Abdominal: Soft, Tender: RUQ, , Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not\n assessed, somewhat drowsy\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Notable for Hct 26, Plt 101, Uric Acid 13,\n Calcium 18, Cr 2.2,\n Peripheral smear: Normocytic RBC with anisocytosis, many teardrops,\n some cigar forms, no schistocytes, no acanthocytes or echinocytes.\n Possibly roleaux formation, but uncertain. Platlets are somewhat\n reduced in number and there are some large platlets. No obvious blasts\n in the main portion of the smear or the feathered edge. Several large\n mononuclear cells ? atypical lymphocytes, many bands, metamyelocytes,\n and myelocytes. Many monocytes.\n Imaging: - CXR: No acute process on admission.\n Microbiology: Blood Cultures Pending\n ECG: New RBBB.\n Assessment and Plan\n 47M with a history asthma, recent dental infection, recent rib\n fracures, now presents with progressive malaise in setting of\n hypercalcemia, renal failure, hyperuricemia, and abnormal differential\n which is highly suggestive of a new malignancy diagnosis. Would favor\n multiple myeloma as most likely, although lymphoma/leukemia are in\n differential. Altered mental status, renal failure and\n thrombocytopenia c/w TTP but no schistocytes on smear excluding dx.\n Overall constellation of symptoms is likely explained by severe\n hypercalcemia.\n .\n # Hypercalcemia: Likely malignant given the degree of hypercalcemia.\n Admission calcium is 17.7 with an ionized calcium of 2.13. Not on HCTZ,\n not taking vitamin D, and not taking calcium. Sarcoidosis is also\n within the differential but does not explain the hematologic\n abnormalities.\n - Continue IV normal saline at 200cc/hr until 2Liters given\n - Furosemide dosing q6 hours (await repeat labs, but anticipate can\n start as intravascularly replete).\n - Place foley for accurate Is and Os\n - Zoledronate 4mg IV once (Pamidronate associated with FSGS so opt for\n zoledronate).\n - Calcitonin -> can be dosed , one dose given this AM.\n - Trend calcium Q6H for now\n - Malignancy work up as below\n - TSH pending\n - Parathyroid Hormone pending for endocrine cause of his hypercalcemia\n - Vitamin D pending\n - Vitamin D 25 pending\n - Heme-Onc consult\n - Renal Consult\n - ACE Level\n .\n # Respiratory Status/volume: Increasing O2 requirement in setting of\n volume resuscitation. Likely pulmonary edema. Potentially underlying\n valvular disease given murmur on exam. Lasix as needed. Got 20mg IV\n lasix on floor -> unclear what was to that dose, but lasix naive.\n - lasix q6hours\n - CXR now\n - Echo, f/u blood cultures\n .\n # Hyperuricemia: Likely due to cell turn over given elevated LDH, in\n setting of dehydration. Complicated by and likely contributing to\n .\n - Start allopurinol 100mg daily\n - serum pH remains alkalemic so will defer bicarbonate infusion.\n - trend pH\n .\n # Acute kidney injury: Likely combination of hypercalcemia,\n hyperuricemia as a component of tumor lysis, and poor POs.\n - Renal consult in AM.\n - require HD for calcium, uric acid, possible tumor lysis\n - Moderate UEos, etiology unclear. Stopping all nonessential meds\n .\n # Likely cancer diagnosis:\n - Heme onc consult for BM biopsy, hold steroids until biopsy performed.\n - PSA pending\n - skeletal survey if can be done as portable\n - ESR and CRP are elevated\n - SPEP pending for ?MM\n - UPEP pending for ?MM\n - Serum free light chains pending\n - B2uGlobulin pending\n - No steroids to avoid complicating possible diagnosis\n - EBV Antibody Panel, CMV IgG/IgM Antibody Panel, and Toxoplasma\n IgG/IgM Antibody Panel pending given atypical lymphocytes on smear all\n ordered\n .\n # Anemia: Likely due to a bone marrow process. No evidence of TTP or\n intravascular hemolysis. Elevated haptoglobin and ferritin.\n - Likely marrow failure\n - Type and screen up to date, cross match one unit as will likely need\n blood after IVFs given\n - Transfuse for H/H < \n - Guaiac stools.\n .\n # Hypertension: Continue to follow. Treat accordingly.\n # Asthma:\n - Albuterol and ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, NPO for now, but ADAT\n # Prophylaxis:\n -DVT ppx with SC heparin\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n # Access: peripherals\n # Communication: Patient\n # Code: full\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736404,
"text": "47 year old man with a history of asthma, OSA, chronic low back pain\n with recent rib fractures now presenting from the ed with anemia,\n thrombocytopenia, hypercalcemia and arf. Bone marrow biopsy c/w\n myeloma.\n Events Overnight: Pt transfused with 1 unit prbc\ns last evening. He\n received his initial dose of bortezomib iv from the oncology nurse last\n evening as well. He was premedicated with zofran.\n Anemia, other\n Assessment:\n Received pt with a repeat hct 21; per MICU team\ns discussion with\n oncology, the decision was made to transfuse the pt with 1 unit prbc\n As noted above, the pt received his initial dose of chemotherapy.\n Action:\n Transfused w/1 unit prbc\ns without incident. Received chemotherapy\n without incident or c/o nausea.\n Response:\n Repeat hct this morning ~24. Plt count 62K.\n Plan:\n Monitor serial cbc results. Transfuse for hct >21 and plt count >40. Pt\n not scheduled for another dose of chemo until the weekend.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Serial creatinine levels are slowly trending downward. The pt continues\n to receive aggressive fluid resuscitation with prn lasix dosing as\n needed.\n Action:\n ARF likely d/t hypercalcemia slowly improving. Pt did receive another\n 80mg iv lasix dose early this morning to meet fluid loss goals.\n Response:\n Good response to diuretic. Pt completed yesterday nearly 2 liters total\n fluid balance negative.\n Plan:\n Monitor i&o\ns closely. Diurese to maintain a daily 2L fluid loss goal.\n Monitor serial bun/creat levels.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt receiving 50% cool face tent for most of the evening. He was placed\n back on his bipap ~mn this morning. He is maintaining saturations\n <93%. He denies subjective c/o sob although he is transiently\n tachypneic w/rates <35.\n Action:\n NARD. Tachypnea mostly r/t exertion. He is afebrile, receiving abx\n coverage for a pnx.\n Response:\n Unchanged.\n Plan:\n Monitor lung exam, saturations, fever curve. Wean o2 as the pt is able\n to tolerate. Get oob to the chair.\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 736878,
"text": "Chief Complaint: Respiratory distress\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 Overall, improving.\n States breathing is easier.\n Less rib pain.\n History obtained from Medical records\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, 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\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 35.9\nC (96.7\n HR: 83 (70 - 83) bpm\n BP: 120/58(70) {108/50(66) - 138/78(86)} mmHg\n RR: 19 (13 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 5,716 mL\n 3,682 mL\n PO:\n 1,560 mL\n 1,460 mL\n TF:\n IVF:\n 4,156 mL\n 1,872 mL\n Blood products:\n 350 mL\n Total out:\n 7,690 mL\n 3,170 mL\n Urine:\n 7,690 mL\n 3,170 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,974 mL\n 512 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: No(t) Resonant : , No(t) Hyperresonant: , No(t) Dullness :\n ), (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , 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: , Obese\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal, Speech much clearer & fluent, sensorium much\n clearer\n Labs / Radiology\n 7.4 g/dL\n 50 K/uL\n 159 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 122 mg/dL\n 105 mEq/L\n 141 mEq/L\n 21.1 %\n 8.3 K/uL\n [image002.jpg]\n 10:03 PM\n 05:25 AM\n 09:36 AM\n 03:07 PM\n 10:00 PM\n 04:10 AM\n 09:52 AM\n 03:20 PM\n 09:45 PM\n 05:41 AM\n WBC\n 11.5\n 12.7\n 9.7\n 8.3\n Hct\n 22.5\n 24.5\n 23.7\n 23.1\n 21.1\n Plt\n 43\n 66\n 62\n 55\n 57\n 50\n Cr\n 3.6\n 3.5\n 3.5\n 3.4\n 3.3\n 3.1\n 3.0\n 2.7\n 2.5\n TropT\n 0.01\n Glucose\n 149\n 163\n 166\n 147\n 155\n 174\n 150\n 159\n Other labs: PT / PTT / INR:17.0/23.1/1.5, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:67/88, Alk Phos / T Bili:54/0.4,\n Differential-Neuts:33.0 %, Band:1.0 %, Lymph:51.0 %, Mono:5.0 %,\n Eos:0.0 %, D-dimer:150 ng/mL, Fibrinogen:440 mg/dL, Lactic Acid:0.8\n mmol/L, LDH:2214 IU/L, Ca++:7.1 mg/dL, Mg++:2.3 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 47 yom asthma, OSA, chronic low back pain, recent rib fracure now with\n multiple myeloma. Gradual clinical improvement.\n RESPIRATORY DISTRESS -- Prior CXR and CT consistent with pulmonary\n edema, now much improved. Underlying asthma, OSA, moderate pulmonary\n HTN. Rib fractures likely contributing to limiting respiratory\n efforts. Continue net diuresis. Provide oxygen, maintain SaO2 >90%.\n PNEUMONIA -- Possible RLL pneuomonia. Continue Levofloxacin &\n Cefepime, renal dosing.\n ASTHMA -- Continue Albuterol, Fluticasone, & Ipratropium nebs q6H PRN\n OSA\n Nasal CPAP at night at 11cm H20.\n MULTIPLE MYELOMA -- Dx confirmed by bone marrow biopsy. Awaiting\n initiating chemotherapy. Continue dexamethasome.\n ALTERED MENTAL STATUS -- improved. Monitor.\n FLUIDS -- Continue IVF's at 150cc NS/hr, titrate to UOP of\n 200-300cc/hr. Use lasix as needed. Restrict PO intake.\n EPISTAXIS -- chronic history, escalation in context of\n thrombocytopenia. If persists or escalated, consider ENT evaluation\n and packing\n THROMBOCYTOPENIA -- related to myeloma. Good response to plts\n transfusion. Monitor. Transfuse <50\n HYPERCALCEMIA -- Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n HYPERURICEMIA -- Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase this PM. Continue\n Allopurinol 100mg daily\n ACUTE RENAL FAILURE -- Cr 3.7 and continuing to rise. Renal following.\n Renal failure is likely tubular injury from cast nephropathy in\n conjunction with hypercalcemia, hyperuricemia.\n ANEMIA -- Low reticulocyte count, elevated haptoglobin & ferritin.\n demonstrating insufficient erythropoeisis. No evidence of TTP or\n intravascular hemolysis. Transfuse for HCT <25. Guaiac stools\n FLUIDS -- IVF as above, replete electrolytes.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-15 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 735382,
"text": "Chief Complaint: Malaise\n HPI:\n 47M with a history of obesity, asthma, chronic low back pain, 2 recent\n rib fractures, and a recent dental abscess who presented to the ED for\n malaise. He had been seen by his pulmonologist recently who diagnosed\n the second of his 2 rib fractures and he was started on Aleve. Both\n fractures occured with incidental trauma - (first with bumping his\n couch, second with coughing). He reports that he has been feeling\n unwell for a month or so, but has been severely fatigued for the past 2\n weeks. Over the past 2 weeks he also has had progressive exertional\n dyspnea with significant decrease in his exercise tolerance. Mild\n subjective fevers at home, no weigh gain or weight loss, night sweats,\n or chills. complains of total body pain but no focal pain in back or\n other areas. He called his PCP with complaint DOE for the past 3 days\n and was called in to the ED.\n .\n In the ED his initial vital signs were 98.4 85 129/98 and 97% on RA. He\n was found to have progressive anemia from H/H 14.9/44.9 a year ago to\n 9.0/25.7 with almost no change in MCV with new thrombocytopenia to 101\n and an abnormal differential with a WBC of 8.7. He also had new \n with creatinine of 2.2. Given an initial concern for TTP, Tbili and LDH\n were added. The Tbili came back WNL but his LDH was elevated to 764.\n He was also noted to have a new murmur on exam. BCx were taken for\n possible endocarditis. Cardiology was consulted for TTE but this was\n deferred. He was admitted to for further management.\n .\n On the floor he was lethargic and ill appearing. Given his\n constellation of anemia, thrombocytopenia, and abnormal differential\n with multiple myeloid forms, his smear was reviewed and uric acid,\n LFTs, Ca, Mg, and Pi were added to his labs. His uric acid came back at\n 12.9 and his calcium came back at 17.7. An ionized calcium was then\n sent, a second PIV was placed, and IVF were started. Coags and\n fibrinogen were also sent, which were WNL.\n .\n Patient tolerated IV fluids with some increase in his O2 requirement to\n 2L-4L NC. Triggered this AM for somnolence and altered mental status.\n Heme-Onc consulted for concern for new myeloma diagnosis vs. TTP.\n Requesting unit transfer for close monitoring of his volume status and\n for nursing concern.\n .\n ROS low grade temps at home, marked new dyspnea with exertion.\n .\n Patient admitted from: \n History obtained from Patient, Family / Medical records\n Allergies:\n Iodine; Iodine Containing\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 Past Medical History:\n - Asthma - using inhaler more frequently, but with no good effect\n - Costrochondritis recently diagnosed\n - Lower back pain w/ L3-L4 lateral disc protrusion\n - Obesity\n - Nephrolithiasis\n - H/O atypical chest pain\n - Rectal bleeding\n - Hyperlipidemia\n - Sleep apnea, OSA 11cm H20\n - S/P rib fractures x2\n - Depression\n .\n Home Medications:\n - ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - \n puffs(s) by mouth every four (4) to six (6) hours as needed for\n cough/wheezing\n - BUDESONIDE [PULMICORT FLEXHALER] - 180 mcg/Actuation (160 mcg\n delivered) Aerosol Powdr Breath Activated - 2 (Two) puffs(s)\n inhaled twice a day\n - BUPROPION HCL [BUDEPRION SR] - 150 mg Tablet Sustained Release -\n 1 Tablet(s) by mouth once a day in the morning; increase to 150\n mg twice daily by day 4 if tolerated --> not taking\n - NAPROXEN SODIUM [ALEVE] - 220 mg Tablet - 1 to 2 Tablet(s) by\n mouth twice a day with food as needed for chest pain\n .\n Allergies:\n - Iodine --> Choking sensation\n - Mother: CAD and DM\n - Father: DM\n - No history of cancer or sarcoidosis\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives in with his wife. They have three sons. She is a\n plastic surgeon who trained at .\n - Tobacco: Denies\n - etOH: Denies\n - Illicits: Denies\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: diffuse body aches\n Flowsheet Data as of 10:51 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 85 (85 - 85) bpm\n RR: 23 (23 - 23) insp/min\n SpO2: 96%\n Total In:\n PO:\n TF:\n IVF:\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 -250 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), radiates to axilla, posterior chest, III/VI\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n very scattered at bases, Diminished: )\n Abdominal: Soft, Tender: RUQ, , Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not\n assessed, somewhat drowsy\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Notable for Hct 26, Plt 101, Uric Acid 13,\n Calcium 18, Cr 2.2,\n Peripheral smear: Normocytic RBC with anisocytosis, many teardrops,\n some cigar forms, no schistocytes, no acanthocytes or echinocytes.\n Possibly roleaux formation, but uncertain. Platlets are somewhat\n reduced in number and there are some large platlets. No obvious blasts\n in the main portion of the smear or the feathered edge. Several large\n mononuclear cells ? atypical lymphocytes, many bands, metamyelocytes,\n and myelocytes. Many monocytes.\n Imaging: - CXR: No acute process on admission.\n Microbiology: Blood Cultures Pending\n ECG: New RBBB.\n Assessment and Plan\n 47M with a history asthma, recent dental infection, recent rib\n fracures, now presents with progressive malaise in setting of\n hypercalcemia, renal failure, hyperuricemia, and abnormal differential\n which is highly suggestive of a new malignancy diagnosis. Would favor\n multiple myeloma as most likely, although lymphoma/leukemia are in\n differential. Altered mental status, renal failure and\n thrombocytopenia c/w TTP but no schistocytes on smear excluding dx.\n Overall constellation of symptoms is likely explained by severe\n hypercalcemia.\n .\n # Hypercalcemia: Likely malignant given the degree of hypercalcemia.\n Admission calcium is 17.7 with an ionized calcium of 2.13. Not on HCTZ,\n not taking vitamin D, and not taking calcium. Sarcoidosis is also\n within the differential but does not explain the hematologic\n abnormalities.\n - Continue IV normal saline at 200cc/hr until 2Liters given\n - Furosemide dosing q6 hours (await repeat labs, but anticipate can\n start as intravascularly replete).\n - Place foley for accurate Is and Os\n - Zoledronate 4mg IV once (Pamidronate associated with FSGS so opt for\n zoledronate).\n - Calcitonin -> can be dosed , one dose given this AM.\n - Trend calcium Q6H for now\n - Malignancy work up as below\n - TSH pending\n - Parathyroid Hormone pending for endocrine cause of his hypercalcemia\n - Vitamin D pending\n - Vitamin D 25 pending\n - Heme-Onc consult\n - Renal Consult\n - ACE Level\n .\n # Respiratory Status/volume: Increasing O2 requirement in setting of\n volume resuscitation. Likely pulmonary edema. Potentially underlying\n valvular disease given murmur on exam. Lasix as needed. Got 20mg IV\n lasix on floor -> unclear what was to that dose, but lasix naive.\n - lasix q6hours\n - CXR now\n - Echo, f/u blood cultures\n .\n # Hyperuricemia: Likely due to cell turn over given elevated LDH, in\n setting of dehydration. Complicated by and likely contributing to\n .\n - Start allopurinol 100mg daily\n - serum pH remains alkalemic so will defer bicarbonate infusion.\n - trend pH\n .\n # Acute kidney injury: Likely combination of hypercalcemia,\n hyperuricemia as a component of tumor lysis, and poor POs.\n - Renal consult in AM.\n - require HD for calcium, uric acid, possible tumor lysis\n - Moderate UEos, etiology unclear. Stopping all nonessential meds\n .\n # Likely cancer diagnosis:\n - Heme onc consult for BM biopsy, hold steroids until biopsy performed.\n - PSA pending\n - skeletal survey if can be done as portable\n - ESR and CRP are elevated\n - SPEP pending for ?MM\n - UPEP pending for ?MM\n - Serum free light chains pending\n - B2uGlobulin pending\n - No steroids to avoid complicating possible diagnosis\n - EBV Antibody Panel, CMV IgG/IgM Antibody Panel, and Toxoplasma\n IgG/IgM Antibody Panel pending given atypical lymphocytes on smear all\n ordered\n .\n # Anemia: Likely due to a bone marrow process. No evidence of TTP or\n intravascular hemolysis. Elevated haptoglobin and ferritin.\n - Likely marrow failure\n - Type and screen up to date, cross match one unit as will likely need\n blood after IVFs given\n - Transfuse for H/H < \n - Guaiac stools.\n .\n # Hypertension: Continue to follow. Treat accordingly.\n # Asthma:\n - Albuterol and ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, NPO for now, but ADAT\n # Prophylaxis:\n -DVT ppx with SC heparin\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n # Access: peripherals\n # Communication: Patient\n # Code: full\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-15 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 735383,
"text": "Chief Complaint: Malaise\n HPI:\n 47M with a history of obesity, asthma, chronic low back pain, 2 recent\n rib fractures, and a recent dental abscess who presented to the ED for\n malaise. He had been seen by his pulmonologist recently who diagnosed\n the second of his 2 rib fractures and he was started on Aleve. Both\n fractures occured with incidental trauma - (first with bumping his\n couch, second with coughing). He reports that he has been feeling\n unwell for a month or so, but has been severely fatigued for the past 2\n weeks. Over the past 2 weeks he also has had progressive exertional\n dyspnea with significant decrease in his exercise tolerance. Mild\n subjective fevers at home, no weigh gain or weight loss, night sweats,\n or chills. complains of total body pain but no focal pain in back or\n other areas. He called his PCP with complaint DOE for the past 3 days\n and was called in to the ED.\n .\n In the ED his initial vital signs were 98.4 85 129/98 and 97% on RA. He\n was found to have progressive anemia from H/H 14.9/44.9 a year ago to\n 9.0/25.7 with almost no change in MCV with new thrombocytopenia to 101\n and an abnormal differential with a WBC of 8.7. He also had new \n with creatinine of 2.2. Given an initial concern for TTP, Tbili and LDH\n were added. The Tbili came back WNL but his LDH was elevated to 764.\n He was also noted to have a new murmur on exam. BCx were taken for\n possible endocarditis. Cardiology was consulted for TTE but this was\n deferred. He was admitted to for further management.\n .\n On the floor he was lethargic and ill appearing. Given his\n constellation of anemia, thrombocytopenia, and abnormal differential\n with multiple myeloid forms, his smear was reviewed and uric acid,\n LFTs, Ca, Mg, and Pi were added to his labs. His uric acid came back at\n 12.9 and his calcium came back at 17.7. An ionized calcium was then\n sent, a second PIV was placed, and IVF were started. Coags and\n fibrinogen were also sent, which were WNL.\n .\n Patient tolerated IV fluids with some increase in his O2 requirement to\n 2L-4L NC. Triggered this AM for somnolence and altered mental status.\n Heme-Onc consulted for concern for new myeloma diagnosis vs. TTP.\n Requesting unit transfer for close monitoring of his volume status and\n for nursing concern.\n .\n ROS low grade temps at home, marked new dyspnea with exertion.\n .\n Patient admitted from: \n History obtained from Patient, Family / Medical records\n Allergies:\n Iodine; Iodine Containing\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 Past Medical History:\n - Asthma - using inhaler more frequently, but with no good effect\n - Costrochondritis recently diagnosed\n - Lower back pain w/ L3-L4 lateral disc protrusion\n - Obesity\n - Nephrolithiasis\n - H/O atypical chest pain\n - Rectal bleeding\n - Hyperlipidemia\n - Sleep apnea, OSA 11cm H20\n - S/P rib fractures x2\n - Depression\n .\n Home Medications:\n - ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - \n puffs(s) by mouth every four (4) to six (6) hours as needed for\n cough/wheezing\n - BUDESONIDE [PULMICORT FLEXHALER] - 180 mcg/Actuation (160 mcg\n delivered) Aerosol Powdr Breath Activated - 2 (Two) puffs(s)\n inhaled twice a day\n - BUPROPION HCL [BUDEPRION SR] - 150 mg Tablet Sustained Release -\n 1 Tablet(s) by mouth once a day in the morning; increase to 150\n mg twice daily by day 4 if tolerated --> not taking\n - NAPROXEN SODIUM [ALEVE] - 220 mg Tablet - 1 to 2 Tablet(s) by\n mouth twice a day with food as needed for chest pain\n .\n Allergies:\n - Iodine --> Choking sensation\n - Mother: CAD and DM\n - Father: DM\n - No history of cancer or sarcoidosis\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives in with his wife. They have three sons. She is a\n plastic surgeon who trained at .\n - Tobacco: Denies\n - etOH: Denies\n - Illicits: Denies\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: diffuse body aches\n Flowsheet Data as of 10:51 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 85 (85 - 85) bpm\n RR: 23 (23 - 23) insp/min\n SpO2: 96%\n Total In:\n PO:\n TF:\n IVF:\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 -250 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), radiates to axilla, posterior chest, III/VI\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n very scattered at bases, Diminished: )\n Abdominal: Soft, Tender: RUQ, , Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not\n assessed, somewhat drowsy\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Notable for Hct 26, Plt 101, Uric Acid 13,\n Calcium 18, Cr 2.2,\n Peripheral smear: Normocytic RBC with anisocytosis, many teardrops,\n some cigar forms, no schistocytes, no acanthocytes or echinocytes.\n Possibly roleaux formation, but uncertain. Platlets are somewhat\n reduced in number and there are some large platlets. No obvious blasts\n in the main portion of the smear or the feathered edge. Several large\n mononuclear cells ? atypical lymphocytes, many bands, metamyelocytes,\n and myelocytes. Many monocytes.\n Imaging: - CXR: No acute process on admission.\n Microbiology: Blood Cultures Pending\n ECG: New RBBB.\n Assessment and Plan\n 47M with a history asthma, recent dental infection, recent rib\n fracures, now presents with progressive malaise in setting of\n hypercalcemia, renal failure, hyperuricemia, and abnormal differential\n which is highly suggestive of a new malignancy diagnosis. Would favor\n multiple myeloma as most likely, although lymphoma/leukemia are in\n differential. Altered mental status, renal failure and\n thrombocytopenia c/w TTP but no schistocytes on smear excluding dx.\n Overall constellation of symptoms is likely explained by severe\n hypercalcemia.\n .\n # Hypercalcemia: Likely malignant given the degree of hypercalcemia.\n Admission calcium is 17.7 with an ionized calcium of 2.13. Not on HCTZ,\n not taking vitamin D, and not taking calcium. Sarcoidosis is also\n within the differential but does not explain the hematologic\n abnormalities.\n - Continue IV normal saline at 200cc/hr until 2Liters given\n - Furosemide dosing q6 hours (await repeat labs, but anticipate can\n start as intravascularly replete).\n - Place foley for accurate Is and Os\n - Zoledronate 4mg IV once (Pamidronate associated with FSGS so opt for\n zoledronate).\n - Calcitonin -> can be dosed , one dose given this AM.\n - Trend calcium Q6H for now\n - Malignancy work up as below\n - TSH pending\n - Parathyroid Hormone pending for endocrine cause of his hypercalcemia\n - Vitamin D pending\n - Vitamin D 25 pending\n - Heme-Onc consult\n - Renal Consult\n - ACE Level\n .\n # Respiratory Status/volume: Increasing O2 requirement in setting of\n volume resuscitation. Likely pulmonary edema. Potentially underlying\n valvular disease given murmur on exam. Lasix as needed. Got 20mg IV\n lasix on floor -> unclear what was to that dose, but lasix naive.\n - lasix q6hours\n - CXR now\n - Echo, f/u blood cultures\n .\n # Hyperuricemia: Likely due to cell turn over given elevated LDH, in\n setting of dehydration. Complicated by and likely contributing to\n .\n - Start allopurinol 100mg daily\n - serum pH remains alkalemic so will defer bicarbonate infusion.\n - trend pH\n .\n # Acute kidney injury: Likely combination of hypercalcemia,\n hyperuricemia as a component of tumor lysis, and poor POs.\n - Renal consult in AM.\n - require HD for calcium, uric acid, possible tumor lysis\n - Moderate UEos, etiology unclear. Stopping all nonessential meds\n .\n # Likely cancer diagnosis:\n - Heme onc consult for BM biopsy, hold steroids until biopsy performed.\n - PSA pending\n - skeletal survey if can be done as portable\n - ESR and CRP are elevated\n - SPEP pending for ?MM\n - UPEP pending for ?MM\n - Serum free light chains pending\n - B2uGlobulin pending\n - No steroids to avoid complicating possible diagnosis\n - EBV Antibody Panel, CMV IgG/IgM Antibody Panel, and Toxoplasma\n IgG/IgM Antibody Panel pending given atypical lymphocytes on smear all\n ordered\n .\n # Anemia: Likely due to a bone marrow process. No evidence of TTP or\n intravascular hemolysis. Elevated haptoglobin and ferritin.\n - Likely marrow failure\n - Type and screen up to date, cross match one unit as will likely need\n blood after IVFs given\n - Transfuse for H/H < \n - Guaiac stools.\n .\n # Hypertension: Continue to follow. Treat accordingly.\n # Asthma:\n - Albuterol and ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, NPO for now, but ADAT\n # Prophylaxis:\n -DVT ppx with SC heparin\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n # Access: peripherals\n # Communication: Patient\n # Code: full\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736341,
"text": "47 year old man with a history of asthma, OSA, chronic low back pain\n with recent rib fractures now presenting from the ed with anemia,\n thrombocytopenia, hypercalcemia and arf. Bone marrow biopsy c/w\n myeloma.\n Events Overnight: Pt transfused with 1 unit prbc\ns last evening. He\n received his initial dose of bortezomib iv from the oncology nurse last\n evening as well. He was premedicated with zofran.\n Anemia, other\n Assessment:\n Received pt with a repeat hct 21; per MICU team\ns discussion with\n oncology, the decision was made to transfuse the pt with 1 unit prbc\n As noted above, the pt received his initial dose of chemotherapy.\n Action:\n Transfused w/1 unit prbc\ns without incident. Received chemotherapy\n without incident or c/o nausea.\n Response:\n Repeat hct this morning-------.\n Plan:\n Monitor serial cbc results. Transfuse for hct >21 and plt count >40. pt\n not scheduled for another dose of chemo until the weekend.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Serial creatinine levels are slowly trending downward. The pt continues\n to receive aggressive fluid resuscitation with prn lasix dosing as\n needed.\n Action:\n ARF likely d/t hypercalcemia slowly improving. Pt did receive another\n 80mg iv lasix dose early this morning to meet fluid loss goals.\n Response:\n Good response to diuretic. Pt completed yesterday nearly 2 liters total\n fluid balance negative.\n Plan:\n Monitor i&o\ns closely. Diurese to maintain a daily 2L fluid loss goal.\n Monitor serial bun/creat levels.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt receiving 50% cool face tent for most of the evening. He was placed\n back on his bipap ~mn this morning. He is maintaining saturations\n <93%. He denies subjective c/o sob although he is transiently\n tachypneic w/rates <35.\n Action:\n NARD. Tachypnea mostly r/t exertion. He is afebrile, receiving abx\n coverage for a pnx.\n Response:\n Unchanged.\n Plan:\n Monitor lung exam, saturations, fever curve. Wean o2 as the pt is able\n to tolerate. Get oob to the chair.\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 736457,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - hct/plt, transfuse plt, bumped appropriately, gotten type and cross.\n - BMT rec: hit, fungal markers, IgG level, UPEP, LFTs daily, DIC labs\n daily, TLS labs Q8, d/c allopurinol, starting chemo treatment.\n - Renal rec: SPEP, UPEP, 24 Urine protein, avoid diuresis if possible,\n smear to look for schisto, PRN lasix, and transfuse 1 U PRBC\n - EKG did not show anything impressive.\n - started Chemo, gained fluid after transfusion, giving lasix 80mg IV\n x1.\n - got Hepatitis panel and HIV serology\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Azithromycin - 11:30 AM\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 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 07:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.4\nC (97.6\n HR: 70 (70 - 85) bpm\n BP: 116/65(77) {108/48(65) - 141/84(89)} mmHg\n RR: 19 (19 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 6,032 mL\n 1,478 mL\n PO:\n 1,560 mL\n 120 mL\n TF:\n IVF:\n 3,922 mL\n 1,358 mL\n Blood products:\n 550 mL\n Total out:\n 7,340 mL\n 2,680 mL\n Urine:\n 7,340 mL\n 2,680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,308 mL\n -1,202 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 95%\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 62 K/uL\n 8.0 g/dL\n 174 mg/dL\n 3.1 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 136 mg/dL\n 102 mEq/L\n 143 mEq/L\n 24.5 %\n 12.7 K/uL\n [image002.jpg]\n 05:07 PM\n 10:37 PM\n 04:55 AM\n 07:51 PM\n 10:03 PM\n 05:25 AM\n 09:36 AM\n 03:07 PM\n 10:00 PM\n 04:10 AM\n WBC\n 10.7\n 11.5\n 12.7\n Hct\n 23.4\n 22.5\n 24.5\n Plt\n 59\n 43\n 66\n 62\n Cr\n 3.4\n 3.4\n 3.6\n 3.6\n 3.5\n 3.5\n 3.4\n 3.3\n 3.1\n TropT\n 0.01\n TCO2\n 33\n Glucose\n 169\n 149\n 163\n 166\n 147\n 155\n 174\n Other labs: PT / PTT / INR:17.4/24.1/1.6, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:67/88, Alk Phos / T Bili:54/0.4,\n Differential-Neuts:33.0 %, Band:1.0 %, Lymph:51.0 %, Mono:5.0 %,\n Eos:0.0 %, D-dimer:150 ng/mL, Fibrinogen:435 mg/dL, Lactic Acid:0.8\n mmol/L, LDH:2435 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:6.7 mg/dL\n Assessment and Plan\n 47 yo M with asthma, OSA, chronic low back pain, recent rib fracure,\n who presented with malaise & DOE found to have bony lesions on CT and a\n constellation of hematologic/electrolyte findings consistent with\n multiple myeloma.\n .\n # Dyspnea/Respiratory Distress: Patient with increasing O2 requirement\n in setting of known asthma, fluid therapy, and new right middle lobe\n pneumonia with pulmonary edema. Also with CT chest on with diffuse\n ground glass opacities. Patient also with hyperdynamic heart on TTE\n (EF 75%), elevated BNP to 4232, moderate pulmonary artery hypertension.\n Receiving Lasix with fluids and now on antibiotics.\n - Lasix 80mg \n - IVF's to titrate to UOP 200-300cc/hr\n - Levofloxacin & Cefepime, renally dosed, day \n - O2 to maintain sats >92% using face tent for now\n - CPAP at night at 11cm H2O\n .\n # Multiple Myeloma: Patient with M-protein in both urine & serum\n identified as IgG kappa as well as end-organ dammage manifested as ARF\n and anemia, diffuse lytic lesions on CT and hypercalcemia suggests a\n diagnosis multiple myeloma. Bone marrow biopsy results are positive for\n myeloma, but patient has commenced Dexamethasone therapy as of .\n Normal serum viscosity and patient without signs or symptoms of\n hyperviscosity syndrome, but beta-2 microglobulin was 6.8. EBV/CMV/Toxo\n negative.\n - K/L light chain ratio pending\n - Continue Dexamethasone 40mg IV qday, day \n - Continue IVF's at 150cc NS/hr, titrate to UOP of 200-300cc/hr\n - Continue Lasix 80mg \n - F/U skeletal survey results\n - Oncology following, will guide treatment\n .\n # Hypercalcemia: Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n - Goal urine output 200-300cc/hr\n - Continue IV NS as above\n - Lasix as above\n - Dexamethasone as above\n - q6H labs\n - Vitamin D pending\n - Vitamin D 25 pending\n .\n # Hyperuricemia: Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase .\n - Continue Allopurinol 100mg daily\n - Brisk UOP as above\n - Avoid HCO3 as it will precipitate calcium & phosphate\n - Repeat tumor lysis labs q6h (rasburicase precautions; uric acid level\n must be measured in green top on ice and spun on a cooled centrifuge)\n .\n # Acute renal insufficiency: Cr 3.1, stable/downtrending from\n yesterday. Renal following. Renal failure is likely tubular injury from\n cast nephropathy in conjunction with hypercalcemia, hyperuricemia.\n - f/u renal recs\n - require renal biopsy if function does not improve\n - Continuous IVF's/Lasix to preempt further tubular injury\n .\n # Anemia/Thrombocytopenia: Low reticulocyte count, elevated haptoglobin\n & ferritin demonstrating insufficient erythropoeisis. Likely secondary\n to massive marrow infilitration from multiple myeloma. No evidence of\n TTP, ITP, or intravascular hemolysis.\n - Maintain active T&S\n - Transfuse for HCT <25\n - obtain transfusion goals for platelets from BMT service\n - Guaiac stools\n .\n # Epistaxis: baseline problem worsened by thrombocytopenia and dry air\n of Nasal cannula\n - afrin first line, packing if profuse with appropriate antibiotic ppx\n - avoid nasal cannula, CPAP may worsen as well\n - transfuse plateletes prn\n .\n # Asthma: Continue Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, regular\n .\n # Prophylaxis:\n -DVT ppx with pneumoboots/CPAP\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n .\n # Access: peripherals\n # Communication: Patient\n # Code: FULL\n # Disposition: to BMT floor today if respiratory status remains stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:00 PM\n 20 Gauge - 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": "2136-04-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 736459,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - hct/plt, transfuse plt, bumped appropriately, gotten type and cross.\n - BMT rec: hit, fungal markers, IgG level, UPEP, LFTs daily, DIC labs\n daily, TLS labs Q8, d/c allopurinol, starting chemo treatment.\n - Renal rec: SPEP, UPEP, 24 Urine protein, avoid diuresis if possible,\n smear to look for schisto, PRN lasix, and transfuse 1 U PRBC\n - EKG did not show anything impressive.\n - started Chemo, gained fluid after transfusion, giving lasix 80mg IV\n x1.\n - got Hepatitis panel and HIV serology\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Azithromycin - 11:30 AM\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 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 07:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.4\nC (97.6\n HR: 70 (70 - 85) bpm\n BP: 116/65(77) {108/48(65) - 141/84(89)} mmHg\n RR: 19 (19 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 6,032 mL\n 1,478 mL\n PO:\n 1,560 mL\n 120 mL\n TF:\n IVF:\n 3,922 mL\n 1,358 mL\n Blood products:\n 550 mL\n Total out:\n 7,340 mL\n 2,680 mL\n Urine:\n 7,340 mL\n 2,680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,308 mL\n -1,202 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 95%\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 62 K/uL\n 8.0 g/dL\n 174 mg/dL\n 3.1 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 136 mg/dL\n 102 mEq/L\n 143 mEq/L\n 24.5 %\n 12.7 K/uL\n [image002.jpg]\n 05:07 PM\n 10:37 PM\n 04:55 AM\n 07:51 PM\n 10:03 PM\n 05:25 AM\n 09:36 AM\n 03:07 PM\n 10:00 PM\n 04:10 AM\n WBC\n 10.7\n 11.5\n 12.7\n Hct\n 23.4\n 22.5\n 24.5\n Plt\n 59\n 43\n 66\n 62\n Cr\n 3.4\n 3.4\n 3.6\n 3.6\n 3.5\n 3.5\n 3.4\n 3.3\n 3.1\n TropT\n 0.01\n TCO2\n 33\n Glucose\n 169\n 149\n 163\n 166\n 147\n 155\n 174\n Other labs: PT / PTT / INR:17.4/24.1/1.6, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:67/88, Alk Phos / T Bili:54/0.4,\n Differential-Neuts:33.0 %, Band:1.0 %, Lymph:51.0 %, Mono:5.0 %,\n Eos:0.0 %, D-dimer:150 ng/mL, Fibrinogen:435 mg/dL, Lactic Acid:0.8\n mmol/L, LDH:2435 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:6.7 mg/dL\n Skeletal Survey:\n 1. No obvious lucent lesions identified radiographically. However, the\n torso\n CT obtained the same day shows innumerable small lytic foci which are\n consistent with myeloma. Please see report of that exam. Subtle\n scalloping\n along left femoral diaphysis lateral cortex is of equivocal clinical\n significance.\n 2. Diffuse pulmonary parenchymal opacities which require further\n evaluation.\n Again, please see contemporaneous CT report.\n 3. Degenerative changes in the spine.\n 4. Aortic calcification, unusual in someone of this age. Is there a\n history of\n diabetes or vasculopathy?\n Assessment and Plan\n 47 yo M with asthma, OSA, chronic low back pain, recent rib fracure,\n who presented with malaise & DOE found to have bony lesions on CT and a\n constellation of hematologic/electrolyte findings consistent with\n multiple myeloma.\n .\n # Dyspnea/Respiratory Distress: Patient with increasing O2 requirement\n in setting of known asthma, fluid therapy, and new right middle lobe\n pneumonia with pulmonary edema. Also with CT chest on with diffuse\n ground glass opacities. Patient also with hyperdynamic heart on TTE\n (EF 75%), elevated BNP to 4232, moderate pulmonary artery hypertension.\n Receiving Lasix with fluids and now on antibiotics.\n - Lasix 80mg \n - IVF's to titrate to UOP 200-300cc/hr\n - Levofloxacin & Cefepime, renally dosed, day \n - O2 to maintain sats >92% using face tent for now\n - CPAP at night at 11cm H2O\n .\n # Multiple Myeloma: Patient with M-protein in both urine & serum\n identified as IgG kappa as well as end-organ dammage manifested as ARF\n and anemia, diffuse lytic lesions on CT and hypercalcemia suggests a\n diagnosis multiple myeloma. Bone marrow biopsy results are positive for\n myeloma, but patient has commenced Dexamethasone therapy as of .\n Normal serum viscosity and patient without signs or symptoms of\n hyperviscosity syndrome, but beta-2 microglobulin was 6.8. EBV/CMV/Toxo\n negative.\n - K/L light chain ratio pending\n - Continue Dexamethasone 40mg IV qday, day \n - Continue IVF's at 150cc NS/hr, titrate to UOP of 200-300cc/hr\n - Continue Lasix 80mg \n - F/U skeletal survey results\n - Oncology following, will guide treatment\n .\n # Hypercalcemia: Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n - Goal urine output 200-300cc/hr\n - Continue IV NS as above\n - Lasix as above\n - Dexamethasone as above\n - q6H labs\n - Vitamin D pending\n - Vitamin D 25 pending\n .\n # Hyperuricemia: Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase .\n - Continue Allopurinol 100mg daily\n - Brisk UOP as above\n - Avoid HCO3 as it will precipitate calcium & phosphate\n - Repeat tumor lysis labs q6h (rasburicase precautions; uric acid level\n must be measured in green top on ice and spun on a cooled centrifuge)\n .\n # Acute renal insufficiency: Cr 3.1, stable/downtrending from\n yesterday. Renal following. Renal failure is likely tubular injury from\n cast nephropathy in conjunction with hypercalcemia, hyperuricemia.\n - f/u renal recs\n - require renal biopsy if function does not improve\n - Continuous IVF's/Lasix to preempt further tubular injury\n .\n # Anemia/Thrombocytopenia: Low reticulocyte count, elevated haptoglobin\n & ferritin demonstrating insufficient erythropoeisis. Likely secondary\n to massive marrow infilitration from multiple myeloma. No evidence of\n TTP, ITP, or intravascular hemolysis.\n - Maintain active T&S\n - Transfuse for HCT <25\n - obtain transfusion goals for platelets from BMT service\n - Guaiac stools\n .\n # Epistaxis: baseline problem worsened by thrombocytopenia and dry air\n of Nasal cannula\n - afrin first line, packing if profuse with appropriate antibiotic ppx\n - avoid nasal cannula, CPAP may worsen as well\n - transfuse plateletes prn\n .\n # Asthma: Continue Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, regular\n .\n # Prophylaxis:\n -DVT ppx with pneumoboots/CPAP\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n .\n # Access: peripherals\n # Communication: Patient\n # Code: FULL\n # Disposition: to BMT floor today if respiratory status remains stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:00 PM\n 20 Gauge - 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": "2136-04-19 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 736527,
"text": "Chief Complaint: Respiratory distress\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 Tolerating net diuresis.\n States overall to feel \"much better\"\n Remains thirsty, requesting water.\n Received PRBC 1 unit.\n Received plts.\n No further nosebleeds.\n Started chemotherapy last PM.\n History obtained from Medical records\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, 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, Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:20 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 70 (68 - 85) bpm\n BP: 118/57(70) {109/48(65) - 133/84(89)} mmHg\n RR: 22 (19 - 33) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 6,032 mL\n 2,063 mL\n PO:\n 1,560 mL\n 360 mL\n TF:\n IVF:\n 3,922 mL\n 1,703 mL\n Blood products:\n 550 mL\n Total out:\n 7,340 mL\n 3,610 mL\n Urine:\n 7,340 mL\n 3,610 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,308 mL\n -1,547 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 91%\n ABG: ///26/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice, petichae on palms soles\n resolving\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.9 g/dL\n 55 K/uL\n 174 mg/dL\n 3.1 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 136 mg/dL\n 100 mEq/L\n 141 mEq/L\n 23.7 %\n 9.7 K/uL\n [image002.jpg]\n 10:37 PM\n 04:55 AM\n 07:51 PM\n 10:03 PM\n 05:25 AM\n 09:36 AM\n 03:07 PM\n 10:00 PM\n 04:10 AM\n 09:52 AM\n WBC\n 10.7\n 11.5\n 12.7\n 9.7\n Hct\n 23.4\n 22.5\n 24.5\n 23.7\n Plt\n 59\n 43\n 66\n 62\n 55\n Cr\n 3.4\n 3.6\n 3.6\n 3.5\n 3.5\n 3.4\n 3.3\n 3.1\n TropT\n 0.01\n TCO2\n 33\n Glucose\n 169\n 149\n 163\n 166\n 147\n 155\n 174\n Other labs: PT / PTT / INR:17.1/25.2/1.5, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:67/88, Alk Phos / T Bili:54/0.3,\n Differential-Neuts:33.0 %, Band:1.0 %, Lymph:51.0 %, Mono:5.0 %,\n Eos:0.0 %, D-dimer:150 ng/mL, Fibrinogen:440 mg/dL, Lactic Acid:0.8\n mmol/L, LDH:2214 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:6.4 mg/dL\n Assessment and Plan\n 47 yom asthma, OSA, chronic low back pain, recent rib fracure now with\n multiple myeloma.\n RESPIRATORY DISTRESS -- CXR and CT consistent with pulmonary edema,\n suspect related to volume resusitation. Underlying asthma, OSA,\n moderate pulmonary HTN. Continue net diuresis. Provide oxygen,\n maintain SaO2 >90%.\n PNEUMONIA -- Possible RLL pneuomonia. Continue Levofloxacin &\n Cefepime, renally dosed.\n ASTHMA -- Continue Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN\n OSA -- CPAP at night at 11cm H20\n MULTIPLE MYELOMA -- Dx confirmed by bone marrow biopsy. Awaiting\n initiating chemotherapy. Continue dexamethasome.\n ALTERED MENTAL STATUS -- improved. Monitor.\n FLUIDS -- Continue IVF's at 150cc NS/hr, titrate to UOP of\n 200-300cc/hr. Use lasix as needed. Restrict PO intake.\n EPISTAXIS -- chronic history, escalation in context of\n thrombocytopenia. If persists or escalated, consider ENT evaluation\n and packing\n THROMBOCYTOPENIA -- related to myeloma. Good response to plts\n transfusion. Monitor. Transfuse <50\n HYPERCALCEMIA -- Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n HYPERURICEMIA -- Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase this PM. Continue\n Allopurinol 100mg daily\n ACUTE RENAL FAILURE -- Cr 3.7 and continuing to rise. Renal following.\n Renal failure is likely tubular injury from cast nephropathy in\n conjunction with hypercalcemia, hyperuricemia.\n ANEMIA -- Low reticulocyte count, elevated haptoglobin & ferritin.\n demonstrating insufficient erythropoeisis. No evidence of TTP or\n intravascular hemolysis. Transfuse for HCT <25. Guaiac stools\n FLUIDS -- IVF as above, replete electrolytes.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 736535,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - hct/plt, transfuse plt, bumped appropriately, gotten type and cross.\n - BMT rec: hit, fungal markers, IgG level, UPEP, LFTs daily, DIC labs\n daily, TLS labs Q8, d/c allopurinol, starting chemo treatment.\n - Renal rec: SPEP, UPEP, 24 Urine protein, avoid diuresis if possible,\n smear to look for schisto, PRN lasix, and transfuse 1 U PRBC\n - EKG did not show anything impressive.\n - started Chemo, gained fluid after transfusion, giving lasix 80mg IV\n x1.\n - got Hepatitis panel and HIV serology\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Azithromycin - 11:30 AM\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 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 07:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.4\nC (97.6\n HR: 70 (70 - 85) bpm\n BP: 116/65(77) {108/48(65) - 141/84(89)} mmHg\n RR: 19 (19 - 33) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 6,032 mL\n 1,478 mL\n PO:\n 1,560 mL\n 120 mL\n TF:\n IVF:\n 3,922 mL\n 1,358 mL\n Blood products:\n 550 mL\n Total out:\n 7,340 mL\n 2,680 mL\n Urine:\n 7,340 mL\n 2,680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,308 mL\n -1,202 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 95%\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 62 K/uL\n 8.0 g/dL\n 174 mg/dL\n 3.1 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 136 mg/dL\n 102 mEq/L\n 143 mEq/L\n 24.5 %\n 12.7 K/uL\n [image002.jpg]\n 05:07 PM\n 10:37 PM\n 04:55 AM\n 07:51 PM\n 10:03 PM\n 05:25 AM\n 09:36 AM\n 03:07 PM\n 10:00 PM\n 04:10 AM\n WBC\n 10.7\n 11.5\n 12.7\n Hct\n 23.4\n 22.5\n 24.5\n Plt\n 59\n 43\n 66\n 62\n Cr\n 3.4\n 3.4\n 3.6\n 3.6\n 3.5\n 3.5\n 3.4\n 3.3\n 3.1\n TropT\n 0.01\n TCO2\n 33\n Glucose\n 169\n 149\n 163\n 166\n 147\n 155\n 174\n Other labs: PT / PTT / INR:17.4/24.1/1.6, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:67/88, Alk Phos / T Bili:54/0.4,\n Differential-Neuts:33.0 %, Band:1.0 %, Lymph:51.0 %, Mono:5.0 %,\n Eos:0.0 %, D-dimer:150 ng/mL, Fibrinogen:435 mg/dL, Lactic Acid:0.8\n mmol/L, LDH:2435 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:6.7 mg/dL\n Skeletal Survey:\n 1. No obvious lucent lesions identified radiographically. However, the\n torso\n CT obtained the same day shows innumerable small lytic foci which are\n consistent with myeloma. Please see report of that exam. Subtle\n scalloping\n along left femoral diaphysis lateral cortex is of equivocal clinical\n significance.\n 2. Diffuse pulmonary parenchymal opacities which require further\n evaluation.\n Again, please see contemporaneous CT report.\n 3. Degenerative changes in the spine.\n 4. Aortic calcification, unusual in someone of this age. Is there a\n history of\n diabetes or vasculopathy?\n Assessment and Plan\n 47 yo M with asthma, OSA, chronic low back pain, recent rib fracure,\n who presented with malaise & DOE found to have bony lesions on CT and a\n constellation of hematologic/electrolyte findings consistent with\n multiple myeloma.\n .\n # Dyspnea/Respiratory Distress: Patient with increasing O2 requirement\n in setting of known asthma, fluid therapy, and new right middle lobe\n pneumonia with pulmonary edema. Also with CT chest on with diffuse\n ground glass opacities. Patient also with hyperdynamic heart on TTE\n (EF 75%), elevated BNP to 4232, moderate pulmonary artery hypertension.\n Receiving Lasix with fluids and now on antibiotics.\n - IVFs + lasix PRN to titrate to UOP 200-300cc/hr\n - Levofloxacin & Cefepime, renally dosed, day \n - O2 to maintain sats >92% using NC\n - CPAP at night at 11cm H2O\n .\n # Multiple Myeloma: Patient with M-protein in both urine & serum\n identified as IgG kappa as well as end-organ dammage manifested as ARF\n and anemia, diffuse lytic lesions on CT and hypercalcemia suggests a\n diagnosis multiple myeloma. Bone marrow biopsy results are positive for\n myeloma, but patient has commenced Dexamethasone therapy as of .\n Normal serum viscosity and patient without signs or symptoms of\n hyperviscosity syndrome, but beta-2 microglobulin was 6.8. EBV/CMV/Toxo\n negative.\n - K/L light chain ratio pending\n - Continue Dexamethasone 40mg IV qday, day \n - Continue IVF's at 150cc NS/hr, titrate to UOP of 200-300cc/hr\n - Oncology following, will guide treatment\n .\n # Hypercalcemia: Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n - Goal urine output 200-300cc/hr\n - Vitamin D levels low\n .\n # Hyperuricemia: Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase .\n - d/ced allopurinol\n - Brisk UOP as above\n - Avoid HCO3 as it will precipitate calcium & phosphate\n - Repeat tumor lysis labs q6h (rasburicase precautions; uric acid level\n must be measured in green top on ice and spun on a cooled centrifuge)\n .\n # Acute renal insufficiency: Cr 3.1, stable/downtrending from\n yesterday. Renal following. Renal failure is likely tubular injury from\n cast nephropathy in conjunction with hypercalcemia, hyperuricemia.\n - f/u renal recs\n - Continuous IVF's/Lasix to preempt further tubular injury\n .\n # Anemia/Thrombocytopenia: Low reticulocyte count, elevated haptoglobin\n & ferritin demonstrating insufficient erythropoeisis. Likely secondary\n to massive marrow infilitration from multiple myeloma. No evidence of\n TTP, ITP, or intravascular hemolysis.\n - Maintain active T&S\n - Transfuse for HCT < 23\n - obtain transfusion goals for platelets from BMT service\n - Guaiac stools\n .\n # Epistaxis: now resolved\n - humidified O2 when possible\n - transfuse platelets prn\n .\n # Asthma: Continue Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, regular\n .\n # Prophylaxis:\n -DVT ppx with pneumoboots/CPAP\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n .\n # Access: peripherals\n # Communication: Patient\n # Code: FULL\n # Disposition: to BMT floor today if respiratory status remains stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:00 PM\n 20 Gauge - 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": "2136-04-20 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 736995,
"text": "Chief Complaint: Respiratory distress\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 Overall, improving.\n States breathing is easier.\n Less rib pain.\n Up in chair.\n Speech more clear, fluent.\n History obtained from Medical records\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, 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\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 35.9\nC (96.7\n HR: 83 (70 - 83) bpm\n BP: 120/58(70) {108/50(66) - 138/78(86)} mmHg\n RR: 19 (13 - 27) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 5,716 mL\n 3,682 mL\n PO:\n 1,560 mL\n 1,460 mL\n TF:\n IVF:\n 4,156 mL\n 1,872 mL\n Blood products:\n 350 mL\n Total out:\n 7,690 mL\n 3,170 mL\n Urine:\n 7,690 mL\n 3,170 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,974 mL\n 512 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: No(t) Resonant : , No(t) Hyperresonant: , No(t) Dullness :\n ), (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , 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: , Obese\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal, Speech much clearer & fluent, sensorium much\n clearer\n Labs / Radiology\n 7.4 g/dL\n 50 K/uL\n 159 mg/dL\n 2.5 mg/dL\n 25 mEq/L\n 3.8 mEq/L\n 122 mg/dL\n 105 mEq/L\n 141 mEq/L\n 21.1 %\n 8.3 K/uL\n [image002.jpg]\n 10:03 PM\n 05:25 AM\n 09:36 AM\n 03:07 PM\n 10:00 PM\n 04:10 AM\n 09:52 AM\n 03:20 PM\n 09:45 PM\n 05:41 AM\n WBC\n 11.5\n 12.7\n 9.7\n 8.3\n Hct\n 22.5\n 24.5\n 23.7\n 23.1\n 21.1\n Plt\n 43\n 66\n 62\n 55\n 57\n 50\n Cr\n 3.6\n 3.5\n 3.5\n 3.4\n 3.3\n 3.1\n 3.0\n 2.7\n 2.5\n TropT\n 0.01\n Glucose\n 149\n 163\n 166\n 147\n 155\n 174\n 150\n 159\n Other labs: PT / PTT / INR:17.0/23.1/1.5, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:67/88, Alk Phos / T Bili:54/0.4,\n Differential-Neuts:33.0 %, Band:1.0 %, Lymph:51.0 %, Mono:5.0 %,\n Eos:0.0 %, D-dimer:150 ng/mL, Fibrinogen:440 mg/dL, Lactic Acid:0.8\n mmol/L, LDH:2214 IU/L, Ca++:7.1 mg/dL, Mg++:2.3 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 47 yom asthma, OSA, chronic low back pain, recent rib fracure now with\n multiple myeloma. Gradual clinical improvement.\n RESPIRATORY DISTRESS -- Prior CXR and CT consistent with pulmonary\n edema, now much improved. Underlying asthma, OSA, moderate pulmonary\n HTN. Rib fractures likely contributing to limiting respiratory\n efforts. Continue net diuresis. Provide oxygen, maintain SaO2 >90%.\n PNEUMONIA -- Possible RLL pneuomonia. Continue Levofloxacin &\n Cefepime, renal dosing.\n ASTHMA -- Continue Albuterol, Fluticasone, & Ipratropium nebs q6H PRN\n OSA\n Nasal CPAP at night at 11cm H20.\n MULTIPLE MYELOMA -- Dx confirmed by bone marrow biopsy. Awaiting\n initiating chemotherapy. Continue dexamethasome.\n ALTERED MENTAL STATUS -- improved. Monitor.\n FLUIDS -- Continue IVF's at 150cc NS/hr, titrate to UOP of\n 200-300cc/hr. Use lasix as needed. Restrict PO intake.\n EPISTAXIS -- chronic history, escalation in context of\n thrombocytopenia. If persists or escalated, consider ENT evaluation\n and packing\n THROMBOCYTOPENIA -- related to myeloma. Good response to plts\n transfusion. Monitor. Transfuse <50\n HYPERCALCEMIA -- Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n HYPERURICEMIA -- Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase this PM. Continue\n Allopurinol 100mg daily\n ACUTE RENAL FAILURE -- Cr 3.7 and continuing to rise. Renal following.\n Renal failure is likely tubular injury from cast nephropathy in\n conjunction with hypercalcemia, hyperuricemia.\n ANEMIA -- Low reticulocyte count, elevated haptoglobin & ferritin.\n demonstrating insufficient erythropoeisis. No evidence of TTP or\n intravascular hemolysis. Transfuse for HCT <25. Guaiac stools\n FLUIDS -- IVF as above, replete electrolytes.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments: Discussed with family members.\n status: Full code\n Disposition : Transfer to medical \n Total time spent: 40 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735670,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Ineffective Coping\n Assessment:\n Pt\ns wife and brother in to visit pt throughout day. Pt has 3 small\n children at home. Pt seems to be coping appropriately, very supportive\n family, involved in pt\ns care.\n Action:\n Social work in to see family. Emotional support provided to pt and\n family by staff.\n Response:\n Plan:\n Hypercalcemia (high Calcium)\n Assessment:\n AM calcium 18.8 (non-ionized). Pt with recent rib fractures related to\n increased calcium levels.\n Action:\n Started on calcitonin salmon SC injection, NS @ 300cc/hr for 2L,\n and lasix. Taken for skeletal survey this afternoon for films of\n skull, long bones and spine.\n Response:\n 1100 calcium (non-ionized) down to 15.7. Pt tolerated test well, final\n film reads pending.\n Plan:\n Calcium to be rechecked q6h, monitor for signs and symptoms of\n hypercalcemia, arrhythmias. Follow up skeletal survey results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards, UOP >100cc/hr, clear, yellow. Renal following\n for .\n Action:\n Response:\n Plan:\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets (pt\ns baseline HCT40s).\n Bone marrow biopsy done . No obvious signs of bleeding noted.\n Action:\n Drop discussed during , team likely related to disease\n process in bone marrow. Abdominal US and CT torso done to evaluate for\n presence of lymphadenopthy.\n Response:\n C results supporting atypical myeloma diagnosis. Started on IV\n steroids.\n Plan:\n Continue to monitor HCT, monitor for signs of bleeding, continue IV\n steroids, HCT goal >21.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736335,
"text": "Anemia, other\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 Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735662,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Ineffective Coping\n Assessment:\n Pt\ns wife and brother in to visit pt throughout day. Pt has 3 small\n children at home. Pt seems to be coping appropriately, very supportive\n family, involved in pt\ns care.\n Action:\n Social work in to see family. Emotional support provided to pt and\n family by staff.\n Response:\n Plan:\n Hypercalcemia (high Calcium)\n Assessment:\n AM calcium 18.8 (non-ionized). Pt with recent rib fractures related to\n increased calcium levels.\n Action:\n Started on calcitonin salmon SC injection, NS @ 300cc/hr for 2L,\n and lasix. Taken for skeletal survey this afternoon for films of\n skull, long bones and spine.\n Response:\n 1100 calcium (non-ionized) down to 15.7. Pt tolerated test well, final\n film reads pending.\n Plan:\n Calcium to be rechecked q6h, monitor for signs and symptoms of\n hypercalcemia, arrhythmias. Follow up skeletal survey results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards, UOP >100cc/hr\n Action:\n Response:\n Plan:\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets (pt\ns baseline HCT40s).\n Bone marrow biopsy done . No obvious signs of bleeding noted.\n Action:\n Drop discussed during , team likely related to disease\n process in bone marrow. Abdominal US and CT torso done to evaluate for\n presence of lymphadenopthy.\n Response:\n C results supporting atypical myeloma diagnosis. Started on IV\n steroids.\n Plan:\n Continue to monitor HCT, monitor for signs of bleeding, continue IV\n steroids, HCT goal >21.\n"
},
{
"category": "Respiratory ",
"chartdate": "2136-04-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 736336,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 53.5 None\n Ideal tidal volume: mL/kg\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 Comments: Occasional non productive cough.\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Comments: Received on 70% to 50% face tent. Well tolerated with no c/o\n dyspnea. Placed on patient's own nasal CPAP machine at night, on\n pre-set setting of 11cmH2O. O2 bleed in initially @ 5L, with acceptable\n (90-95%) sats.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Continue nocturnal\n nasal CPAP overnight, adjusting O2 bleed in as needed, to maintain Sats\n within desired range of 90-95%, for this patient. PRN Albuterol &\n Atrovent.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736600,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward. Pt with recent rib fractures\n related to increased calcium levels. Skeletal survey films of skull,\n long bones and spine showed No obvious lucent lesions and innumerable\n small lytic foci which are consistent with myeloma; also Degenerative\n changes in the spine and Aortic calcification, unusual in someone of\n this age\n Action:\n completed his calcitonin SC injection, continues on NS @ 150cc/hr and\n PRN IV lasix; tumor lysis labs q6hrs\n Response:\n Calcium trending down 8.2 this am\n Plan:\n Monitor for signs and symptoms of hypercalcemia / arrhythmias;\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr remains elevated but trending down; urine output less than\n 200cc/hr but 12 noon; clear, yellow urine via foley; Renal following,\n renal failure likely related to hypercalcemia induced vasoconstriction\n to renal vasculature.\n Action:\n Continues on NS 150cc/hr and IV lasix PRN to flush kidney ; started on\n regular diet\n renagel started to bind phosphorus, serum phos remains\n high\n Response:\n Diuresed well with 80 mgs of IV lasix; negative 8L LOS and 1.6 liters\n since MN, renal function improving\n Plan:\n Continue lytes check with tumor lysis labs, monitor I/O\n keep\n patient negative\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . Pt. had nosebleed yesterday. CT done consistent of myeloma.\n ECHO from showing EF >55%; petechia on hands and feet steady; BMT\n following for chemotherapy; received 1 unit PRBC and 1 pack of\n platelets\n Action:\n Afrin x 3 days ( day 2), IV steroids continues ( last dose today);\n received chemo valcade last night\n Response:\n no episode of nosebleed noted\n Plan:\n transfuse to keep hct >23 and platelet >10 if no s/s of bleeding; next\n chemo on sat (72 hrs after last was given) will add cytoxan as\n second if patient remains to be stable\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Transferred from BMT floor for increased O2 requirement, placed on CPAP\n overnight for sleep apnea\n uses his own set-up; desatted down to mids\n 80\ns whenever he takes his O2 off; lung sounds clear, diminished at\n bases; occasional non-productive cough\n no wheezing noted\n Action:\n Off bipap at 10 am, O2 at 4 liters via nasal cannula; PRN albuterol and\n atrovent nebs continues; continues on cefipime and levofloxacin IV for\n RML pneumonia; OOB to chair\n tolerated well\n Response:\n O2 sats > 92% 4 liters, afebrile, WBC trending down\n Plan:\n Wean O2 as tolerated\n Oriented x 3, c/o pain around lower rib cage whenever he coughs or deep\n breath\n most like due to recent rib fracture\n BP stable in the 110\ns MAP above 60 mmHg; pedal pulses easily palpable,\n normal sinus rhythm in the 80\ns, frequent PVC\ns noted\n Started on regular diet, small BM x 2 this shift\n quite loose\n Patient\ns brother stayed most of the day, no calls yet from his wife (\n patient\ns 3 sons came and visited yesterday)wife and patient family are\n very supportive with recent diagnosis\n Uric Acid blood test to be rechecked @ 2200( this specimen is in a\n green top vial and placed on ice.) PLEASE CALL STAT LABS WHEN YOU ARE\n ABOUT TO SEND URIC ACID ON A GREEN TOP WITH ICE.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 736984,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Obtained pt on nasal Cpap at home levels with 10 L leaked in. Quickly\n transitioning to 4 L NC. Pt denies SOB or increased WOB. Breath sounds\n clear to upper lobes and dim to bases. Dry non-productive cough early\n in shift new per patient report.\n Action:\n OOB to chair x2. Pt is coughing and deep breathing.\n Response:\n Tolerating activity well. Continues to be O2 dependant though without\n increased requirements.\n Plan:\n Continue to titrate NC as tolerated. Nasal CPap while sleeping. Pt has\n home set-up.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr this am 2.5. Continues to trend down. Electrolytes largely\n normalizing. Pt is autoduiresing. u/o >200cc/hr. Currently grossly\n negative about 9L. Receiving maintenance fluids at 150cc/hr. Renal\n following.\n Action:\n Pt is taking Pos well. u/o remains adequate. Maintenance fluids\n decreased to 100cc/hr. Pm lytes and tumor lysis labs sent.\n Response:\n Renal failure resolving. U/o remains adequate. Maintenaince fluids and\n oral intake remain adequate.\n Plan:\n Continue to follow i/o. Renal is following.\n Anemia, other\n Assessment:\n Hct this am 21.1.\n Action:\n Transfused 1 U PRBC.\n Response:\n PM hct 23.1.\n Plan:\n Continue to trend. Pt is being transfused for hct <23 and plt <10.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 736986,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to have progressive anemia from 44 to 25 and in\n acute renal failure with creatinine 2.2, elevated LFT's, and Ca+ 17.7.\n He was originally admitted to 3 but during fluid resuscitation\n became hypoxic so he was transferred to the MICU.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Obtained pt on nasal Cpap at home levels with 10 L leaked in. Quickly\n transitioning to 4 L NC. Pt denies SOB or increased WOB. Breath sounds\n clear to upper lobes and dim to bases. Dry non-productive cough early\n in shift new per patient report.\n Action:\n OOB to chair x2. Pt is coughing and deep breathing.\n Response:\n Tolerating activity well. Continues to be O2 dependant though without\n increased requirements.\n Plan:\n Continue to titrate NC as tolerated. Nasal CPap while sleeping. Pt has\n home set-up.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr this am 2.5. Continues to trend down. Electrolytes largely\n normalizing. Pt is autoduiresing. u/o >200cc/hr. Currently grossly\n negative about 9L. Receiving maintenance fluids at 150cc/hr. Renal\n following.\n Action:\n Pt is taking Pos well. u/o remains adequate. Maintenance fluids\n decreased to 100cc/hr. Pm lytes and tumor lysis labs sent.\n Response:\n Renal failure resolving. U/o remains adequate. Maintenaince fluids and\n oral intake remain adequate.\n Plan:\n Continue to follow i/o. Renal is following.\n Anemia, other\n Assessment:\n Hct this am 21.1.\n Action:\n Transfused 1 U PRBC.\n Response:\n PM hct 23.1.\n Plan:\n Continue to trend. Pt is being transfused for hct <23 and plt <10.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 736987,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to have progressive anemia from 44 to 25 and in\n acute renal failure with creatinine 2.2, elevated LFT's, and Ca+ 17.7.\n He was originally admitted to 3 but during fluid resuscitation\n became hypoxic so he was transferred to the MICU. Then transferred to\n 7F. After a short stay on 7F pt found to have increased O2 requirements\n and was transferred to ICU.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Obtained pt on nasal Cpap at home levels with 10 L leaked in. Quickly\n transitioning to 4 L NC. Pt denies SOB or increased WOB. Breath sounds\n clear to upper lobes and dim to bases. Dry non-productive cough early\n in shift new per patient report.\n Action:\n OOB to chair x2. Pt is coughing and deep breathing.\n Response:\n Tolerating activity well. Continues to be O2 dependant though without\n increased requirements.\n Plan:\n Continue to titrate NC as tolerated. Nasal CPap while sleeping. Pt has\n home set-up.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr this am 2.5. Continues to trend down. Electrolytes largely\n normalizing. Pt is autoduiresing. u/o >200cc/hr. Currently grossly\n negative about 9L. Receiving maintenance fluids at 150cc/hr. Renal\n following.\n Action:\n Pt is taking Pos well. u/o remains adequate. Maintenance fluids\n decreased to 100cc/hr. Pm lytes and tumor lysis labs sent.\n Response:\n Renal failure resolving. U/o remains adequate. Maintenaince fluids and\n oral intake remain adequate.\n Plan:\n Continue to follow i/o. Renal is following.\n Anemia, other\n Assessment:\n Hct this am 21.1.\n Action:\n Transfused 1 U PRBC.\n Response:\n PM hct 23.1.\n Plan:\n Continue to trend. Pt is being transfused for hct <23 and plt <10.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 736988,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to have progressive anemia from 44 to 25 and in\n acute renal failure with creatinine 2.2, elevated LFT's, and Ca+ 17.7.\n He was originally admitted to 3 but during fluid resuscitation\n became hypoxic so he was transferred to the MICU. Then transferred to\n 7F. After a short stay on 7F pt found to have increased O2 requirements\n and was transferred to ICU.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Obtained pt on nasal Cpap at home levels with 10 L leaked in. Quickly\n transitioning to 4 L NC. Pt denies SOB or increased WOB. Breath sounds\n clear to upper lobes and dim to bases. Dry non-productive cough early\n in shift new per patient report.\n Action:\n OOB to chair x2. Pt is coughing and deep breathing.\n Response:\n Tolerating activity well. Continues to be O2 dependant though without\n increased requirements.\n Plan:\n Continue to titrate NC as tolerated. Nasal CPap while sleeping. Pt has\n home set-up.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr this am 2.5. Continues to trend down. Electrolytes largely\n normalizing. Pt is autoduiresing. u/o >200cc/hr. Currently grossly\n negative about 9L. Receiving maintenance fluids at 150cc/hr. Renal\n following.\n Action:\n Pt is taking Pos well. u/o remains adequate. Maintenance fluids\n decreased to 100cc/hr. Pm lytes and tumor lysis labs sent.\n Response:\n Renal failure resolving. U/o remains adequate. Maintenaince fluids and\n oral intake remain adequate.\n Plan:\n Continue to follow i/o. Renal is following.\n Anemia, other\n Assessment:\n Hct this am 21.1. Bone marrow biopsy done . ECHO from showing\n EF >55%; petechia on hands and feet steady; BMT following for\n chemotherapy; received 1 unit PRBC and 1 pack of platelets yesterday.\n Action:\n Transfused 1 U PRBC.\n Response:\n PM hct 23.1.\n Plan:\n Continue to trend. Pt is being transfused for hct <23 and plt <10. next\n chemo on sat (72 hrs after last was given) will add cytoxan as\n second if patient remains to be stable\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward. Pt with recent rib fractures\n related to increased calcium levels. Skeletal survey films of skull,\n long bones and spine showed no obvious lucent lesions and innumerable\n small lytic foci which are consistent with myeloma; also Degenerative\n changes in the spine and Aortic calcification.\n Action:\n completed his calcitonin SC injection, continues on NS @ 100cc/hr\n Response:\n Calcium trending down. Good U/O. K, MG stable.\n Plan:\n Monitor for signs and symptoms of hypercalcemia / arrhythmias.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n DYSPNEA\n Code status:\n Full code\n Height:\n 62 Inch\n Admission weight:\n 112.6 kg\n Daily weight:\n Allergies/Reactions:\n Iodine; Iodine Containing\n Anaphylaxis;\n Precautions: No Additional Precautions\n PMH: Asthma\n CV-PMH:\n Additional history: costrochondritis; lower back pain w L3-L4 lateral\n disc protrusion; nephrolithiasis; H/O atypical chest pain;\n hyperlipedemia; S/P rib fracture; depression.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:59\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 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 95% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 6,035 mL\n 24h total out:\n 4,590 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 03:15 PM\n Potassium:\n 3.7 mEq/L\n 03:15 PM\n Chloride:\n 106 mEq/L\n 03:15 PM\n CO2:\n 23 mEq/L\n 03:15 PM\n BUN:\n 110 mg/dL\n 03:15 PM\n Creatinine:\n 2.1 mg/dL\n 03:15 PM\n Glucose:\n 163 mg/dL\n 03:15 PM\n Hematocrit:\n 23.1 %\n 03:15 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 2 PIV\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: Pt has many belongings. All transferred with pt.\n Including home CPap.\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU/\n Transferred to: 7F.\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 736252,
"text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Experienced epistaxis last PM, eventually controlled with pressure on\n nares.\n Less dyspneic.\n Mental status clearer.\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Azithromycin - 11:30 AM\n Ceftriaxone - 12:00 PM\n Levofloxacin - 10:00 PM\n Cefipime - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:03 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 (97.2\n HR: 80 (73 - 95) bpm\n BP: 128/65(78) {120/53(72) - 150/76(91)} mmHg\n RR: 20 (20 - 30) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 2,271 mL\n 1,630 mL\n PO:\n 500 mL\n TF:\n IVF:\n 1,771 mL\n 1,630 mL\n Blood products:\n Total out:\n 4,110 mL\n 3,340 mL\n Urine:\n 4,110 mL\n 3,340 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,839 mL\n -1,710 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Face tent\n SpO2: 92%\n ABG: 7.47/44/209/31/8\n PaO2 / FiO2: 261\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube, Dryed blood in nares\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, Rash: petichae on hands/palms, feet/soles, No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.7 g/dL\n 43 K/uL\n 163 mg/dL\n 3.5 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 127 mg/dL\n 96 mEq/L\n 140 mEq/L\n 22.5 %\n 11.5 K/uL\n [image002.jpg]\n 02:29 PM\n 03:47 AM\n 05:02 AM\n 10:42 AM\n 05:07 PM\n 10:37 PM\n 04:55 AM\n 07:51 PM\n 10:03 PM\n 05:25 AM\n WBC\n 7.4\n 10.7\n 11.5\n Hct\n 24.5\n 23.4\n 22.5\n Plt\n 77\n 59\n 43\n Cr\n 2.6\n 3.1\n 3.4\n 3.4\n 3.4\n 3.6\n 3.6\n 3.5\n TropT\n 0.01\n TCO2\n 34\n 33\n Glucose\n 121\n 123\n 169\n 149\n 163\n Other labs: PT / PTT / INR:14.4/22.8/1.2, CK / CKMB /\n Troponin-T:104/2/0.01, ALT / AST:95/102, Alk Phos / T Bili:68/0.4,\n Differential-Neuts:33.0 %, Band:1.0 %, Lymph:51.0 %, Mono:5.0 %,\n Eos:0.0 %, Fibrinogen:641 mg/dL, Lactic Acid:0.8 mmol/L, LDH:2590 IU/L,\n Ca++:9.9 mg/dL, Mg++:2.2 mg/dL, PO4:6.6 mg/dL\n Assessment and Plan\n 47 yom asthma, OSA, chronic low back pain, recent rib fracure now with\n multiple myeloma.\n RESPIRATORY DISTRESS -- CXR and CT consistent with pulmonary edema,\n suspect related to volume resusitation. Underlying asthma, OSA,\n moderate pulmonary HTN. Continue net diuresis. Provide oxygen,\n maintain SaO2 >90%.\n PNEUMONIA -- continue Levofloxacin & Cefepime, renally dosed, day 1 for\n CAP\n ASTHMA -- Continue Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN\n OSA -- CPAP at night at 11cm H20\n MULTIPLE MYELOMA -- Dx confirmed by bone marrow biopsy. Awaiting\n initiating chemotherapy. Continue dexamethasome.\n ALTERED MENTAL STATUS -- improved. Monitor.\n FLUIDS -- Continue IVF's at 150cc NS/hr, titrate to UOP of\n 200-300cc/hr. Use lasix as needed.\n EPISTAXIS -- chronic history, escalation in context of\n thrombocytopenia. If persists or escalated, consider ENT evaluation\n and packing\n THROMBOCYTOPENIA -- related to myeloma. Monitor. WOuld transfuse if\n active bleeding.\n HYPERCALCEMIA -- Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n HYPERURICEMIA -- Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase this PM. Continue\n Allopurinol 100mg daily\n ACUTE RENAL FAILURE -- Cr 3.7 and continuing to rise. Renal following.\n Renal failure is likely tubular injury from cast nephropathy in\n conjunction with hypercalcemia, hyperuricemia.\n ANEMIA -- Low reticulocyte count, elevated haptoglobin & ferritin.\n demonstrating insufficient erythropoeisis. No evidence of TTP or\n intravascular hemolysis. Transfuse for HCT <25. Guaiac stools\n FLUIDS -- IVF as above, replete electrolytes.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments: Discussed with wife during AM rounds (family\n attended bedside rounds). Answered all questions.\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736253,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward. Pt with recent rib fractures\n related to increased calcium levels.\n Action:\n Yesterday pt. completed his calcitonin SC injection, continues on NS @\n 150cc/hr and IV lasixtumor lysis labs q6hrs\n Response:\n Calcium trending down 9.0 this am; Skeletal survey films of skull, long\n bones and spine showed No obvious lucent lesions and innumerable small\n lytic foci which are consistent with myeloma; also Degenerative changes\n in the spine and Aortic calcification, unusual in someone of this age;\n Plan:\n Monitor for signs and symptoms of hypercalcemia, arrhythmias;\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr remain elevated, UOP >200cc/hr, clear, yellow. Renal following\n tubular injury likely related to hypercalcemia induced vasoconstriction\n to renal vasculature.\n Action:\n NS 150cc/hr to flush kidneys, continues to IV lasix to flush kidney\n Response:\n Continues to maintain good urine output. Tolerating lasix well,\n BUN/Cr remains elevated but kidney function expected to improve over\n time as calcium levels decreases\n Plan:\n Continue lytes check with tumor lysis labs, monitor I/O\ns. Renal team\n suggesting kidney biopsy if no improvement over next few days.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . Pt. continue to have noosebleed. CT done consistent of\n myeloma. ECHO from showing EF >55%; petechia on hands and feet\n increasing\n Action:\n Afrin x 3 days ( day 1), transfused with 1 unit platelet for\n platelet of 43, IV steroids continues\n Response:\n No further nosebleed noted\n Plan:\n Continue to monitor HCT and PLTS, monitor for further signs of\n bleeding, continue IV steroids, HCT goal >21; plan to start\n chemotherapy tonight or tomorrow\n Oriented x 3, denies pain still with weakness but helps with turning.\n BP stable in the 110\ns MAP above 60 mmHg; pedal pulses easily palpable,\n normal sinus rhythm in the 80\ns no PVC\ns noted\n Uric Acid blood test to be rechecked @ 1000 (this specimen is in a\n green top vial and placed on ice.)\n"
},
{
"category": "Respiratory ",
"chartdate": "2136-04-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 736385,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 53.5 None\n Ideal tidal volume: mL/kg\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 Comments: Occasional non productive cough.\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Comments: Received on 70% to 50% face tent. Well tolerated with no c/o\n dyspnea. Placed patient on his own nasal CPAP machine at night, on\n pre-set setting of 11cmH2O. O2 bleed in initially @ 5L, with acceptable\n (90-95%) sats. Later ^ to 10L O2 to correct low sats, due to Pt\n unconsciously mouth breathing.\n Plan\n Next 24-48 hours:\n Reason for continuing current support: Continue nocturnal nasal CPAP,\n adjusting O2\nbleed in\n to maintain Sats within desired range of\n 90-95%. Albuterol & Atrovent prn. Resume humidified O2 via face tent\n on days.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736671,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward. Pt with recent rib fractures\n related to increased calcium levels. Skeletal survey films of skull,\n long bones and spine showed No obvious lucent lesions and innumerable\n small lytic foci which are consistent with myeloma; also Degenerative\n changes in the spine and Aortic calcification, unusual in someone of\n this age\n Action:\n completed his calcitonin SC injection, continues on NS @ 150cc/hr and\n PRN IV lasix; tumor lysis labs q6hrs\n Response:\n Calcium trending down 8.2 this am\n Plan:\n Monitor for signs and symptoms of hypercalcemia / arrhythmias;\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr remains elevated but trending down; urine output less than\n 200cc/hr but 12 noon; clear, yellow urine via foley; Renal following,\n renal failure likely related to hypercalcemia induced vasoconstriction\n to renal vasculature.\n Action:\n Continues on NS 150cc/hr and IV lasix PRN to flush kidney ; started on\n regular diet\n renagel started to bind phosphorus, serum phos remains\n high\n Response:\n Diuresed well with 80 mgs of IV lasix; negative 8L LOS and 1.6 liters\n since MN, renal function improving\n Plan:\n Continue lytes check with tumor lysis labs, monitor I/O\n keep\n patient negative\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . Pt. had nosebleed yesterday. CT done consistent of myeloma.\n ECHO from showing EF >55%; petechia on hands and feet steady; BMT\n following for chemotherapy; received 1 unit PRBC and 1 pack of\n platelets\n Action:\n Afrin x 3 days ( day 2), IV steroids continues ( last dose today);\n received chemo valcade last night\n Response:\n no episode of nosebleed noted\n Plan:\n transfuse to keep hct >23 and platelet >10 if no s/s of bleeding; next\n chemo on sat (72 hrs after last was given) will add cytoxan as\n second if patient remains to be stable\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Transferred from BMT floor for increased O2 requirement, placed on CPAP\n overnight for sleep apnea\n uses his own set-up; desatted down to mids\n 80\ns whenever he takes his O2 off; lung sounds clear, diminished at\n bases; occasional non-productive cough\n no wheezing noted\n Action:\n Off bipap at 10 am, O2 at 4 liters via nasal cannula; PRN albuterol and\n atrovent nebs continues; continues on cefipime and levofloxacin IV for\n RML pneumonia; OOB to chair\n tolerated well\n Response:\n O2 sats > 92% 4 liters, afebrile, WBC trending down\n Plan:\n Wean O2 as tolerated\n Oriented x 3, c/o pain around lower rib cage whenever he coughs or deep\n breath\n most like due to recent rib fracture\n BP stable in the 110\ns MAP above 60 mmHg; pedal pulses easily palpable,\n normal sinus rhythm in the 80\ns, frequent PVC\ns noted\n Started on regular diet, small BM x 2 this shift\n quite loose\n Patient\ns brother stayed most of the day, no calls yet from his wife (\n patient\ns 3 sons came and visited yesterday)wife and patient family are\n very supportive with recent diagnosis\n Uric Acid blood test to be rechecked @ 2200( this specimen is in a\n green top vial and placed on ice.) PLEASE CALL STAT LABS WHEN YOU ARE\n ABOUT TO SEND URIC ACID ON A GREEN TOP WITH ICE.\n"
},
{
"category": "Respiratory ",
"chartdate": "2136-04-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 736687,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 53.5 None\n Ideal tidal volume: mL/kg\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: /\n Comments: Non productive cough\n Comments: Received on continuous 4L nasal cannula, weaned down from\n 70-50% face tent previous day. Rested overnight on Pt's own nasal CPAP\n machine, preset @ 11cmH2O. O2 \"bleed in\" titrated to meet sat goal of\n 90-95%. Well tolerated by patient. Albuterol/Atrovent prn not needed.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Continue present\n respiratory care plan, as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735453,
"text": "47 YO male with Hx of asthma, chronic low back pain, 2 recent rib\n fractures, was recently dx w/ dental abscess who presented to ED for\n malaise. He was also dx w/ his 2nd rib fx (7th rib right side). He\n states that he has not been feeling well for the past 2 weeks w/\n progressive severe fatigue, night sweats, and subjective fevers. The\n last 3 days he has had DOE so was called to the ED. In ED his creat\n 2.2 and LFT's that were abnormal, Ca+ 17.7. He was admitted to 3\n but with fluid recussitation he started to become hypoxic so he was\n transfered to the MICU\n Hypercalcemia (high Calcium)\n Assessment:\n Pt\ns calcium level has been 16.5, ionized calcium was 2.10.\n Action:\n He has been receiving NS at 200cc/hr, increased to 300cc/hr at 1700.\n He also is receiving a single dose of pamidronate 90 mg IV over 2.5\n hours.\n Response:\n Treatment to reduce his calcium level.\n Plan:\n Maintain IVF, Monitor I&O, recheck Ca++ as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creat is 2.5-2.6,\n Action:\n he was given lasix 20mg on 3 prior to his transfer. He had just\n under 3L urine output prior to transfer.\n Response:\n His U/O in the MICU has been ~200cc/hr.\n Plan:\n Continue to monitor U/O, maintain IVF according to MD\ns orders.\n .H/O asthma\n Assessment:\n Pt had received 1L IV bolus which started him to have some rales and be\n hypoxic with O2 sats 89-90%.\n Action:\n He was placed on 2L NC then transferred to MICU. His O2 sats have been\n 93-95%. RR 22-28.\n Response:\n He has been comfortable without complaints of being SOB. No signs of\n an asthma flare.\n Plan:\n Continue to monitor resp status.\n Anemia, other\n Assessment:\n HCT on admission was 26.6.\n Action:\n He has no signs of bleeding. The hem/onc attending did a bone marrow\n biopsy.\n Response:\n The preliminary report showed a diagnosis of aplastic multiple myloma.\n Plan:\n Pt does know of the dx, support him and his wife in this difficult\n time.\n Pt is having a CT of the torso in the am. He cannot receive IV\n contrast dye. He will be NPO after MN tonight then needs to drink 2\n bottles of barocat starting at 7am for the CT following injestion.\n"
},
{
"category": "Respiratory ",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 735528,
"text": "Demographics\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Ventilation Assessment\n Level of breathing assistance: PSV\n Visual assessment of breathing pattern: regular\n Assessment of breathing comfort: comfortable while asleep\n Non-invasive ventilation assessment: Excessive mask leak, Mask\n discomfort, Patient non compliant; Comments: pt has thick beard.\n Comments: Pt presents in medium \ns position on 6L N/C. BS tight\n with diffuse expiratory wheezes. MD informed, Albuterol/Atrovent neb\n given with some effect, second Albuterol given 30 min later with good\n effect. Nasal CPAP applied with 10L O2 bled in tolerated for 2 hours\n took mask of and quickly desaturated to 80\ns. Pt required frequent\n reminding to keep O2 on. 0500 pt removed n/c found sitting on edge of\n bed in respiratory distress, BS diffuse crackles throughout. MD aware,\n ABG drawn, NIV W XL full FM started with immediate relief per pt.\n 0545 pt felt better removed mask..\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735518,
"text": "47 YO male with Hx of asthma, chronic low back pain, 2 recent rib\n fractures, was recently dx w/ dental abscess who presented to ED for\n malaise. He was also dx w/ his 2nd rib fx (7th rib right side). He\n states that he has not been feeling well for the past 2 weeks w/\n progressive severe fatigue, night sweats, and subjective fevers. The\n last 3 days he has had DOE so was called to the ED. In ED his creat\n 2.2 and LFT's that were abnormal, Ca+ 17.7. He was admitted to 3\n but with fluid resuscitations, he started to become hypoxic so he was\n transfered to the MICU\n NPO after MN tonight then needs to drink 2 bottles of barocat starting\n at 7am for the CT following injestion.\n Hypercalcemia (high Calcium)\n Assessment:\n Pt\ns calcium level has been 16.5, ionized calcium was 2.10, receiving\n NS 300mls/hr. patient also received a single dose of pamidronate 90 mg\n IV.\n Action:\n Continued fluids, NS 300mls/hr\n Response:\n AM labs\n Plan:\n Maintain IVF, Monitor I&O, recheck Ca++ as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creat is 2.5-2.6, passing good amount of urine via \n Action:\n Lasix 40mg/iv given for fluid overload in CXR\n Response:\n U/O 200-400 mls/hr\n Plan:\n Continue to monitor U/O, maintain IVF according to MD\ns orders.\n .H/O asthma\n Assessment:\n Received patient on 3L nasal canula, sitting on the chair, RR in high\n 30\ns and O2 sats low 90\ns. H/O asthama and using nasal CPAP at home.\n Bilateral lung sounds clear and exp wheeze and diminished bases.\n Patient has h/o rib fracture\n Action:\n C/o SOB and desats to 88-89%. CXR done\nshows fluid overload\n.lasix 40mg\n iv given with good response\n intermittent nasal CPAP and nasal canula 4L\n Nebs/ PRN as needed\n Patient desats to low 80\ns, on and off CPAP and nasal canula\n Received total of 120mg lasix and maintance fluid d/ced\n Response:\n Appears to be uncomfortable and very tired, RR in high 30\n Plan:\n Continue to monitor resp status and continue fluid bolus 300mls/hr for\n hypercalcemia and monitor CXR and lasix iv accordingly\n Ineffective Coping\n Assessment:\n HCT 26.6 this Am, bone marrow biopsy done yesterday evening, and\n preliminary report showed a diagnosis of aplastic multiple myeloma.\n Patient and wife do know of the dx.\n Action:\n No signs of bleeding, emotional support to patient and family\n Response:\n Plan:\n Emotional support and encouragement to patient and family\n SW consult in Am\n ? transfer to 4 for cancer treatment in AM\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735519,
"text": "47 YO male with Hx of asthma, chronic low back pain, 2 recent rib\n fractures, was recently dx w/ dental abscess who presented to ED for\n malaise. He was also dx w/ his 2nd rib fx (7th rib right side). He\n states that he has not been feeling well for the past 2 weeks w/\n progressive severe fatigue, night sweats, and subjective fevers. The\n last 3 days he has had DOE so was called to the ED. In ED his creat\n 2.2 and LFT's that were abnormal, Ca+ 17.7. He was admitted to 3\n but with fluid resuscitations, he started to become hypoxic so he was\n transfered to the MICU\n NPO after MN tonight then needs to drink 2 bottles of barocat starting\n at 7am for the CT following injestion.\n Hypercalcemia (high Calcium)\n Assessment:\n Pt\ns calcium level has been 16.5, ionized calcium was 2.10, receiving\n NS 300mls/hr. patient also received a single dose of pamidronate 90 mg\n IV.\n Action:\n Continued fluids, NS 300mls/hr until 5am\n Response:\n AM labs Ca 18.8 and ionized Ca 2.09\n Plan:\n Maintain IVF, Monitor I&O, recheck Ca++ as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creat is 2.5-2.6, passing good amount of urine via \n Action:\n Lasix 40mg/iv given for fluid overload in CXR\n Response:\n U/O 200-400 mls/hr\n Plan:\n Continue to monitor U/O, maintain IVF according to MD\ns orders.\n .H/O asthma\n Assessment:\n Received patient on 3L nasal canula, sitting on the chair, RR in high\n 30\ns and O2 sats low 90\ns. H/O asthama and using nasal CPAP at home.\n Bilateral lung sounds clear and exp wheeze and diminished bases.\n Patient has h/o rib fracture\n Action:\n C/o SOB and desats to 88-89%. CXR done\nshows fluid overload\n.lasix 40mg\n iv given with good response\n intermittent nasal CPAP and nasal canula 4L\n Nebs/ PRN as needed\n Patient desats to low 80\ns, on and off CPAP and nasal canula\n Received total of 120mg lasix and maintance fluid d/ced\n Response:\n Appears to be uncomfortable and very tired, RR in high 30\n Plan:\n Continue to monitor resp status and continue fluid bolus 300mls/hr for\n hypercalcemia and monitor CXR and lasix iv accordingly\n Ineffective Coping\n Assessment:\n HCT 26.6 this Am, bone marrow biopsy done yesterday evening, and\n preliminary report showed a diagnosis of aplastic multiple myeloma.\n Patient and wife do know of the dx.\n Action:\n No signs of bleeding, emotional support to patient and family\n Response:\n Plan:\n Emotional support and encouragement to patient and family\n SW consult in Am\n ? transfer to 4 for cancer treatment in AM\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735523,
"text": "47 YO male with Hx of asthma, chronic low back pain, 2 recent rib\n fractures, was recently dx w/ dental abscess who presented to ED for\n malaise. He was also dx w/ his 2nd rib fx (7th rib right side). He\n states that he has not been feeling well for the past 2 weeks w/\n progressive severe fatigue, night sweats, and subjective fevers. The\n last 3 days he has had DOE so was called to the ED. In ED his creat\n 2.2 and LFT's that were abnormal, Ca+ 17.7. He was admitted to 3\n but with fluid resuscitations, he started to become hypoxic so he was\n transfered to the MICU\n NPO after MN tonight then needs to drink 2 bottles of barocat starting\n at 7am for the CT following injestion.\n Hypercalcemia (high Calcium)\n Assessment:\n Pt\ns calcium level has been 16.5, ionized calcium was 2.10, receiving\n NS 300mls/hr. patient also received a single dose of pamidronate 90 mg\n IV.\n Action:\n Continued fluids, NS 300mls/hr until 5am\n Response:\n AM labs Ca 18.8 and ionized Ca 2.09\n Plan:\n Maintain IVF, Monitor I&O, recheck Ca++ as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creat is 2.5-2.6, passing good amount of urine via \n Action:\n Lasix 40mg/iv given for fluid overload in CXR\n Response:\n U/O 200-400 mls/hr, received 80mg iv this am, BUN/creat 62/3.1\n Plan:\n Continue to monitor U/O, maintain IVF according to MD\ns orders.\n .H/O asthma\n Assessment:\n Received patient on 3L nasal canula, sitting on the chair, RR in high\n 30\ns and O2 sats low 90\ns. H/O asthama and using nasal CPAP at home.\n Bilateral lung sounds clear and exp wheeze and diminished bases.\n Patient has h/o rib fracture\n Action:\n C/o SOB and desats to 88-89%. CXR done\nshows fluid overload\n.lasix 40mg\n iv given with good response\n intermittent nasal CPAP and nasal canula 4L\n Nebs/ PRN as needed\n Patient desats to low 80\ns, on and off CPAP and nasal canula\n Received total of 120mg lasix and maintance fluid d/ced\n Response:\n Appears to be uncomfortable and very tired, RR in high 30\ns, patient\n desats to low 80\ns, SOB, blood gas 7.44/49/72/7, changed to BIPAP mask\n with improvement in O2 sats\n Plan:\n Continue to monitor resp status and continue fluid bolus 300mls/hr for\n hypercalcemia and monitor CXR and lasix iv accordingly\n Ineffective Coping\n Assessment:\n HCT 26.6 this Am, bone marrow biopsy done yesterday evening, and\n preliminary report showed a diagnosis of aplastic multiple myeloma.\n Patient and wife do know of the dx.\n Action:\n No signs of bleeding, emotional support to patient and family\n Response:\n HCt 24.5, LFt\ns elevated\n Plan:\n Emotional support and encouragement to patient and family\n SW consult in Am\n ? transfer to 4 for cancer treatment in AM\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-15 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 735449,
"text": "Chief Complaint: Malaise\n HPI:\n 47M with a history of obesity, asthma, chronic low back pain, 2 recent\n rib fractures, and a recent dental abscess who presented to the ED for\n malaise. He had been seen by his pulmonologist recently who diagnosed\n the second of his 2 rib fractures and he was started on Aleve. Both\n fractures occured with incidental trauma - (first with bumping his\n couch, second with coughing). He reports that he has been feeling\n unwell for a month or so, but has been severely fatigued for the past 2\n weeks. Over the past 2 weeks he also has had progressive exertional\n dyspnea with significant decrease in his exercise tolerance. Mild\n subjective fevers at home, no weigh gain or weight loss, night sweats,\n or chills. complains of total body pain but no focal pain in back or\n other areas. He called his PCP with complaint DOE for the past 3 days\n and was called in to the ED.\n .\n In the ED his initial vital signs were 98.4 85 129/98 and 97% on RA. He\n was found to have progressive anemia from H/H 14.9/44.9 a year ago to\n 9.0/25.7 with almost no change in MCV with new thrombocytopenia to 101\n and an abnormal differential with a WBC of 8.7. He also had new \n with creatinine of 2.2. Given an initial concern for TTP, Tbili and LDH\n were added. The Tbili came back WNL but his LDH was elevated to 764.\n He was also noted to have a new murmur on exam. BCx were taken for\n possible endocarditis. Cardiology was consulted for TTE but this was\n deferred. He was admitted to for further management.\n .\n On the floor he was lethargic and ill appearing. Given his\n constellation of anemia, thrombocytopenia, and abnormal differential\n with multiple myeloid forms, his smear was reviewed and uric acid,\n LFTs, Ca, Mg, and Pi were added to his labs. His uric acid came back at\n 12.9 and his calcium came back at 17.7. An ionized calcium was then\n sent, a second PIV was placed, and IVF were started. Coags and\n fibrinogen were also sent, which were WNL.\n .\n Patient tolerated IV fluids with some increase in his O2 requirement to\n 2L-4L NC. Triggered this AM for somnolence and altered mental status.\n Heme-Onc consulted for concern for new myeloma diagnosis vs. TTP.\n Requesting unit transfer for close monitoring of his volume status and\n for nursing concern.\n .\n ROS low grade temps at home, marked new dyspnea with exertion.\n .\n Patient admitted from: \n History obtained from Patient, Family / Medical records\n Allergies:\n Iodine; Iodine Containing\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 Past Medical History:\n - Asthma - using inhaler more frequently, but with no good effect\n - Costrochondritis recently diagnosed\n - Lower back pain w/ L3-L4 lateral disc protrusion\n - Obesity\n - Nephrolithiasis\n - H/O atypical chest pain\n - Rectal bleeding\n - Hyperlipidemia\n - Sleep apnea, OSA 11cm H20\n - S/P rib fractures x2\n - Depression\n .\n Home Medications:\n - ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - \n puffs(s) by mouth every four (4) to six (6) hours as needed for\n cough/wheezing\n - BUDESONIDE [PULMICORT FLEXHALER] - 180 mcg/Actuation (160 mcg\n delivered) Aerosol Powdr Breath Activated - 2 (Two) puffs(s)\n inhaled twice a day\n - BUPROPION HCL [BUDEPRION SR] - 150 mg Tablet Sustained Release -\n 1 Tablet(s) by mouth once a day in the morning; increase to 150\n mg twice daily by day 4 if tolerated --> not taking\n - NAPROXEN SODIUM [ALEVE] - 220 mg Tablet - 1 to 2 Tablet(s) by\n mouth twice a day with food as needed for chest pain\n .\n Allergies:\n - Iodine --> Choking sensation\n - Mother: CAD and DM\n - Father: DM\n - No history of cancer or sarcoidosis\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives in with his wife. They have three sons. She is a\n plastic surgeon who trained at .\n - Tobacco: Denies\n - etOH: Denies\n - Illicits: Denies\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: diffuse body aches\n Flowsheet Data as of 10:51 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 85 (85 - 85) bpm\n RR: 23 (23 - 23) insp/min\n SpO2: 96%\n Total In:\n PO:\n TF:\n IVF:\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 -250 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), radiates to axilla, posterior chest, III/VI\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n very scattered at bases, Diminished: )\n Abdominal: Soft, Tender: RUQ, , Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not\n assessed, somewhat drowsy\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Notable for Hct 26, Plt 101, Uric Acid 13,\n Calcium 18, Cr 2.2,\n Peripheral smear: Normocytic RBC with anisocytosis, many teardrops,\n some cigar forms, no schistocytes, no acanthocytes or echinocytes.\n Possibly roleaux formation, but uncertain. Platlets are somewhat\n reduced in number and there are some large platlets. No obvious blasts\n in the main portion of the smear or the feathered edge. Several large\n mononuclear cells ? atypical lymphocytes, many bands, metamyelocytes,\n and myelocytes. Many monocytes.\n Imaging: - CXR: No acute process on admission.\n Microbiology: Blood Cultures Pending\n ECG: New RBBB.\n Assessment and Plan\n 47M with a history asthma, recent dental infection, recent rib\n fracures, now presents with progressive malaise in setting of\n hypercalcemia, renal failure, hyperuricemia, and abnormal differential\n which is highly suggestive of a new malignancy diagnosis. Would favor\n multiple myeloma as most likely, although lymphoma/leukemia are in\n differential. Altered mental status, renal failure and\n thrombocytopenia c/w TTP but no schistocytes on smear excluding dx.\n Overall constellation of symptoms is likely explained by severe\n hypercalcemia.\n .\n # Hypercalcemia: Likely malignant given the degree of hypercalcemia.\n Admission calcium is 17.7 with an ionized calcium of 2.13. Not on HCTZ,\n not taking vitamin D, and not taking calcium. Sarcoidosis is also\n within the differential but does not explain the hematologic\n abnormalities.\n - Continue IV normal saline at 200cc/hr until 2Liters given\n - Furosemide dosing q6 hours (await repeat labs, but anticipate can\n start as intravascularly replete).\n - Place foley for accurate Is and Os\n - Zoledronate 4mg IV once (Pamidronate associated with FSGS so opt for\n zoledronate).\n - Calcitonin -> can be dosed , one dose given this AM.\n - Trend calcium Q6H for now\n - Malignancy work up as below\n - TSH pending\n - Parathyroid Hormone pending for endocrine cause of his hypercalcemia\n - Vitamin D pending\n - Vitamin D 25 pending\n - Heme-Onc consult\n - Renal Consult\n - ACE Level\n .\n # Respiratory Status/volume: Increasing O2 requirement in setting of\n volume resuscitation. Likely pulmonary edema. Potentially underlying\n valvular disease given murmur on exam. Lasix as needed. Got 20mg IV\n lasix on floor -> unclear what was to that dose, but lasix naive.\n - lasix q6hours\n - CXR now\n - Echo, f/u blood cultures\n .\n # Hyperuricemia: Likely due to cell turn over given elevated LDH, in\n setting of dehydration. Complicated by and likely contributing to\n .\n - Start allopurinol 100mg daily\n - serum pH remains alkalemic so will defer bicarbonate infusion.\n - trend pH\n .\n # Acute kidney injury: Likely combination of hypercalcemia,\n hyperuricemia as a component of tumor lysis, and poor POs.\n - Renal consult in AM.\n - require HD for calcium, uric acid, possible tumor lysis\n - Moderate UEos, etiology unclear. Stopping all nonessential meds\n .\n # Likely cancer diagnosis:\n - Heme onc consult for BM biopsy, hold steroids until biopsy performed.\n - PSA pending\n - skeletal survey if can be done as portable\n - ESR and CRP are elevated\n - SPEP pending for ?MM\n - UPEP pending for ?MM\n - Serum free light chains pending\n - B2uGlobulin pending\n - No steroids to avoid complicating possible diagnosis\n - EBV Antibody Panel, CMV IgG/IgM Antibody Panel, and Toxoplasma\n IgG/IgM Antibody Panel pending given atypical lymphocytes on smear all\n ordered\n .\n # Anemia: Likely due to a bone marrow process. No evidence of TTP or\n intravascular hemolysis. Elevated haptoglobin and ferritin.\n - Likely marrow failure\n - Type and screen up to date, cross match one unit as will likely need\n blood after IVFs given\n - Transfuse for H/H < \n - Guaiac stools.\n .\n # Hypertension: Continue to follow. Treat accordingly.\n # Asthma:\n - Albuterol and ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, NPO for now, but ADAT\n # Prophylaxis:\n -DVT ppx with SC heparin\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n # Access: peripherals\n # Communication: Patient\n # Code: full\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n Chart reviewed, pt examined, case discussed in detail with resident\n team. I was present for delivery of all key aspects of care. I agree\n with the note above. In addition I would add/emphasize:\n 47M h/o asthma, chronic low back pain presented to the ED with malaise.\n He has had two recent rib fractures after incidental traumas - (bumping\n his couch and then with coughing). States that has felt unwell for a\n month and for the last two weeks has been severely fatigued and noted\n DOE with decreased exercise tolerance. In ED afebrile VSS, new murmur\n noted on exam. Labs notable for new anemia, and \n creat 2.2, LDH,\n 764. On admission to floor, smear was reviewed and labs notable for\n Calcium 17.7. IVF were started. Transferred to MICU for altered\n mental status and close management of hypercalcemia.\n Pleasant male, alert but somewhat somnolent\n AAOx3 in NAD\n Lungs\n rales in bases, otherwise CTA\n CV\n 3/6 SEM\n Abd soft NTND BS+\n Ext\n no edema\n 47M with h/o progressive malaise, DOE and recent rib fractures due to\n incidental trauma presents with hypercalcemia, altered mental status,\n AKD and an abnormal differential suggestive of a malignancy.\n Presumed malignancy\n -presentation concerning for malignancy\n -heme-onc consulted, reviewing smear\n -likely BM Bx today\n -several possibilities including multiple myeloma, lymphoma, leukemia\n -multiple studies pending including SPEP, UPEP, serum free light\n chains, B2uGlobulin\n Hypercalcemia\n -degree of disturbance most c/w malignancy, not on any meds which would\n cause elevation\n -cont IVNS\n -lasix once intravascularly replete\n -zoledronate\n -calcitonin\n -follow levels q6hrs, titrate levels accordingly\n AKD\n -trending creat\n -mod urine eos ? etiology\n -renal consulted\n Hypoxemia\n -requiring supp O2\n -? Related to volume resuscitation though not usual for otherwise\n healthy pt in 40s.\n -new murmur raises question of valvular disease as etiology\n -TTE\n -bcx\n .\n Hyperuricemia:\n - likely due to cell turnover given elevated LDH\n - start allopurinol\n Anemia\n -new\n -likely related malignancy\n Remainder of plan per note above.\n Patient is critically ill. Time spent on care: 40minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:21 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 735630,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 53.5 None\n Ideal tidal volume: mL/kg\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum source/amount: Expectorated / Scant\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 off the vent all day vent was pulled and pt placed on NC 5L tol\n well. See respiratory page of meta vision for more information.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735641,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to be in acute renal failure with creatinine\n 2.2, elevated LFT's, and Ca+ 17.7. He was originally admitted to \n 3 but during fluid resuscitation became hypoxic so he was transferred\n to the MICU.\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Hypercalcemia (high Calcium)\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 Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735644,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to be in acute renal failure with creatinine\n 2.2, elevated LFT's, and Ca+ 17.7. He was originally admitted to \n 3 but during fluid resuscitation became hypoxic so he was transferred\n to the MICU.\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Hypercalcemia (high Calcium)\n Assessment:\n AM calcium 18.8 (non-ionized)\n Action:\n Started on calcitonin salmon SC injection and NS @ 300cc/hr for 2L.\n Response:\n 1100 calcium (non-ionized) down to 15.7\n Plan:\n Calcium to be rechecked this evening, monitor for signs and symptoms of\n hypercalcemia, arrhythmias.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735651,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to be in acute renal failure with creatinine\n 2.2, elevated LFT's, and Ca+ 17.7. He was originally admitted to \n 3 but during fluid resuscitation became hypoxic so he was transferred\n to the MICU.\n Ineffective Coping\n Assessment:\n Pt\ns wife and brother in to visit pt throughout day. Pt has 3 small\n children at home. Pt seems to be coping appropriately, very supportive\n family, involved in pt\ns care.\n Action:\n Social work in to see family. Emotional support provided to pt and\n family by staff.\n Response:\n Plan:\n Hypercalcemia (high Calcium)\n Assessment:\n AM calcium 18.8 (non-ionized). Pt with recent rib fractures related to\n increased calcium levels.\n Action:\n Started on calcitonin salmon SC injection and NS @ 300cc/hr for 2L.\n Taken for skeletal survey this afternoon for films of skull, long\n bones and spine.\n Response:\n 1100 calcium (non-ionized) down to 15.7. Pt tolerated test well, final\n film reads pending.\n Plan:\n Calcium to be rechecked q6h, monitor for signs and symptoms of\n hypercalcemia, arrhythmias. Follow up skeletal survey results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n AM labs revealing decreased HCT and platelets (pt\ns baseline HCT40s).\n Bone marrow biopsy done . No obvious signs of bleeding noted.\n Action:\n Drop discussed during , team likely related to disease\n process in bone marrow. Abdominal US and CT torso done to evaluate for\n presence of lymphadenopthy.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735411,
"text": "47 YO male\n Hypercalcemia (high Calcium)\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 .H/O asthma\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735786,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to have progressive anemia from 44 to 25 and in\n acute renal failure with creatinine 2.2, elevated LFT's, and Ca+ 17.7.\n He was originally admitted to 3 but during fluid resuscitation\n became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n PM calcium 14.6 (down from 15.3). HR 80s-90s with PACs. Received on\n 6L NC with RR 20s, breathing shallow and sats 92-94%. Pt very\n lethargic but oriented.\n Action:\n Given calcitonin salmon SC injection\n NS IVF finished and now NS to KVO.\n 40mg IVP lasix.\n Labs checked q6hour.\n Pt placed on home CPAP nasal prongs with 10L O2 running in.\n Response:\n Am calcium 13.7\n Chest CT wet read more consistent with atypical myeloma.\n Skeletal survey final read still pending.\n Tolerated CPAP with RR 20s and sats 88-96%\n Plan:\n Calcium checked q6hour, next due at 1100.\n Admin meds per order.\n Home CPAP at night.\n F/u with official read from CT and skeletal survey.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards. Renal following for . Likely related to\n hypercalcemia.\n Action:\n Treating hypercalcemia as noted above\n 12 hour urine collection sent for testing\n Labs trended.\n Response:\n Tolerating IVP lasix well\n UOP >100cc/hr, clear, yellow\n Am BUN/Cr 93/3.6 (from 62/3.4)\n Plan:\n Continue to trend labs.\n Monitor UOP.\n f/u with 12 hour collection results.\n Anemia/thrombocytopenia\n Assessment:\n On admission pt noted to have low Hct from baseline of 40. plt low as\n well.\n Action:\n Labs trended.\n Monitored for s/s of bleeding.\n Response:\n CT results supporting atypical myeloma diagnosis.\n Hct 23.4 from 24.5.\n Plt 59 from 77.\n Plan:\n Continue to monitor HCT, goal >21.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 735916,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n \n CT torso, skeletal survey, ECHO, abdominal US\n Ineffective Coping\n Assessment:\n Pt\ns wife and brother in to visit pt throughout day. Pt has 3 small\n children at home.\n Action:\n Social work in to see family. Emotional support provided to pt and\n family by staff.\n Response:\n Family and pt seems to be coping appropriately, very supportive family,\n involved in pt\ns care.\n Plan:\n Continue to provide support as needed, SW aware and involved.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward, this AM 13.7 (non-ionized). Pt\n with recent rib fractures related to increased calcium levels.\n Action:\n This AM completed calcitonin salmon SC injection, ordered for NS @\n 200cc/hr for 2L, and lasix. Skeletal survey films of skull, long\n bones and spine pending. EKG done. Calcium rechecked at 1400.\n results pending.\n Response:\n Final read of skeletal survey pending. Calcium trending down\n appropriately. EKG showing no changes.\n Plan:\n Calcium to be rechecked q6h, next due at , monitor for signs and\n symptoms of hypercalcemia, arrhythmias. Follow up skeletal survey\n results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards, UOP >100cc/hr, clear, yellow. Renal following\n for . Likely related to hypercalcemia induced vasoconstriction to\n renal vasculature.\n Action:\n NS 2 200cc/hr to flush kidneys, lasix.\n Response:\n Continues to maintain good urine output. Tolerating lasix well,\n afternoon BUN/Cr continuing to climb however renal unimpressed. Per\n discussion with renal kidney function expected to improve over time and\n as calcium levels decrease.\n Plan:\n Continue to trend BUN/Cr frequently, monitor UOP. Renal team\n suggesting kidney biopsy if no improvement over next few days.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . No obvious signs of bleeding noted. Stool guiac positive\n however pt with known hemorrhoids. CT done . ECHO from \n showing EF >55%.\n Action:\n Drop discussed during , team likely related to disease\n process in bone marrow.\n Response:\n CT results supporting atypical myeloma diagnosis. Started on IV\n steroids.\n Plan:\n Continue to monitor HCT, monitor for signs of bleeding, continue IV\n steroids, HCT goal >21\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n DYSPNEA\n Code status:\n Full code\n Height:\n 62 Inch\n Admission weight:\n 112.6 kg\n Daily weight:\n Allergies/Reactions:\n Iodine; Iodine Containing\n Anaphylaxis;\n Precautions: No Additional Precautions\n PMH: Asthma\n CV-PMH:\n Additional history: costrochondritis; lower back pain w L3-L4 lateral\n disc protrusion; nephrolithiasis; H/O atypical chest pain;\n hyperlipedemia; S/P rib fracture; depression.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:120\n D:67\n Temperature:\n 97.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 28 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 92% %\n O2 flow:\n 5 L/min\n FiO2 set:\n 24h total in:\n 1,207 mL\n 24h total out:\n 2,590 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 04:55 AM\n Potassium:\n 3.8 mEq/L\n 04:55 AM\n Chloride:\n 93 mEq/L\n 04:55 AM\n CO2:\n 31 mEq/L\n 04:55 AM\n BUN:\n 93 mg/dL\n 04:55 AM\n Creatinine:\n 3.6 mg/dL\n 04:55 AM\n Glucose:\n 169 mg/dL\n 04:55 AM\n Hematocrit:\n 23.4 %\n 04:55 AM\n Additional pertinent labs:\n Ca 13.7 0400, BUN/Cr 93/3.6\n Lines / Tubes / Drains:\n PIV x 2\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: CPAP machine, watch\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:\n Jewelry: none\n Transferred from: MICU 6\n Transferred to: 7\n Date & time of Transfer: 1500\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735412,
"text": "47 YO male with Hx of asthma, chronic low back pain, 2 recent rib\n fractures, was recently dx w/ dental abscess who presented to ED for\n malaise. He was also dx w/ his 2nd rib fx (7th rib right side). He\n states that he has not been feeling well for the past 2 weeks w/\n progressive severe fatigue, night sweats, and subjective fevers. The\n last 3 days he has had DOE so was called to the ED. In ED his creat\n 2.2 and LFT's that were abnormal, Ca+ 17.7. He was admitted to 3\n but with fluid recussitation he started to become hypoxic so he was\n transfered to the MICU\n Hypercalcemia (high Calcium)\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 .H/O asthma\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735491,
"text": "47 YO male with Hx of asthma, chronic low back pain, 2 recent rib\n fractures, was recently dx w/ dental abscess who presented to ED for\n malaise. He was also dx w/ his 2nd rib fx (7th rib right side). He\n states that he has not been feeling well for the past 2 weeks w/\n progressive severe fatigue, night sweats, and subjective fevers. The\n last 3 days he has had DOE so was called to the ED. In ED his creat\n 2.2 and LFT's that were abnormal, Ca+ 17.7. He was admitted to 3\n but with fluid recussitation he started to become hypoxic so he was\n transfered to the MICU\n Hypercalcemia (high Calcium)\n Assessment:\n Pt\ns calcium level has been 16.5, ionized calcium was 2.10, receiving\n NS 300mls/hr. patient also received a single dose of pamidronate 90 mg\n IV.\n Action:\n Continued fluids, NS 300mls/hr\n Response:\n AM labs\n Plan:\n Maintain IVF, Monitor I&O, recheck Ca++ as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creat is 2.5-2.6, passing good amount of urine via \n Action:\n Lasix 40mg/iv given for fluid overload in CXR\n Response:\n U/O 200-400 mls/hr\n Plan:\n Continue to monitor U/O, maintain IVF according to MD\ns orders.\n .H/O asthma\n Assessment:\n Received patient on 3L nasal canula, sitting on the chair, RR in high\n 30\ns and O2 sats low 90\ns. H/O asthama and using nasal CPAP at home.\n Bilateral lung sounds clear and exp wheeze and diminished bases.\n Action:\n C/o SOB and desats to 88-89%. CXR done\nshows fluid overload\n.lasix 40mg\n iv given with good response\n intermittent nasal CPAP and nasal canula 4L\n Nebs/ PRN as needed\n Response:\n Appears to be uncomfortable and very tired, RR in high 30\n Plan:\n Continue to monitor resp status and continue fluid bolus 300mls/hr for\n hypercalcemia and monitor CXR and lasix iv accordingly\n Anemia, other\n Assessment:\n HCT on admission was 26.6.\n Action:\n He has no signs of bleeding. The hem/onc attending did a bone marrow\n biopsy.\n Response:\n The preliminary report showed a diagnosis of aplastic multiple myloma.\n Plan:\n Pt does know of the dx, support him and his wife in this difficult\n time.\n Pt is having a CT of the torso in the am. He cannot receive IV\n contrast dye. He will be NPO after MN tonight then needs to drink 2\n bottles of barocat starting at 7am for the CT following injestion.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735492,
"text": "47 YO male with Hx of asthma, chronic low back pain, 2 recent rib\n fractures, was recently dx w/ dental abscess who presented to ED for\n malaise. He was also dx w/ his 2nd rib fx (7th rib right side). He\n states that he has not been feeling well for the past 2 weeks w/\n progressive severe fatigue, night sweats, and subjective fevers. The\n last 3 days he has had DOE so was called to the ED. In ED his creat\n 2.2 and LFT's that were abnormal, Ca+ 17.7. He was admitted to 3\n but with fluid recussitation he started to become hypoxic so he was\n transfered to the MICU\n Hypercalcemia (high Calcium)\n Assessment:\n Pt\ns calcium level has been 16.5, ionized calcium was 2.10, receiving\n NS 300mls/hr. patient also received a single dose of pamidronate 90 mg\n IV.\n Action:\n Continued fluids, NS 300mls/hr\n Response:\n AM labs\n Plan:\n Maintain IVF, Monitor I&O, recheck Ca++ as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creat is 2.5-2.6, passing good amount of urine via \n Action:\n Lasix 40mg/iv given for fluid overload in CXR\n Response:\n U/O 200-400 mls/hr\n Plan:\n Continue to monitor U/O, maintain IVF according to MD\ns orders.\n .H/O asthma\n Assessment:\n Received patient on 3L nasal canula, sitting on the chair, RR in high\n 30\ns and O2 sats low 90\ns. H/O asthama and using nasal CPAP at home.\n Bilateral lung sounds clear and exp wheeze and diminished bases.\n Action:\n C/o SOB and desats to 88-89%. CXR done\nshows fluid overload\n.lasix 40mg\n iv given with good response\n intermittent nasal CPAP and nasal canula 4L\n Nebs/ PRN as needed\n Response:\n Appears to be uncomfortable and very tired, RR in high 30\n Plan:\n Continue to monitor resp status and continue fluid bolus 300mls/hr for\n hypercalcemia and monitor CXR and lasix iv accordingly\n Anemia, other\n Assessment:\n HCT 26.6 this Am, bone marrow biopsy done yesterday evening, and\n preliminary report showed a diagnosis of aplastic multiple myloma\n Action:\n Response:\n The.\n Plan:\n Pt does know of the dx, support him and his wife in this difficult\n time.\n Pt is having a CT of the torso in the am. He cannot receive IV\n contrast dye. He will be NPO after MN tonight then needs to drink 2\n bottles of barocat starting at 7am for the CT following injestion.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735493,
"text": "47 YO male with Hx of asthma, chronic low back pain, 2 recent rib\n fractures, was recently dx w/ dental abscess who presented to ED for\n malaise. He was also dx w/ his 2nd rib fx (7th rib right side). He\n states that he has not been feeling well for the past 2 weeks w/\n progressive severe fatigue, night sweats, and subjective fevers. The\n last 3 days he has had DOE so was called to the ED. In ED his creat\n 2.2 and LFT's that were abnormal, Ca+ 17.7. He was admitted to 3\n but with fluid resuscitations, he started to become hypoxic so he was\n transfered to the MICU\n NPO after MN tonight then needs to drink 2 bottles of barocat starting\n at 7am for the CT following injestion.\n Hypercalcemia (high Calcium)\n Assessment:\n Pt\ns calcium level has been 16.5, ionized calcium was 2.10, receiving\n NS 300mls/hr. patient also received a single dose of pamidronate 90 mg\n IV.\n Action:\n Continued fluids, NS 300mls/hr\n Response:\n AM labs\n Plan:\n Maintain IVF, Monitor I&O, recheck Ca++ as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creat is 2.5-2.6, passing good amount of urine via \n Action:\n Lasix 40mg/iv given for fluid overload in CXR\n Response:\n U/O 200-400 mls/hr\n Plan:\n Continue to monitor U/O, maintain IVF according to MD\ns orders.\n .H/O asthma\n Assessment:\n Received patient on 3L nasal canula, sitting on the chair, RR in high\n 30\ns and O2 sats low 90\ns. H/O asthama and using nasal CPAP at home.\n Bilateral lung sounds clear and exp wheeze and diminished bases.\n Patient has h/o rib fracture\n Action:\n C/o SOB and desats to 88-89%. CXR done\nshows fluid overload\n.lasix 40mg\n iv given with good response\n intermittent nasal CPAP and nasal canula 4L\n Nebs/ PRN as needed\n Response:\n Appears to be uncomfortable and very tired, RR in high 30\n Plan:\n Continue to monitor resp status and continue fluid bolus 300mls/hr for\n hypercalcemia and monitor CXR and lasix iv accordingly\n Ineffective Coping\n Assessment:\n HCT 26.6 this Am, bone marrow biopsy done yesterday evening, and\n preliminary report showed a diagnosis of aplastic multiple myeloma.\n Patient and wife do know of the dx.\n Action:\n No signs of bleeding, emotional support to patient and family\n Response:\n Plan:\n Emotional support and encouragement to patient and family\n SW consult in Am\n ? transfer to 4 for cancer treatment in AM\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 735902,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n \n CT torso, skeletal survey, ECHO, abdominal US\n Ineffective Coping\n Assessment:\n Pt\ns wife and brother in to visit pt throughout day. Pt has 3 small\n children at home.\n Action:\n Social work in to see family. Emotional support provided to pt and\n family by staff.\n Response:\n Family and pt seems to be coping appropriately, very supportive family,\n involved in pt\ns care.\n Plan:\n Continue to provide support as needed, SW aware and involved.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward, this AM 13.7 (non-ionized). Pt\n with recent rib fractures related to increased calcium levels.\n Action:\n This AM completed calcitonin salmon SC injection, NS @ 300cc/hr for\n 2L, and lasix. Taken for skeletal survey this afternoon for films\n of skull, long bones and spine. EKG done.\n Response:\n 1100 calcium (non-ionized) down to 15.7. Pt tolerated test well, final\n film reads pending.\n Plan:\n Calcium to be rechecked q6h, monitor for signs and symptoms of\n hypercalcemia, arrhythmias. Follow up skeletal survey results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards, UOP >100cc/hr, clear, yellow. Renal following\n for . Likely related to hypercalcemia.\n Action:\n Treating hypercalcemia as noted above, urine culture sent, started on\n lasix. Ordered for 12 hour urine collection. Started at 1600, due\n to end at 4/13 0400. Collection bottle in room.\n Response:\n Continues to maintain good urine output. Tolerating lasix well,\n afternoon BUN/Cr continuing to climb however renal unimpressed.\n Plan:\n Continue to trend BUN/Cr frequently, monitor UOP, continue 12 hour\n urine collection until 0400.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets (pt\ns baseline HCT40s).\n Bone marrow biopsy done . No obvious signs of bleeding noted.\n Action:\n Drop discussed during , team likely related to disease\n process in bone marrow. Abdominal US and CT torso done to evaluate for\n presence of lymphadenopthy.\n Response:\n CT results supporting atypical myeloma diagnosis. Started on IV\n steroids.\n Plan:\n Continue to monitor HCT, monitor for signs of bleeding, continue IV\n steroids, HCT goal >21\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-18 00:00:00.000",
"description": "Physician Resident/Attending Admission Note - MICU",
"row_id": 736025,
"text": "Chief Complaint: hypoxia\n HPI:\n Mr. is a 47 year old man with a history of obesity, asthma,\n chronic low back pain, and recent rib fracture who presented to the ED\n on for 2 weeks of severe fatigue & dyspnea on exertion. In\n of this year, the patient was diagnosed with a right lateral\n seventh rib fracture following incidental trauma (leaning over the arm\n of a chair). On , the patient was seen in Pulmonology clinic for\n progressive dyspnea and bony pain, and his dyspne awas thought\n attributable to asthma. He was therefore restarted on pulmicort. ,\n though a CXR was negative for fracture. His DOE progressed and he\n developed profound fatigue, along with nightsweats and fevers. He\n therefore presented to the ED on .\n .\n There, he endorsed mild subjective fevers at home, but denied any other\n B symptoms. Initial vital signs were T98.4 P85 BP129/98 and 97% on RA.\n Blood work demonstrated a hematocrit of 25.7 (baseline Hct 45), a new\n thrombocytopenia to 101, and a WBC of 8.7 with abnormal myeloid cells.\n He also had a Cr of 2.2 (baseline 0.8) and was noted to have a new\n murmur on exam. He was admitted to 3 for further management, but\n on the floor he was ill-appearing and further work-up demonstrated a Ca\n of 17.7 and Uric Acid of 12.9. Coags and fibrinogen were WNL, so he\n initiated IVF's, but then triggered on for increasing O2\n requirement, somnolence and AMS and he was transferred to the ICU for\n further management.\n .\n In the ICU, Heme-Onc & Renal were consulted. He was continued on\n aggressive IVF's, Lasix 80mg , Allopurinol, Pamidronate (last dose\n on ), Calcitonin, & Dexamethasone 40mg IV (first dose on ). His\n Cr rose to 3.6, but he continued to produce urine. A CT torso\n demonstrated diffuse lucencies in the bone without associated\n lymphadenopathy consistent with multiple myeloma, and his SPEP\n demonstrated a monocloncal IgG kappa spike of 15% of total protein with\n normal viscosity. Over the course of his ICU stay, his serum Ca trended\n down to 13.7, but his serum phosphate & uric acid continued to climb.\n His O2 requirement also continued to rise and a CXR on suggested a\n right middle lobe pneumonia so he was started on Ceftriaxone &\n Azithromycin for CAP. Oncology recommended initiation of chemotherapy\n and he was therefore transferred to BMT.\n .\n At the time of transfer, his vital signs were: T 97.9 P84 BP 120/67 R\n 20's O2Sat 95% on 5L, I 4,618cc O 7,090cc. On arrival to the floor, the\n patient immediately triggered for an O2Sat of 88-89% on 6L NC, so he\n was switched to a NRB sat'ing 97%. He was quickly switched back to 6L,\n sat'ing 95-96% with a RR of 36. He appeared uncomfortable and was\n unable to speak in complete sentences.\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Azithromycin - 11:30 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Other medications:\n Medications on Transfer:\n Dexamethasone 40 mg IV DAILY Duration: 4 Doses\n Calcitonin Salmon 400 UNIT SC BID Duration: 3 Doses\n Rasburicase *NF* 6 mg Injection once\n Furosemide 80 mg IV BID\n Allopurinol 100 mg PO/NG DAILY\n Cefepime\n Levaquin\n Fluticasone Propionate 110mcg 2 PUFF IH \n Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB\n Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB\n Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing/sob\n Acetaminophen mg PO/NG Q6H:PRN pain\n Senna 1 TAB PO/NG :PRN constipation\n Past medical history:\n Family history:\n Social History:\n Asthma\n Costrochondritis\n Lower back pain w/ L3-L4 lateral disc protrusion\n Obesity\n Nephrolithiasis\n H/O atypical chest pain\n Rectal bleeding\n Hyperlipidemia\n Sleep apnea, OSA 11cm H20\n s/p rib fractures x 1, \n Depression\n Mother: CAD and DM\n Father: DM\n known family history of cancer\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Patient lives in with his wife & works on faculty at\n . They have three sons. His wife is a\n plastic surgeon who trained at the .\n Review of systems:\n Flowsheet Data as of 07:35 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98\n HR: 84 (80 - 95) bpm\n BP: 138/62(79) {103/54(63) - 148/68(84)} mmHg\n RR: 29 (22 - 34) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 4,618 mL\n 1,413 mL\n PO:\n 420 mL\n 500 mL\n TF:\n IVF:\n 4,198 mL\n 913 mL\n Blood products:\n Total out:\n 7,090 mL\n 3,050 mL\n Urine:\n 7,090 mL\n 3,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,472 mL\n -1,637 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n ABG: ///31/\n Physical Examination\n VS: T 98.0 84 138/62 25 98% NRB\n GEN: obese, ill-appearing, man with nasal cannula in place, moderate\n respiratory distress, speaking softly & unable to speak in complete\n sentences. somnolent but awakens to voice.\n HEENT: NC/AT, anicteric sclera, oropharynx clear, no LAD\n CV: RRR, no murmurs, rubs, gallops\n PULM: Mild expiratory wheezes throughout with crackles at the bases\n bilaterally and increased work of breathing\n ABD: soft, obese, NT/ND, normoactive bowel sounds\n LIMBS: warm, well-perfused, 2+ dorsalis pedis pulsations\n SKIN: no rashes, ecchymoses, or petichiae\n Labs / Radiology\n 59 K/uL\n 8.1 g/dL\n 169 mg/dL\n 3.6 mg/dL\n 113 mg/dL\n 31 mEq/L\n 93 mEq/L\n 3.8 mEq/L\n 137 mEq/L\n 23.4 %\n 10.7 K/uL\n [image002.jpg]\n \n 2:33 A4/11/ 02:29 PM\n \n 10:20 P4/12/ 03:47 AM\n \n 1:20 P4/12/ 05:02 AM\n \n 11:50 P4/12/ 10:42 AM\n \n 1:20 A4/12/ 05:07 PM\n \n 7:20 P4/12/ 10:37 PM\n 1//11/006\n 1:23 P4/13/ 04:55 AM\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.4\n 10.7\n Hct\n 24.5\n 23.4\n Plt\n 77\n 59\n Cr\n 2.6\n 3.1\n 3.4\n 3.4\n 3.4\n 3.6\n TC02\n 34\n Glucose\n 121\n 123\n 169\n Other labs: PT / PTT / INR:14.4/22.8/1.2, ALT / AST:95/102, Alk Phos /\n T Bili:68/0.4, Fibrinogen:641 mg/dL, Lactic Acid:1.3 mmol/L, LDH:2470\n IU/L, Ca++:13.7 mg/dL, Mg++:1.9 mg/dL, PO4:6.3 mg/dL\n Fluid analysis / Other labs: Peripheral smear: Normocytic RBC with\n anisocytosis, many teardrops, some cigar forms, no schistocytes, no\n acanthocytes or echinocytes. Possibly roleaux formation, but uncertain.\n Platelets are somewhat reduced in number and there are some large\n platlets. No obvious blasts in the main portion of the smear or the\n feathered edge. Several large mononuclear cells ? atypical lymphocytes,\n many bands, metamyelocytes, and myelocytes. Many monocytes.\n Imaging: Imaging: CXR : In comparison with study of , there is\n continued mild enlargement of the cardiac silhouette with engorgement\n of pulmonary vessels consistent with increased pulmonary venous\n pressure. More focal opacification is seen at the right base with\n silhouetting of the right heart border, this is suspicious for a right\n middle lobe pneumonia.\n .\n CT Torso :\n 1. Findings most consistent with multiple myeloma with innumerable\n lucent lesions seen throughout all visualized osseous structures.\n 2. Diffuse ground glass and partially nodular opacities throughout both\n lungs is a nonspecific finding, though raises concern for an atypical\n infection; pulmonary edema alone is felt less likely.\n 3. No lymphadenopathy.\n Assessment and Plan\n 47M with asthma, OSA, chronic low back pain, recent rib fracure, who\n presented with malaise & DOE found to have bony lesions on CT and a\n constellation of hematologic/electrolyte findings consistent with\n multiple myeloma.\n .\n # Dyspnea/Respiratory Distress: Patient with increasing O2 requirement\n in setting of known asthma, fluid therapy, and new right middle lobe\n pneumonia with pulmonary edema. Also with CT chest on with diffuse\n ground glass opacities. Patient also with hyperdynamic state of heart\n on TTE (EF 75%), elevated BNP to 4232, moderate pulmonary artery\n hypertension. Receiving Lasix with fluids and now on antibiotics.\n - Lasix 80mg \n - IVF's to titrate to UOP 200-300cc/hr\n - Levofloxacin & Cefepime, renally dosed, day 1 for CAP\n - O2 to maintain sats >92%\n - CPAP at night at 11cm H20\n .\n # Multiple Myeloma: Patient with M-protein in both urine & serum\n identified as IgG kappa as well as end-organ dammage manifested as ARF\n and anemia, diffuse lytic lesions on CT and hypercalcemia suggests a\n diagnosis multiple myeloma. Bone marrow biopsy results are positive for\n myeloma, but patient has commenced Dexamethasone therapy as of .\n Normal serum viscosity and patient without signs or symptoms of\n hyperviscosity syndrome, but beta-2 microglobulin was 6.8. EBV/CMV/Toxo\n negative.\n - K/L light chain ratio pending\n - Continue Dexamethasone 40mg IV qday, day \n - Continue IVF's at 150cc NS/hr, titrate to UOP of 200-300cc/hr\n - Continue Lasix 80mg \n - F/U skeletal survey results\n - F/U final CT torso, but verbal report by radiology as above\n - Oncology following, will guide treatment\n .\n # Hypercalcemia: Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n - Goal urine output 200-300cc/hr\n - Continue IV NS as above\n - Lasix as above\n - Dexamethasone as above\n - q6H labs\n - Vitamin D pending\n - Vitamin D 25 pending\n .\n # Hyperuricemia: Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase this PM.\n - Continue Allopurinol 100mg daily\n - Avoid HCO3 as it will precipitate calcium & phosphate\n - Repeat labs at 10PM (uric acid level must be measured in green top on\n ice and spun on a cooled centrifuge)\n .\n # Acute renal insufficiency: Cr 3.7 and continuing to rise. Renal\n following. Renal failure is likely tubular injury from cast nephropathy\n in conjunction with hypercalcemia, hyperuricemia.\n - Renal recs\n - require renal biopsy if function does not improve\n - Continuous IVF's/Lasix to preempt further tubular injury\n .\n # Anemia: Low reticulocyte count, elevated haptoglobin & ferritin.\n demonstrating insufficient erythropoeisis. No evidence of TTP or\n intravascular hemolysis.\n - Maintain active T&S\n - Transfuse for HCT <25\n - Guaiac stools\n .\n # Asthma: Continue Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, regular\n .\n # Prophylaxis:\n -DVT ppx with pneumoboots/CPAP\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n .\n # Access: peripherals\n # Communication: Patient\n # Code: FULL\n # Disposition: BMT floor for now\n INEFFECTIVE COPING\n HYPERCALCEMIA (HIGH CALCIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O ASTHMA\n ANEMIA, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 47M asthma, obesity, OSA initially p/w\n hypercalcemia (18), anemia, thrombocytopenia and fatigue - w/u notable\n for + SPEP, bony lesions and BMBx c/w MM. Treated in West MICU with\n IVF, lasix, IV bisphosphonate, calcitonin, steroids and sent earlier\n today to BMT. Of note, AM CXR concerning for ? pneumonia, started on\n CTX / azithro. On arrival to BMT, hypoxemic and in respiratory\n distress, CXR c/w CHF, ABG 7.47/44/209. Echo hyperdynamic with mod\n PHTN.\n Exam notable for Tm 98.0 BP 130/60 HR 75 RR 18 with sat 94 on 3LNC. JVD\n to mid neck at 90 deg. Rales B bases, schattered wheeze. RRR s1s2. Soft\n +BS. Petechiae on hands and feet. Labs notable for WBC 10K, HCT 23, K+\n 3.8, Cr 3.6, Ca .9 (peak >18), Uric acid 8.3 (from 12.9 s/p\n rasburicase), BNP 3000. CXR with , EKG c old RB3 yesterday (new EKG\n pending).\n Agree with plan to manage acute respiratory distress, likely flash\n pulmonary edema, with ongoing diuresis, d/c IVF for the moment, cycle,\n check repeat EKG, check sputum GS/C+S, inducted sputum PCP, \n , and continue broad abx coverage, including addition of vanco if he\n is febrile or does not respond to rx for pulm edema. Multiple myeloma -\n dex, plan for velcade in AM, suportive care for potential tumor lysis -\n allopurinol, rasburicase, labs q6, maintain UOP >200cc/h, ongoing d/w\n BMT service re oncologic care. Hypercalcemia - s/p calcitonin,\n pamidronate, lasix - improving. ARF - progressive - likely combination\n of MM, hypercalcemia, RD meds, renal following. Anemia - likely marrow\n infiltration / ACD, no e/o blood loss, will maintain BBS, likely xfuse\n in AM when respiratory status stabilized. Remainder of plan as outlined\n above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:41 ------\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735484,
"text": "47 YO male with Hx of asthma, chronic low back pain, 2 recent rib\n fractures, was recently dx w/ dental abscess who presented to ED for\n malaise. He was also dx w/ his 2nd rib fx (7th rib right side). He\n states that he has not been feeling well for the past 2 weeks w/\n progressive severe fatigue, night sweats, and subjective fevers. The\n last 3 days he has had DOE so was called to the ED. In ED his creat\n 2.2 and LFT's that were abnormal, Ca+ 17.7. He was admitted to 3\n but with fluid recussitation he started to become hypoxic so he was\n transfered to the MICU\n Hypercalcemia (high Calcium)\n Assessment:\n Pt\ns calcium level has been 16.5, ionized calcium was 2.10, receiving\n NS 300mls/hr. patient also received a single dose of pamidronate 90 mg\n IV.\n Action:\n Continued fluids, NS 300mls/hr\n Response:\n AM labs\n Plan:\n Maintain IVF, Monitor I&O, recheck Ca++ as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creat is 2.5-2.6, passing good amount of urine via \n Action:\n Lasix 40mg/iv given for fluid overload in CXR\n Response:\n U/O 200-400 mls/hr\n Plan:\n Continue to monitor U/O, maintain IVF according to MD\ns orders.\n .H/O asthma\n Assessment:\n Pt had received 1L IV bolus which started him to have some rales and be\n hypoxic with O2 sats 89-90%.\n Action:\n He was placed on 2L NC then transferred to MICU. His O2 sats have been\n 93-95%. RR 22-28.\n Response:\n He has been comfortable without complaints of being SOB. No signs of\n an asthma flare.\n Plan:\n Continue to monitor resp status.\n Anemia, other\n Assessment:\n HCT on admission was 26.6.\n Action:\n He has no signs of bleeding. The hem/onc attending did a bone marrow\n biopsy.\n Response:\n The preliminary report showed a diagnosis of aplastic multiple myloma.\n Plan:\n Pt does know of the dx, support him and his wife in this difficult\n time.\n Pt is having a CT of the torso in the am. He cannot receive IV\n contrast dye. He will be NPO after MN tonight then needs to drink 2\n bottles of barocat starting at 7am for the CT following injestion.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735486,
"text": "47 YO male with Hx of asthma, chronic low back pain, 2 recent rib\n fractures, was recently dx w/ dental abscess who presented to ED for\n malaise. He was also dx w/ his 2nd rib fx (7th rib right side). He\n states that he has not been feeling well for the past 2 weeks w/\n progressive severe fatigue, night sweats, and subjective fevers. The\n last 3 days he has had DOE so was called to the ED. In ED his creat\n 2.2 and LFT's that were abnormal, Ca+ 17.7. He was admitted to 3\n but with fluid recussitation he started to become hypoxic so he was\n transfered to the MICU\n Hypercalcemia (high Calcium)\n Assessment:\n Pt\ns calcium level has been 16.5, ionized calcium was 2.10, receiving\n NS 300mls/hr. patient also received a single dose of pamidronate 90 mg\n IV.\n Action:\n Continued fluids, NS 300mls/hr\n Response:\n AM labs\n Plan:\n Maintain IVF, Monitor I&O, recheck Ca++ as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creat is 2.5-2.6, passing good amount of urine via \n Action:\n Lasix 40mg/iv given for fluid overload in CXR\n Response:\n U/O 200-400 mls/hr\n Plan:\n Continue to monitor U/O, maintain IVF according to MD\ns orders.\n .H/O asthma\n Assessment:\n Pt had received 1L IV bolus which started him to have some rales and be\n hypoxic with O2 sats 89-90%.\n Action:\n He was placed on 2L NC then transferred to MICU. His O2 sats have been\n 93-95%. RR 22-28.\n Response:\n He has been comfortable without complaints of being SOB. No signs of\n an asthma flare.\n Plan:\n Continue to monitor resp status.\n Anemia, other\n Assessment:\n HCT on admission was 26.6.\n Action:\n He has no signs of bleeding. The hem/onc attending did a bone marrow\n biopsy.\n Response:\n The preliminary report showed a diagnosis of aplastic multiple myloma.\n Plan:\n Pt does know of the dx, support him and his wife in this difficult\n time.\n Pt is having a CT of the torso in the am. He cannot receive IV\n contrast dye. He will be NPO after MN tonight then needs to drink 2\n bottles of barocat starting at 7am for the CT following injestion.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735487,
"text": "47 YO male with Hx of asthma, chronic low back pain, 2 recent rib\n fractures, was recently dx w/ dental abscess who presented to ED for\n malaise. He was also dx w/ his 2nd rib fx (7th rib right side). He\n states that he has not been feeling well for the past 2 weeks w/\n progressive severe fatigue, night sweats, and subjective fevers. The\n last 3 days he has had DOE so was called to the ED. In ED his creat\n 2.2 and LFT's that were abnormal, Ca+ 17.7. He was admitted to 3\n but with fluid recussitation he started to become hypoxic so he was\n transfered to the MICU\n Hypercalcemia (high Calcium)\n Assessment:\n Pt\ns calcium level has been 16.5, ionized calcium was 2.10, receiving\n NS 300mls/hr. patient also received a single dose of pamidronate 90 mg\n IV.\n Action:\n Continued fluids, NS 300mls/hr\n Response:\n AM labs\n Plan:\n Maintain IVF, Monitor I&O, recheck Ca++ as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creat is 2.5-2.6, passing good amount of urine via \n Action:\n Lasix 40mg/iv given for fluid overload in CXR\n Response:\n U/O 200-400 mls/hr\n Plan:\n Continue to monitor U/O, maintain IVF according to MD\ns orders.\n .H/O asthma\n Assessment:\n Received patient on 3L nasal canula, sitting on the chair, RR in high\n 30\ns and O2 sats low 90\ns. H/O asthama and using nasal CPAP at home.\n Bilateral lung sounds clear and exp wheeze and diminished bases.\n Action:\n c/o .\n Response:\n He has been comfortable without complaints of being SOB. No signs of\n an asthma flare.\n Plan:\n Continue to monitor resp status.\n Anemia, other\n Assessment:\n HCT on admission was 26.6.\n Action:\n He has no signs of bleeding. The hem/onc attending did a bone marrow\n biopsy.\n Response:\n The preliminary report showed a diagnosis of aplastic multiple myloma.\n Plan:\n Pt does know of the dx, support him and his wife in this difficult\n time.\n Pt is having a CT of the torso in the am. He cannot receive IV\n contrast dye. He will be NPO after MN tonight then needs to drink 2\n bottles of barocat starting at 7am for the CT following injestion.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735536,
"text": "47 YO male with Hx of asthma, chronic low back pain, 2 recent rib\n fractures, was recently dx w/ dental abscess who presented to ED for\n malaise. He was also dx w/ his 2nd rib fx (7th rib right side). He\n states that he has not been feeling well for the past 2 weeks w/\n progressive severe fatigue, night sweats, and subjective fevers. The\n last 3 days he has had DOE so was called to the ED. In ED his creat\n 2.2 and LFT's that were abnormal, Ca+ 17.7. He was admitted to 3\n but with fluid resuscitations, he started to become hypoxic so he was\n transfered to the MICU\n NPO after MN tonight then needs to drink 2 bottles of barocat starting\n at 7am for the CT following injestion.\n Hypercalcemia (high Calcium)\n Assessment:\n Pt\ns calcium level has been 16.5, ionized calcium was 2.10, receiving\n NS 300mls/hr. patient also received a single dose of pamidronate 90 mg\n IV.\n Action:\n Continued fluids, NS 300mls/hr until 5am\n Response:\n AM labs Ca 18.8 and ionized Ca 2.09\n Plan:\n Maintain IVF, Monitor I&O, recheck Ca++ as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creat is 2.5-2.6, passing good amount of urine via \n Action:\n Lasix 40mg/iv given for fluid overload in CXR\n Response:\n U/O 200-400 mls/hr, received 80mg iv this am, BUN/creat 62/3.1\n Plan:\n Continue to monitor U/O, maintain IVF according to MD\ns orders.\n .H/O asthma\n Assessment:\n Received patient on 3L nasal canula, sitting on the chair, RR in high\n 30\ns and O2 sats low 90\ns. H/O asthama and using nasal CPAP at home.\n Bilateral lung sounds clear and exp wheeze and diminished bases.\n Patient has h/o rib fracture\n Action:\n C/o SOB and desats to 88-89%. CXR done\nshows fluid overload\n.lasix 40mg\n iv given with good response\n intermittent nasal CPAP and nasal canula 4L\n Nebs/ PRN as needed\n Patient desats to low 80\ns, on and off CPAP and nasal canula\n Received total of 120mg lasix and maintance fluid d/ced\n Response:\n Appears to be uncomfortable and very tired, RR in high 30\ns, patient\n desats to low 80\ns, SOB, blood gas 7.44/49/72/7, changed to NIV, BIPAP\n mask with improvement in O2 sats\n Plan:\n Continue to monitor resp status and monitor CXR and lasix iv\n accordingly, ?^^^creat\n Ineffective Coping\n Assessment:\n HCT 26.6 this Am, bone marrow biopsy done yesterday evening, and\n preliminary report showed a diagnosis of aplastic multiple myeloma.\n Patient and wife do know of the dx.\n Action:\n No signs of bleeding, emotional support to patient and family\n Response:\n HCt 24.5, LFt\ns elevated\n Plan:\n Emotional support and encouragement to patient and family\n SW consult in Am\n ? transfer to 4 for cancer treatment in AM\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 735559,
"text": "Chief Complaint:\n 24 Hour Events:\n Bone marrow biopsy performed at bed side by Heme/Onc, pathology\n pending. Patient receiving home asthma medications as well as CPAP\n overnight on home settings.\n Patient becoming hypoxic overnight with O2 sats in the low 90s.\n Received Lasix 40mg IV x 1 and 80mg x 1; IVF stopped and patient\n started on Bipap. Calcitonin given. Despite these measures, calcium\n increasing to 18.8 this morning.\n Pt not tolerating BiPap and continues to remove mask.\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:20 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 06:55 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: 37.7\nC (99.8\n HR: 97 (85 - 106) bpm\n BP: 151/58(78) {118/42(60) - 151/117(149)} mmHg\n RR: 32 (18 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 4,298 mL\n 1,577 mL\n PO:\n TF:\n IVF:\n 3,298 mL\n 1,577 mL\n Blood products:\n Total out:\n 5,850 mL\n 2,320 mL\n Urine:\n 2,900 mL\n 2,320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,552 mL\n -743 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n PS : 8 cmH2O\n RR (Spontaneous): 25\n PEEP: 7 cmH2O\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: 7.44/49/72/31/7\n Ve: 7.2 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), radiates to axilla, posterior chest, III/VI\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n very scattered at bases, Diminished: )\n Abdominal: Soft, Tender: RUQ, , Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not\n assessed, somewhat drowsy\n Labs / Radiology\n 77 K/uL\n 8.5 g/dL\n 123 mg/dL\n 3.1 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 62 mg/dL\n 100 mEq/L\n 141 mEq/L\n 24.5 %\n 7.4 K/uL\n [image002.jpg]\n 02:29 PM\n 03:47 AM\n 05:02 AM\n WBC\n 7.4\n Hct\n 24.5\n Plt\n 77\n Cr\n 2.6\n 3.1\n TCO2\n 34\n Glucose\n 121\n 123\n Other labs:\n PT / PTT / INR:12.6/19.0/1.1\n ALT / AST:113/67, Alk Phos / T Bili:74/0.8,\n Lactic Acid:1.3 mmol/L,\n LDH:813 IU/L,\n Ca++:18.8 mg/dL, Mg++:1.8 mg/dL, PO4:6.1 mg/dL\n 47M with a history asthma, recent dental infection, recent rib\n fracures, now presents with progressive malaise in setting of\n hypercalcemia, renal failure, hyperuricemia, and abnormal differential\n which is highly suggestive of a new malignancy diagnosis. Would favor\n multiple myeloma as most likely, although lymphoma/leukemia are in\n differential. Altered mental status, renal failure and\n thrombocytopenia c/w TTP but no schistocytes on smear excluding dx.\n Overall constellation of symptoms is likely explained by severe\n hypercalcemia.\n .\n # Hypercalcemia: Suspected malignancy given the degree of\n hypercalcemia. Admission calcium is 17.7 with an ionized calcium of\n 2.13. Not on HCTZ, not taking vitamin D, and not taking calcium.\n Preliminary read of BM biopsy suggests aplastic myeloma. PTH = 8,\n SPEP/UPEP, vitamin D 25 and 1,25, B2 globulin and kappa/lambda levels\n pending.\n - IVF with normal saline at 200cc/hr on hold for now give respiratory\n distress\n - Furosemide dosing q6 hours or PRN (will F/U renal recs)\n - Trend , electtrolytes\n - One dose pamidronate on \n - Calcitonin -> written for 3 doses\n - Trend calcium Q6H for now\n - ACE Level\n - F/U final heme report\n - Check EKG this AM for changes\n .\n # Respiratory Status/volume: Increasing O2 requirement in setting of\n volume resuscitation. Likely pulmonary edema. Potentially underlying\n valvular disease given murmur on exam. Lasix as needed. Got 20mg IV\n lasix on floor -> unclear what was to that dose, but lasix naive.\n Increased SOB overnight\n unable to tolerate BiPAP. Currently O2 sats\n ~90%. require intubation if O2 sats fall, increased work of\n breathing.\n - lasix PRN\n - Contiue fluticasone, albuterol inhalers\n - Trend CXR\n - Consider echo\n - f/u blood cultures\n .\n # Hyperuricemia: Likely due to cell turn over given elevated LDH, in\n setting of dehydration. Complicated by and likely contributing to\n .\n - Start allopurinol 100mg daily\n - serum pH remains alkalemic so will defer bicarbonate infusion.\n - trend pH\n .\n # Acute kidney injury: Likely combination of hypercalcemia,\n hyperuricemia as a component of tumor lysis, and poor POs. If tumor is\n of plasma cell origin, immunoglobulins may also play a role. Continues\n to make good urine.\n - Renal following\n will F/U recs\n - require HD for calcium, uric acid, possible tumor lysis\n - Moderate UEos, etiology unclear. Stopping all nonessential meds -\n - Lasix 80 mg IV BID or PRN\n - Check urine albumin, creatinine, total protein\n .\n # Likely cancer diagnosis: Labs pending as above. PSA = 0.3. ESR, CRP\n elevated. EBV Antibody Panel, CMV IgG/IgM Antibody Panel, and\n Toxoplasma IgG/IgM Antibody Panel pending given atypical lymphocytes on\n smear all ordered. Will likely need treatment for underlying malignancy\n soon\n prelim Bx suggests aplastic myeloma.\n - Heme onc following\n appreciate recs\n - Will discuss role of steroids with heme-onc team today\n - Skeletal survey if can be done as portable\n .\n # Anemia: Likely due to a bone marrow process. No evidence of TTP or\n intravascular hemolysis. Elevated haptoglobin and ferritin.\n - Likely marrow failure\n - Type and screen up to date, cross match one unit as will likely need\n blood after IVFs given\n - Transfuse for H/H < \n - Guaiac stools.\n .\n # Hypertension: Continue to follow. Treat accordingly.\n # Asthma:\n - Albuterol and ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, NPO for now, but ADAT\n # Prophylaxis:\n -DVT ppx with SC heparin\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n # Access: peripherals\n # Communication: Patient\n # Code: full\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n 18 Gauge - 08:21 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": "2136-04-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 735583,
"text": "Chief Complaint:\n 24 Hour Events:\n Bone marrow biopsy performed at bed side by Heme/Onc, pathology\n pending. Patient receiving home asthma medications as well as CPAP\n overnight on home settings.\n Patient becoming hypoxic overnight with O2 sats in the low 90s.\n Received Lasix 40mg IV x 1 and 80mg x 1; IVF stopped and patient\n started on Bipap. Calcitonin given. Despite these measures, calcium\n increasing to 18.8 this morning.\n Pt not tolerating BiPap and continues to remove mask.\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:20 AM\n Other medications:\n Changes to medical and family history:\n Unchanged\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Unchanged\n Flowsheet Data as of 06:55 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: 37.7\nC (99.8\n HR: 97 (85 - 106) bpm\n BP: 151/58(78) {118/42(60) - 151/117(149)} mmHg\n RR: 32 (18 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 4,298 mL\n 1,577 mL\n PO:\n TF:\n IVF:\n 3,298 mL\n 1,577 mL\n Blood products:\n Total out:\n 5,850 mL\n 2,320 mL\n Urine:\n 2,900 mL\n 2,320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,552 mL\n -743 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n PS : 8 cmH2O\n RR (Spontaneous): 25\n PEEP: 7 cmH2O\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: 7.44/49/72/31/7\n Ve: 7.2 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), radiates to axilla, posterior chest, III/VI\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n very scattered at bases, Diminished: )\n Abdominal: Soft, Tender: RUQ, , Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not\n assessed, somewhat drowsy\n Labs / Radiology\n 77 K/uL\n 8.5 g/dL\n 123 mg/dL\n 3.1 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 62 mg/dL\n 100 mEq/L\n 141 mEq/L\n 24.5 %\n 7.4 K/uL\n [image002.jpg]\n 02:29 PM\n 03:47 AM\n 05:02 AM\n WBC\n 7.4\n Hct\n 24.5\n Plt\n 77\n Cr\n 2.6\n 3.1\n TCO2\n 34\n Glucose\n 121\n 123\n Other labs:\n PT / PTT / INR:12.6/19.0/1.1\n ALT / AST:113/67, Alk Phos / T Bili:74/0.8,\n Lactic Acid:1.3 mmol/L,\n LDH:813 IU/L,\n Ca++:18.8 mg/dL, Mg++:1.8 mg/dL, PO4:6.1 mg/dL\n 47M with a history asthma, recent dental infection, recent rib\n fracures, now presents with progressive malaise in setting of\n hypercalcemia, renal failure, hyperuricemia, and abnormal differential\n which is highly suggestive of a new malignancy diagnosis. Would favor\n multiple myeloma as most likely, although lymphoma/leukemia are in\n differential. Altered mental status, renal failure and\n thrombocytopenia c/w TTP but no schistocytes on smear excluding dx.\n Overall constellation of symptoms is likely explained by severe\n hypercalcemia.\n .\n # Hypercalcemia: Suspected malignancy given the degree of\n hypercalcemia. Admission calcium is 17.7 with an ionized calcium of\n 2.13. Not on HCTZ, not taking vitamin D, and not taking calcium.\n Preliminary read of BM biopsy suggests aplastic myeloma. PTH = 8,\n SPEP/UPEP, vitamin D 25 and 1,25, B2 globulin and kappa/lambda levels\n pending.\n - IVF with normal saline at 200cc/hr on hold for now give respiratory\n distress\n - Furosemide 80mg q 12 hours based on nephrology recommendations\n - Trend , electrolytes\n - One dose pamidronate on \n - Calcitonin -> written for 3 doses\n - Trend calcium Q6H for now\n - f/u ACE Level\n - F/U final heme report\n - Check EKG this AM for changes\n .\n # Respiratory Status/volume: Increasing O2 requirement in setting of\n volume resuscitation. Likely pulmonary edema. Potentially underlying\n valvular disease given murmur on exam. Lasix as needed. Got 20mg IV\n lasix on floor -> unclear what was to that dose, but lasix naive.\n Increased SOB overnight\n unable to tolerate BiPAP. Currently O2 sats\n ~90%. require intubation if O2 sats fall, increased work of\n breathing. ? Infiltrates on CXR.\n - lasix PRN\n - Contiue fluticasone, albuterol inhalers\n - Trend CXR\n - Consider echo\n - f/u blood cultures\n - check sputum cx\n - Start antibiotics for presumed CAP, ceftriaxone/azithromycin\n - f/u echocardiogram\n .\n # Hyperuricemia: Likely due to cell turn over given elevated LDH, in\n setting of dehydration. Complicated by and likely contributing to\n .\n - Start allopurinol 100mg daily\n - serum pH remains alkalemic so will defer bicarbonate infusion.\n - trend pH\n - follow \n .\n # Acute kidney injury: Likely combination of hypercalcemia,\n hyperuricemia as a component of tumor lysis, and poor POs. If tumor is\n of plasma cell origin, immunoglobulins may also play a role. Continues\n to make good urine.\n - Renal following\n will F/U recs\n - require HD for calcium, uric acid, possible tumor lysis\n - Moderate UEos, etiology unclear. Stopping all nonessential meds -\n - Lasix 80 mg IV BID or PRN\n - Check urine albumin, creatinine, total protein\n - will restart IVF with goal TBB even\n .\n # Likely cancer diagnosis: Labs pending as above. PSA = 0.3. ESR, CRP\n elevated. EBV Antibody Panel, CMV IgG/IgM Antibody Panel, and\n Toxoplasma IgG/IgM Antibody Panel pending given atypical lymphocytes on\n smear all ordered. Will likely need treatment for underlying malignancy\n soon\n prelim Bx suggests anaplastic myeloma.\n - Heme onc following\n appreciate recs; will obtain any possible\n imaging to eval for lymphadenopathy. Ideally, patient would have\n non-contrast CT scan, but at the moment, patient unable to tolerate\n lying flat. Will get abdominal ultrasound at a minimum.\n - Will discuss role of steroids with heme-onc team today\n - Skeletal survey if can be done as portable\n .\n # Anemia: Likely due to a bone marrow process. No evidence of TTP or\n intravascular hemolysis. Elevated haptoglobin and ferritin.\n - Likely marrow failure\n - Type and screen up to date, cross match one unit as will likely need\n blood after IVFs given\n - Transfuse for H/H < \n - Guaiac stools.\n .\n # Hypertension: Continue to follow. Treat accordingly.\n .\n # Asthma:\n - Albuterol and ipratropium nebs Q6H PRN\n .\n # OSA\n - will attempt to obtain patient\ns home CPAP machine as he tolerates\n this better than the machine available here.\n .\n # FEN: IVF as above, replete electrolytes, NPO for now, but ADAT\n # Prophylaxis:\n -pneumoboots\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n # Access: peripherals\n # Communication: Patient\n # Code: full\n # Disposition: ICU for now, transition to when clinically\n stable for oncology services.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n 18 Gauge - 08:21 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": "2136-04-16 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 735584,
"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 47 yo man with h/o asthma, chronic LBP, rib fractures from mild\n trauma. Recent dental abscess. Seen by pulmonologist with malaise,\n SOB, not feeling well. Was found to be anemic to 25, plts of 101,\n which was new compared to 1 year ago. Calcium found to be 17.7, and\n creatinine up. Yesterday got pamidronate, starts on IV NS 200cc/hr,\n and lasix q6h. Had good urine output. Was 4200 in , and 5800 out.\n Overnight with increasing respiratory distress, concern for pulmonary\n edema. Tried on bipap. Seen by renal and hem onc. Marrow bx done\n yesterday - preliminary results consistent with myeloma.\n 24 Hour Events:\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:20 AM\n Other medications:\n allopurinol\n calcitonin\n prn atrovent\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 09:40 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: 37.6\nC (99.6\n HR: 97 (85 - 106) bpm\n BP: 130/55(73) {118/42(60) - 151/117(149)} mmHg\n RR: 38 (18 - 38) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 4,298 mL\n 1,719 mL\n PO:\n 120 mL\n TF:\n IVF:\n 3,298 mL\n 1,599 mL\n Blood products:\n Total out:\n 5,850 mL\n 3,160 mL\n Urine:\n 2,900 mL\n 3,160 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,552 mL\n -1,441 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n PS : 8 cmH2O\n RR (Spontaneous): 25\n PEEP: 7 cmH2O\n PIP: 15 cmH2O\n SpO2: 93%\n ABG: 7.44/49/72/31/7\n Ve: 7.2 L/min\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: mild expiratory)\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.5 g/dL\n 77 K/uL\n 123 mg/dL\n 3.1 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 62 mg/dL\n 100 mEq/L\n 141 mEq/L\n 24.5 %\n 7.4 K/uL\n [image002.jpg]\n 02:29 PM\n 03:47 AM\n 05:02 AM\n WBC\n 7.4\n Hct\n 24.5\n Plt\n 77\n Cr\n 2.6\n 3.1\n TCO2\n 34\n Glucose\n 121\n 123\n Other labs: PT / PTT / INR:12.6/19.0/1.1, ALT / AST:113/67, Alk Phos /\n T Bili:74/0.8, Lactic Acid:1.3 mmol/L, LDH:813 IU/L, Ca++:18.8 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.1 mg/dL\n Assessment and Plan\n Hypoxemia: CXR more worrisome for PNA. Will start to treat with CTX\n and Azithro.\n OSA: Will get home mask.\n Hypercalcemia: Ca still going up. Restart IVF and continue lasix.\n Continue calcitonin. On bisphonate currently.\n Vitamin D levels, SPEP, UPEP pending. Likely due to Myeloma. PTH\n level 8.\n uric acid. on allopurinol.\n Myeloma: Bone marrow bx. pending\n heart murmur: received echo this morning.\n asthma: on flovent.\n pain management: tylenol prn.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n 18 Gauge - 08:21 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735546,
"text": "47 YO male with Hx of asthma, chronic low back pain, 2 recent rib\n fractures, was recently dx w/ dental abscess who presented to ED for\n malaise. He was also dx w/ his 2nd rib fx (7th rib right side). He\n states that he has not been feeling well for the past 2 weeks w/\n progressive severe fatigue, night sweats, and subjective fevers. The\n last 3 days he has had DOE so was called to the ED. In ED his creat\n 2.2 and LFT's that were abnormal, Ca+ 17.7. He was admitted to 3\n but with fluid resuscitations, he started to become hypoxic so he was\n transfered to the MICU\n NPO after MN tonight then needs to drink 2 bottles of barocat starting\n at 7am for the CT following injestion.\n Hypercalcemia (high Calcium)\n Assessment:\n Pt\ns calcium level has been 16.5, ionized calcium was 2.10, receiving\n NS 300mls/hr. patient also received a single dose of pamidronate 90 mg\n IV.\n Action:\n Continued fluids, NS 300mls/hr until 5am\n Response:\n AM labs Ca 18.8 and ionized Ca 2.09\n Plan:\n Maintain IVF, Monitor I&O, recheck Ca++ as ordered\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt\ns creat is 2.5-2.6, passing good amount of urine via \n Action:\n Lasix 40mg/iv given for fluid overload in CXR\n Response:\n U/O 200-400 mls/hr, received 80mg iv this am, BUN/creat 62/3.1\n Plan:\n Continue to monitor U/O, maintain IVF according to MD\ns orders.\n .H/O asthma\n Assessment:\n Received patient on 3L nasal canula, sitting on the chair, RR in high\n 30\ns and O2 sats low 90\ns. H/O asthama and using nasal CPAP at home.\n Bilateral lung sounds clear and exp wheeze and diminished bases.\n Patient has h/o rib fracture\n Action:\n C/o SOB and desats to 88-89%. CXR done\nshows fluid overload\n.lasix 40mg\n iv given with good response\n intermittent nasal CPAP and nasal canula 4L\n Nebs/ PRN as needed\n Patient desats to low 80\ns, on and off CPAP and nasal canula\n Received total of 120mg lasix and maintance fluid d/ced\n Response:\n Appears to be uncomfortable and very tired, RR in high 30\ns, patient\n desats to low 80\ns, SOB, blood gas 7.44/49/72/7, changed to NIV, BIPAP\n mask with improvement in O2 sats\n Plan:\n Continue to monitor resp status and monitor CXR and lasix iv\n accordingly, ?^^^creat\n Ineffective Coping\n Assessment:\n HCT 26.6 this Am, bone marrow biopsy done yesterday evening, and\n preliminary report showed a diagnosis of aplastic multiple myeloma.\n Patient and wife do know of the dx.\n Action:\n No signs of bleeding, emotional support to patient and family\n Response:\n HCt 24.5, LFt\ns elevated\n Plan:\n Emotional support and encouragement to patient and family\n SW consult in Am\n ? transfer to 4 for cancer treatment in AM\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 735552,
"text": "Chief Complaint:\n 24 Hour Events:\n Bone marrow biopsy performed at bed side by Heme/Onc, pathology\n pending. Patient receiving home asthma medications as well as CPAP\n overnight on home settings.\n Patient becoming hypoxic overnight with O2 sats in the low 90s.\n Received Lasix 40mg IV x 1 and 80mg x 1; IVF stopped and patient\n started on Bipap. Calcitonin given. Despite these measures, calcium\n increasing to 18.8 this morning.\n Pt not tolerating BiPap and continues to remove mask.\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:20 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 06:55 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: 37.7\nC (99.8\n HR: 97 (85 - 106) bpm\n BP: 151/58(78) {118/42(60) - 151/117(149)} mmHg\n RR: 32 (18 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 4,298 mL\n 1,577 mL\n PO:\n TF:\n IVF:\n 3,298 mL\n 1,577 mL\n Blood products:\n Total out:\n 5,850 mL\n 2,320 mL\n Urine:\n 2,900 mL\n 2,320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,552 mL\n -743 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n PS : 8 cmH2O\n RR (Spontaneous): 25\n PEEP: 7 cmH2O\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: 7.44/49/72/31/7\n Ve: 7.2 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 77 K/uL\n 8.5 g/dL\n 123 mg/dL\n 3.1 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 62 mg/dL\n 100 mEq/L\n 141 mEq/L\n 24.5 %\n 7.4 K/uL\n [image002.jpg]\n 02:29 PM\n 03:47 AM\n 05:02 AM\n WBC\n 7.4\n Hct\n 24.5\n Plt\n 77\n Cr\n 2.6\n 3.1\n TCO2\n 34\n Glucose\n 121\n 123\n Other labs: PT / PTT / INR:12.6/19.0/1.1, ALT / AST:113/67, Alk Phos /\n T Bili:74/0.8, Lactic Acid:1.3 mmol/L, LDH:813 IU/L, Ca++:18.8 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERCALCEMIA (HIGH CALCIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O ASTHMA\n ANEMIA, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n 18 Gauge - 08:21 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": "2136-04-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 735553,
"text": "Chief Complaint:\n 24 Hour Events:\n Bone marrow biopsy performed at bed side by Heme/Onc, pathology\n pending. Patient receiving home asthma medications as well as CPAP\n overnight on home settings.\n Patient becoming hypoxic overnight with O2 sats in the low 90s.\n Received Lasix 40mg IV x 1 and 80mg x 1; IVF stopped and patient\n started on Bipap. Calcitonin given. Despite these measures, calcium\n increasing to 18.8 this morning.\n Pt not tolerating BiPap and continues to remove mask.\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:20 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 06:55 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: 37.7\nC (99.8\n HR: 97 (85 - 106) bpm\n BP: 151/58(78) {118/42(60) - 151/117(149)} mmHg\n RR: 32 (18 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 4,298 mL\n 1,577 mL\n PO:\n TF:\n IVF:\n 3,298 mL\n 1,577 mL\n Blood products:\n Total out:\n 5,850 mL\n 2,320 mL\n Urine:\n 2,900 mL\n 2,320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,552 mL\n -743 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n PS : 8 cmH2O\n RR (Spontaneous): 25\n PEEP: 7 cmH2O\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: 7.44/49/72/31/7\n Ve: 7.2 L/min\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), radiates to axilla, posterior chest, III/VI\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n very scattered at bases, Diminished: )\n Abdominal: Soft, Tender: RUQ, , Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not\n assessed, somewhat drowsy\n Labs / Radiology\n 77 K/uL\n 8.5 g/dL\n 123 mg/dL\n 3.1 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 62 mg/dL\n 100 mEq/L\n 141 mEq/L\n 24.5 %\n 7.4 K/uL\n [image002.jpg]\n 02:29 PM\n 03:47 AM\n 05:02 AM\n WBC\n 7.4\n Hct\n 24.5\n Plt\n 77\n Cr\n 2.6\n 3.1\n TCO2\n 34\n Glucose\n 121\n 123\n Other labs: PT / PTT / INR:12.6/19.0/1.1, ALT / AST:113/67, Alk Phos /\n T Bili:74/0.8, Lactic Acid:1.3 mmol/L, LDH:813 IU/L, Ca++:18.8 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPERCALCEMIA (HIGH CALCIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O ASTHMA\n ANEMIA, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n 18 Gauge - 08:21 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": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735680,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Ineffective Coping\n Assessment:\n Pt\ns wife and brother in to visit pt throughout day. Pt has 3 small\n children at home.\n Action:\n Social work in to see family. Emotional support provided to pt and\n family by staff.\n Response:\n Family and pt seems to be coping appropriately, very supportive family,\n involved in pt\ns care.\n Plan:\n Continue to provide support as needed, SW aware and involved.\n Hypercalcemia (high Calcium)\n Assessment:\n AM calcium 18.8 (non-ionized). Pt with recent rib fractures related to\n increased calcium levels.\n Action:\n Started on calcitonin salmon SC injection, NS @ 300cc/hr for 2L,\n and lasix. Taken for skeletal survey this afternoon for films of\n skull, long bones and spine. EKG done.\n Response:\n 1100 calcium (non-ionized) down to 15.7. Pt tolerated test well, final\n film reads pending.\n Plan:\n Calcium to be rechecked q6h, monitor for signs and symptoms of\n hypercalcemia, arrhythmias. Follow up skeletal survey results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards, UOP >100cc/hr, clear, yellow. Renal following\n for .\n Action:\n Response:\n Plan:\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets (pt\ns baseline HCT40s).\n Bone marrow biopsy done . No obvious signs of bleeding noted.\n Action:\n Drop discussed during , team likely related to disease\n process in bone marrow. Abdominal US and CT torso done to evaluate for\n presence of lymphadenopthy.\n Response:\n CT results supporting atypical myeloma diagnosis. Started on IV\n steroids.\n Plan:\n Continue to monitor HCT, monitor for signs of bleeding, continue IV\n steroids, HCT goal >21.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735697,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Ineffective Coping\n Assessment:\n Pt\ns wife and brother in to visit pt throughout day. Pt has 3 small\n children at home.\n Action:\n Social work in to see family. Emotional support provided to pt and\n family by staff.\n Response:\n Family and pt seems to be coping appropriately, very supportive family,\n involved in pt\ns care.\n Plan:\n Continue to provide support as needed, SW aware and involved.\n Hypercalcemia (high Calcium)\n Assessment:\n AM calcium 18.8 (non-ionized). Pt with recent rib fractures related to\n increased calcium levels.\n Action:\n Started on calcitonin salmon SC injection, NS @ 300cc/hr for 2L,\n and lasix. Taken for skeletal survey this afternoon for films of\n skull, long bones and spine. EKG done.\n Response:\n 1100 calcium (non-ionized) down to 15.7. Pt tolerated test well, final\n film reads pending.\n Plan:\n Calcium to be rechecked q6h, monitor for signs and symptoms of\n hypercalcemia, arrhythmias. Follow up skeletal survey results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards, UOP >100cc/hr, clear, yellow. Renal following\n for . Likely related to hypercalcemia.\n Action:\n Treating hypercalcemia as noted above, urine culture sent, started on\n lasix. Ordered for 12 hour urine collection. Started at 1600, due\n to end at 4/13 0400. Collection bottle in room.\n Response:\n Continues to maintain good urine output. Tolerating lasix well,\n afternoon BUN/Cr continuing to climb however renal unimpressed.\n Plan:\n Continue to trend BUN/Cr frequently, monitor UOP, continue 12 hour\n urine collection until 0400.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets (pt\ns baseline HCT40s).\n Bone marrow biopsy done . No obvious signs of bleeding noted.\n Action:\n Drop discussed during , team likely related to disease\n process in bone marrow. Abdominal US and CT torso done to evaluate for\n presence of lymphadenopthy.\n Response:\n CT results supporting atypical myeloma diagnosis. Started on IV\n steroids.\n Plan:\n Continue to monitor HCT, monitor for signs of bleeding, continue IV\n steroids, HCT goal >21.\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-17 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 735872,
"text": "Chief Complaint: renal failure, hypercalcemia\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 47 yo man presents with severe hypercalcemia, acute renal failure.\n TTE yesterday with hyperdynamic heart.\n 24 Hour Events:\n EKG - At 08:00 AM\n ULTRASOUND - At 10:30 AM\n abdominal\n TRANSTHORACIC ECHO - At 02:00 PM\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Azithromycin - 11:30 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:47 AM\n Other medications:\n allopurinol\n calcitonin\n lasix 80 \n dexamethasone\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) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: Foley\n Heme / Lymph: Anemia\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: 37.4\nC (99.3\n Tcurrent: 36.3\nC (97.4\n HR: 91 (80 - 98) bpm\n BP: 136/57(71) {103/54(63) - 158/65(84)} mmHg\n RR: 24 (22 - 37) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 4,618 mL\n 590 mL\n PO:\n 420 mL\n 500 mL\n TF:\n IVF:\n 4,198 mL\n 90 mL\n Blood products:\n Total out:\n 7,090 mL\n 2,150 mL\n Urine:\n 7,090 mL\n 2,150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,472 mL\n -1,560 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///31/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: 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 lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 59 K/uL\n 169 mg/dL\n 3.6 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 93 mg/dL\n 93 mEq/L\n 137 mEq/L\n 23.4 %\n 10.7 K/uL\n [image002.jpg]\n 02:29 PM\n 03:47 AM\n 05:02 AM\n 10:42 AM\n 05:07 PM\n 10:37 PM\n 04:55 AM\n WBC\n 7.4\n 10.7\n Hct\n 24.5\n 23.4\n Plt\n 77\n 59\n Cr\n 2.6\n 3.1\n 3.4\n 3.4\n 3.4\n 3.6\n TCO2\n 34\n Glucose\n 121\n 123\n 169\n Other labs: PT / PTT / INR:14.2/23.6/1.2, ALT / AST:95/102, Alk Phos /\n T Bili:68/0.4, Fibrinogen:653 mg/dL, Lactic Acid:1.3 mmol/L, LDH:1494\n IU/L, Ca++:13.7 mg/dL, Mg++:1.9 mg/dL, PO4:6.3 mg/dL\n Assessment and Plan\n Hypercalcemia: calcium is coming down and he is doing well. Continue\n lasix and IVF.\n Respirator distress/hypoxemia: improved. CT concerning for atypical\n infection. Continue azithro and ceftriaxone\n acute renal failure: creatinine increasing\n multiple myeloma: continue dexamethasone. Will transfer to .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n 18 Gauge - 08:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 735873,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 08:00 AM\n ULTRASOUND - At 10:30 AM\n abdominal\n TRANSTHORACIC ECHO - At 02:00 PM\n - CT torso (prelim): No obvious LAD; multiple diffuse lytic lesions\n consistent with myeloma; evidence of lung dx in bases concerning for\n atypical infection\n - US abdomen: Not a good study for assessing LAD; no nodes seen\n - Skeletal survey: final report pending\n - Renal recs: 12-hour urine collection for protein/albumin/creatinine;\n check UA and UCx; may need renal bx if function continues to worsen\n - Onc recs: Start dexamethasone 40 mg IV daily x 4 days; plan for\n transfer to when stable for further treatment\n - Became somewhat somnolent toward evening (as in early AM) but still\n able to answer Qs appropriately after being roused. Wife felt this was\n consistent with recent baseline. Maintained on home CPAP overnight.\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Azithromycin - 11:30 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:47 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 07:02 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: 37.1\nC (98.8\n HR: 85 (80 - 98) bpm\n BP: 129/61(75) {103/49(63) - 158/65(84)} mmHg\n RR: 26 (25 - 38) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 4,618 mL\n 570 mL\n PO:\n 420 mL\n 500 mL\n TF:\n IVF:\n 4,198 mL\n 70 mL\n Blood products:\n Total out:\n 7,090 mL\n 1,680 mL\n Urine:\n 7,090 mL\n 1,680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,472 mL\n -1,110 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 90%\n ABG: ///31/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), radiates to axilla, posterior chest, III/VI\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n very scattered at bases, Diminished: )\n Abdominal: Soft, Tender: RUQ, , Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not\n assessed, somewhat drowsy\n Labs / Radiology\n 59 K/uL\n 8.1 g/dL\n 169 mg/dL\n 3.6 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 93 mg/dL\n 93 mEq/L\n 137 mEq/L\n 23.4 %\n 10.7 K/uL\n [image002.jpg]\n 02:29 PM\n 03:47 AM\n 05:02 AM\n 10:42 AM\n 05:07 PM\n 10:37 PM\n 04:55 AM\n WBC\n 7.4\n 10.7\n Hct\n 24.5\n 23.4\n Plt\n 77\n 59\n Cr\n 2.6\n 3.1\n 3.4\n 3.4\n 3.4\n 3.6\n TCO2\n 34\n Glucose\n 121\n 123\n 169\n Other labs: PT / PTT / INR:14.2/23.6/1.2, ALT / AST:95/102, Alk Phos /\n T Bili:68/0.4, Fibrinogen:653 mg/dL, Lactic Acid:1.3 mmol/L, LDH:1494\n IU/L, Ca++:13.7 mg/dL, Mg++:1.9 mg/dL, PO4:6.3 mg/dL\n TTE: The left atrium is elongated. The right atrium is moderately\n dilated. The estimated right atrial pressure is 10-20mmHg. Left\n ventricular wall thicknesses and cavity size are normal. Left\n ventricular systolic function is hyperdynamic (EF>75%). A mid-cavitary\n and outflow tract gradient is identified without dynamic resting LVOT\n obstruction (high output state). There is no ventricular septal defect.\n Right ventricular chamber size and free wall motion are normal. There\n is abnormal septal motion/position. The aortic valve leaflets (3) are\n mildly thickened. There is no valvular aortic stenosis. The increased\n transaortic velocity is likely related to high cardiac output. No\n aortic regurgitation is seen. The mitral valve leaflets are mildly\n thickened. Trivial mitral regurgitation is seen. There is moderate\n pulmonary artery systolic hypertension. There is no pericardial\n effusion\n CT Chest/Abd (WET READ):\n Multiple lucent lesions through all osseous structurs most consistent\n with\n myeloma. No lymphadenopathy. Diffuse ground glass/nodular lung\n opacities-?\n atypical infection. Perhaps a component of superimposed pulmonary\n edema.\n Assessment and Plan\n 47M with a history asthma, recent dental infection, recent rib\n fracures, now presents with progressive malaise in setting of\n hypercalcemia, renal failure, hyperuricemia, and abnormal differential\n which is highly suggestive of a new malignancy diagnosis. Would favor\n multiple myeloma as most likely, although lymphoma/leukemia are in\n differential. Altered mental status, renal failure and\n thrombocytopenia c/w TTP but no schistocytes on smear excluding dx.\n Overall constellation of symptoms is likely explained by severe\n hypercalcemia.\n .\n # Hypercalcemia: Suspected malignancy given the degree of\n hypercalcemia. Admission calcium is 17.7 with an ionized calcium of\n 2.13. Not on HCTZ, not taking vitamin D, and not taking calcium.\n Preliminary read of BM biopsy suggests anaplastic myeloma. PTH = 8,\n SPEP/UPEP, vitamin D 25 and 1,25, B2 globulin and kappa/lambda levels\n pending. One dose pamidronate on . Calcitonin -> written for 3\n doses\n - continue IVF and lasix as necessary to maintain 200-300cc/hr\n - Trend calcium Q8H for now\n - f/u ACE Level\n - F/U final heme report\n - Check EKG this AM for changes\n .\n # Respiratory Status/volume: Increasing O2 requirement in setting of\n volume resuscitation. Likely pulmonary edema. Potentially underlying\n valvular disease given murmur on exam. Lasix as needed. Got 20mg IV\n lasix on floor -> unclear what was to that dose, but lasix naive.\n Increased SOB overnight\n unable to tolerate BiPAP. Currently O2 sats\n ~90%. require intubation if O2 sats fall, increased work of\n breathing. ? Infiltrates on CXR.\n - lasix PRN\n - Contiue fluticasone, albuterol inhalers\n - Trend CXR\n - f/u blood cultures (NGTD)\n - check sputum cx\n - continue antibiotics for presumed CAP, ceftriaxone/azithromycin\n .\n # Hyperuricemia: Likely due to cell turn over given elevated LDH, in\n setting of dehydration. Complicated by and likely contributing to\n .\n - continue allopurinol 100mg daily\n - serum pH remains alkalemic so will defer bicarbonate infusion.\n - trend pH\n - follow \n .\n # Acute kidney injury: Likely combination of hypercalcemia,\n hyperuricemia as a component of tumor lysis, and poor POs. If tumor is\n of plasma cell origin, immunoglobulins may also play a role. Continues\n to make good urine.\n - Renal following\n will F/U recs; if creatinine worsens, will likely require renal\n biopsy\n - require HD for calcium, uric acid, possible tumor lysis\n - Moderate UEos, etiology unclear. Stopping all nonessential meds\n - Lasix 80 mg IV BID or PRN\n - Check urine albumin, creatinine, total protein\n - will continue IVF with goal TBB even\n .\n # Likely cancer diagnosis: Labs pending as above. PSA = 0.3. ESR, CRP\n elevated. EBV Antibody Panel, CMV IgG/IgM Antibody Panel, and\n Toxoplasma IgG/IgM Antibody Panel pending given atypical lymphocytes on\n smear all ordered. Will likely need treatment for underlying malignancy\n soon\n prelim Bx suggests anaplastic myeloma.\n - Heme onc following\n appreciate recs; will obtain final reads on\n imaging to eval for lymphadenopathy. CT scan concerning for multiple\n lytic lesions but no LAD\n - Continue dexamethasone x 4 days\n - f/u Skeletal survey\n .\n # Anemia: Likely due to a bone marrow process. No evidence of TTP or\n intravascular hemolysis. Elevated haptoglobin and ferritin.\n - Likely marrow failure\n - Type and screen up to date, cross match one unit as will likely need\n blood after IVFs given\n - Transfuse for H/H < \n - Guaiac stools.\n .\n # Hypertension: Continue to follow. Treat accordingly.\n .\n # Asthma:\n - Albuterol and ipratropium nebs Q6H PRN\n .\n # OSA\n - will continue home CPAP machine and settings\n .\n # FEN: IVF as above, replete electrolytes, NPO for now, but ADAT\n # Prophylaxis:\n -pneumoboots\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n # Access: peripherals\n # Communication: Patient\n # Code: full\n # Disposition: ICU for now, transition to for oncology\n services.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n 18 Gauge - 08:21 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": "2136-04-17 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 736009,
"text": "Chief Complaint: hypoxia\n HPI:\n Mr. is a 47 year old man with a history of obesity, asthma,\n chronic low back pain, and recent rib fracture who presented to the ED\n on for 2 weeks of severe fatigue & dyspnea on exertion. In\n of this year, the patient was diagnosed with a right lateral\n seventh rib fracture following incidental trauma (leaning over the arm\n of a chair). On , the patient was seen in Pulmonology clinic for\n progressive dyspnea and bony pain, and his dyspne awas thought\n attributable to asthma. He was therefore restarted on pulmicort. ,\n though a CXR was negative for fracture. His DOE progressed and he\n developed profound fatigue, along with nightsweats and fevers. He\n therefore presented to the ED on .\n .\n There, he endorsed mild subjective fevers at home, but denied any other\n B symptoms. Initial vital signs were T98.4 P85 BP129/98 and 97% on RA.\n Blood work demonstrated a hematocrit of 25.7 (baseline Hct 45), a new\n thrombocytopenia to 101, and a WBC of 8.7 with abnormal myeloid cells.\n He also had a Cr of 2.2 (baseline 0.8) and was noted to have a new\n murmur on exam. He was admitted to 3 for further management, but\n on the floor he was ill-appearing and further work-up demonstrated a Ca\n of 17.7 and Uric Acid of 12.9. Coags and fibrinogen were WNL, so he\n initiated IVF's, but then triggered on for increasing O2\n requirement, somnolence and AMS and he was transferred to the ICU for\n further management.\n .\n In the ICU, Heme-Onc & Renal were consulted. He was continued on\n aggressive IVF's, Lasix 80mg , Allopurinol, Pamidronate (last dose\n on ), Calcitonin, & Dexamethasone 40mg IV (first dose on ). His\n Cr rose to 3.6, but he continued to produce urine. A CT torso\n demonstrated diffuse lucencies in the bone without associated\n lymphadenopathy consistent with multiple myeloma, and his SPEP\n demonstrated a monocloncal IgG kappa spike of 15% of total protein with\n normal viscosity. Over the course of his ICU stay, his serum Ca trended\n down to 13.7, but his serum phosphate & uric acid continued to climb.\n His O2 requirement also continued to rise and a CXR on suggested a\n right middle lobe pneumonia so he was started on Ceftriaxone &\n Azithromycin for CAP. Oncology recommended initiation of chemotherapy\n and he was therefore transferred to BMT.\n .\n At the time of transfer, his vital signs were: T 97.9 P84 BP 120/67 R\n 20's O2Sat 95% on 5L, I 4,618cc O 7,090cc. On arrival to the floor, the\n patient immediately triggered for an O2Sat of 88-89% on 6L NC, so he\n was switched to a NRB sat'ing 97%. He was quickly switched back to 6L,\n sat'ing 95-96% with a RR of 36. He appeared uncomfortable and was\n unable to speak in complete sentences.\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Azithromycin - 11:30 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:00 PM\n Other medications:\n Medications on Transfer:\n Dexamethasone 40 mg IV DAILY Duration: 4 Doses\n Calcitonin Salmon 400 UNIT SC BID Duration: 3 Doses\n Rasburicase *NF* 6 mg Injection once\n Furosemide 80 mg IV BID\n Allopurinol 100 mg PO/NG DAILY\n Cefepime\n Levaquin\n Fluticasone Propionate 110mcg 2 PUFF IH \n Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB\n Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB\n Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing/sob\n Acetaminophen mg PO/NG Q6H:PRN pain\n Senna 1 TAB PO/NG :PRN constipation\n Past medical history:\n Family history:\n Social History:\n Asthma\n Costrochondritis\n Lower back pain w/ L3-L4 lateral disc protrusion\n Obesity\n Nephrolithiasis\n H/O atypical chest pain\n Rectal bleeding\n Hyperlipidemia\n Sleep apnea, OSA 11cm H20\n s/p rib fractures x 1, \n Depression\n Mother: CAD and DM\n Father: DM\n known family history of cancer\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Patient lives in with his wife & works on faculty at\n . They have three sons. His wife is a\n plastic surgeon who trained at the .\n Review of systems:\n Flowsheet Data as of 07:35 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98\n HR: 84 (80 - 95) bpm\n BP: 138/62(79) {103/54(63) - 148/68(84)} mmHg\n RR: 29 (22 - 34) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 4,618 mL\n 1,413 mL\n PO:\n 420 mL\n 500 mL\n TF:\n IVF:\n 4,198 mL\n 913 mL\n Blood products:\n Total out:\n 7,090 mL\n 3,050 mL\n Urine:\n 7,090 mL\n 3,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,472 mL\n -1,637 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n ABG: ///31/\n Physical Examination\n VS: T 98.0 84 138/62 25 98% NRB\n GEN: obese, ill-appearing, man with nasal cannula in place, moderate\n respiratory distress, speaking softly & unable to speak in complete\n sentences. somnolent but awakens to voice.\n HEENT: NC/AT, anicteric sclera, oropharynx clear, no LAD\n CV: RRR, no murmurs, rubs, gallops\n PULM: Mild expiratory wheezes throughout with crackles at the bases\n bilaterally and increased work of breathing\n ABD: soft, obese, NT/ND, normoactive bowel sounds\n LIMBS: warm, well-perfused, 2+ dorsalis pedis pulsations\n SKIN: no rashes, ecchymoses, or petichiae\n Labs / Radiology\n 59 K/uL\n 8.1 g/dL\n 169 mg/dL\n 3.6 mg/dL\n 113 mg/dL\n 31 mEq/L\n 93 mEq/L\n 3.8 mEq/L\n 137 mEq/L\n 23.4 %\n 10.7 K/uL\n [image002.jpg]\n \n 2:33 A4/11/ 02:29 PM\n \n 10:20 P4/12/ 03:47 AM\n \n 1:20 P4/12/ 05:02 AM\n \n 11:50 P4/12/ 10:42 AM\n \n 1:20 A4/12/ 05:07 PM\n \n 7:20 P4/12/ 10:37 PM\n 1//11/006\n 1:23 P4/13/ 04:55 AM\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.4\n 10.7\n Hct\n 24.5\n 23.4\n Plt\n 77\n 59\n Cr\n 2.6\n 3.1\n 3.4\n 3.4\n 3.4\n 3.6\n TC02\n 34\n Glucose\n 121\n 123\n 169\n Other labs: PT / PTT / INR:14.4/22.8/1.2, ALT / AST:95/102, Alk Phos /\n T Bili:68/0.4, Fibrinogen:641 mg/dL, Lactic Acid:1.3 mmol/L, LDH:2470\n IU/L, Ca++:13.7 mg/dL, Mg++:1.9 mg/dL, PO4:6.3 mg/dL\n Fluid analysis / Other labs: Peripheral smear: Normocytic RBC with\n anisocytosis, many teardrops, some cigar forms, no schistocytes, no\n acanthocytes or echinocytes. Possibly roleaux formation, but uncertain.\n Platelets are somewhat reduced in number and there are some large\n platlets. No obvious blasts in the main portion of the smear or the\n feathered edge. Several large mononuclear cells ? atypical lymphocytes,\n many bands, metamyelocytes, and myelocytes. Many monocytes.\n Imaging: Imaging: CXR : In comparison with study of , there is\n continued mild enlargement of the cardiac silhouette with engorgement\n of pulmonary vessels consistent with increased pulmonary venous\n pressure. More focal opacification is seen at the right base with\n silhouetting of the right heart border, this is suspicious for a right\n middle lobe pneumonia.\n .\n CT Torso :\n 1. Findings most consistent with multiple myeloma with innumerable\n lucent lesions seen throughout all visualized osseous structures.\n 2. Diffuse ground glass and partially nodular opacities throughout both\n lungs is a nonspecific finding, though raises concern for an atypical\n infection; pulmonary edema alone is felt less likely.\n 3. No lymphadenopathy.\n Assessment and Plan\n 47M with asthma, OSA, chronic low back pain, recent rib fracure, who\n presented with malaise & DOE found to have bony lesions on CT and a\n constellation of hematologic/electrolyte findings consistent with\n multiple myeloma.\n .\n # Dyspnea/Respiratory Distress: Patient with increasing O2 requirement\n in setting of known asthma, fluid therapy, and new right middle lobe\n pneumonia with pulmonary edema. Also with CT chest on with diffuse\n ground glass opacities. Patient also with hyperdynamic state of heart\n on TTE (EF 75%), elevated BNP to 4232, moderate pulmonary artery\n hypertension. Receiving Lasix with fluids and now on antibiotics.\n - Lasix 80mg \n - IVF's to titrate to UOP 200-300cc/hr\n - Levofloxacin & Cefepime, renally dosed, day 1 for CAP\n - O2 to maintain sats >92%\n - CPAP at night at 11cm H20\n .\n # Multiple Myeloma: Patient with M-protein in both urine & serum\n identified as IgG kappa as well as end-organ dammage manifested as ARF\n and anemia, diffuse lytic lesions on CT and hypercalcemia suggests a\n diagnosis multiple myeloma. Bone marrow biopsy results are positive for\n myeloma, but patient has commenced Dexamethasone therapy as of .\n Normal serum viscosity and patient without signs or symptoms of\n hyperviscosity syndrome, but beta-2 microglobulin was 6.8. EBV/CMV/Toxo\n negative.\n - K/L light chain ratio pending\n - Continue Dexamethasone 40mg IV qday, day \n - Continue IVF's at 150cc NS/hr, titrate to UOP of 200-300cc/hr\n - Continue Lasix 80mg \n - F/U skeletal survey results\n - F/U final CT torso, but verbal report by radiology as above\n - Oncology following, will guide treatment\n .\n # Hypercalcemia: Likely malignant, improved since admission. Received\n Calcitonin () x 3 doses, Pamidronate (). Receiving IVF's &\n Foley in place. PTH low, TSH normal.\n - Goal urine output 200-300cc/hr\n - Continue IV NS as above\n - Lasix as above\n - Dexamethasone as above\n - q6H labs\n - Vitamin D pending\n - Vitamin D 25 pending\n .\n # Hyperuricemia: Likely due to rate of cellular proliferation in\n conjunction with ARF. Received Rasburicase this PM.\n - Continue Allopurinol 100mg daily\n - Avoid HCO3 as it will precipitate calcium & phosphate\n - Repeat labs at 10PM (uric acid level must be measured in green top on\n ice and spun on a cooled centrifuge)\n .\n # Acute renal insufficiency: Cr 3.7 and continuing to rise. Renal\n following. Renal failure is likely tubular injury from cast nephropathy\n in conjunction with hypercalcemia, hyperuricemia.\n - Renal recs\n - require renal biopsy if function does not improve\n - Continuous IVF's/Lasix to preempt further tubular injury\n .\n # Anemia: Low reticulocyte count, elevated haptoglobin & ferritin.\n demonstrating insufficient erythropoeisis. No evidence of TTP or\n intravascular hemolysis.\n - Maintain active T&S\n - Transfuse for HCT <25\n - Guaiac stools\n .\n # Asthma: Continue Albuterol, Fluticasone, & Ipratropium nebs Q6H PRN\n .\n # FEN: IVF as above, replete electrolytes, regular\n .\n # Prophylaxis:\n -DVT ppx with pneumoboots/CPAP\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n .\n # Access: peripherals\n # Communication: Patient\n # Code: FULL\n # Disposition: BMT floor for now\n INEFFECTIVE COPING\n HYPERCALCEMIA (HIGH CALCIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n .H/O ASTHMA\n ANEMIA, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735678,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Ineffective Coping\n Assessment:\n Pt\ns wife and brother in to visit pt throughout day. Pt has 3 small\n children at home. Pt seems to be coping appropriately, very supportive\n family, involved in pt\ns care.\n Action:\n Social work in to see family. Emotional support provided to pt and\n family by staff.\n Response:\n Plan:\n Hypercalcemia (high Calcium)\n Assessment:\n AM calcium 18.8 (non-ionized). Pt with recent rib fractures related to\n increased calcium levels.\n Action:\n Started on calcitonin salmon SC injection, NS @ 300cc/hr for 2L,\n and lasix. Taken for skeletal survey this afternoon for films of\n skull, long bones and spine. EKG done.\n Response:\n 1100 calcium (non-ionized) down to 15.7. Pt tolerated test well, final\n film reads pending.\n Plan:\n Calcium to be rechecked q6h, monitor for signs and symptoms of\n hypercalcemia, arrhythmias. Follow up skeletal survey results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards, UOP >100cc/hr, clear, yellow. Renal following\n for .\n Action:\n Response:\n Plan:\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets (pt\ns baseline HCT40s).\n Bone marrow biopsy done . No obvious signs of bleeding noted.\n Action:\n Drop discussed during , team likely related to disease\n process in bone marrow. Abdominal US and CT torso done to evaluate for\n presence of lymphadenopthy.\n Response:\n C results supporting atypical myeloma diagnosis. Started on IV\n steroids.\n Plan:\n Continue to monitor HCT, monitor for signs of bleeding, continue IV\n steroids, HCT goal >21.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735684,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Ineffective Coping\n Assessment:\n Pt\ns wife and brother in to visit pt throughout day. Pt has 3 small\n children at home.\n Action:\n Social work in to see family. Emotional support provided to pt and\n family by staff.\n Response:\n Family and pt seems to be coping appropriately, very supportive family,\n involved in pt\ns care.\n Plan:\n Continue to provide support as needed, SW aware and involved.\n Hypercalcemia (high Calcium)\n Assessment:\n AM calcium 18.8 (non-ionized). Pt with recent rib fractures related to\n increased calcium levels.\n Action:\n Started on calcitonin salmon SC injection, NS @ 300cc/hr for 2L,\n and lasix. Taken for skeletal survey this afternoon for films of\n skull, long bones and spine. EKG done.\n Response:\n 1100 calcium (non-ionized) down to 15.7. Pt tolerated test well, final\n film reads pending.\n Plan:\n Calcium to be rechecked q6h, monitor for signs and symptoms of\n hypercalcemia, arrhythmias. Follow up skeletal survey results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards, UOP >100cc/hr, clear, yellow. Renal following\n for .\n Action:\n Response:\n Plan:\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets (pt\ns baseline HCT40s).\n Bone marrow biopsy done . No obvious signs of bleeding noted.\n Action:\n Drop discussed during , team likely related to disease\n process in bone marrow. Abdominal US and CT torso done to evaluate for\n presence of lymphadenopthy.\n Response:\n CT results supporting atypical myeloma diagnosis. Started on IV\n steroids.\n Plan:\n Continue to monitor HCT, monitor for signs of bleeding, continue IV\n steroids, HCT goal >21.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735687,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Ineffective Coping\n Assessment:\n Pt\ns wife and brother in to visit pt throughout day. Pt has 3 small\n children at home.\n Action:\n Social work in to see family. Emotional support provided to pt and\n family by staff.\n Response:\n Family and pt seems to be coping appropriately, very supportive family,\n involved in pt\ns care.\n Plan:\n Continue to provide support as needed, SW aware and involved.\n Hypercalcemia (high Calcium)\n Assessment:\n AM calcium 18.8 (non-ionized). Pt with recent rib fractures related to\n increased calcium levels.\n Action:\n Started on calcitonin salmon SC injection, NS @ 300cc/hr for 2L,\n and lasix. Taken for skeletal survey this afternoon for films of\n skull, long bones and spine. EKG done.\n Response:\n 1100 calcium (non-ionized) down to 15.7. Pt tolerated test well, final\n film reads pending.\n Plan:\n Calcium to be rechecked q6h, monitor for signs and symptoms of\n hypercalcemia, arrhythmias. Follow up skeletal survey results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards, UOP >100cc/hr, clear, yellow. Renal following\n for . Likely related to hypercalcemia.\n Action:\n Treating hypercalcemia as noted above, urine culture sent, started on\n lasix. Ordered for 12 hour urine collection. Started at 1600, due\n to end at 4/13 0400. Collection bottle in room.\n Response:\n Continues to maintain good urine output. Tolerating lasix well,\n afternoon BUN/Cr continuing to climb\n Plan:\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets (pt\ns baseline HCT40s).\n Bone marrow biopsy done . No obvious signs of bleeding noted.\n Action:\n Drop discussed during , team likely related to disease\n process in bone marrow. Abdominal US and CT torso done to evaluate for\n presence of lymphadenopthy.\n Response:\n CT results supporting atypical myeloma diagnosis. Started on IV\n steroids.\n Plan:\n Continue to monitor HCT, monitor for signs of bleeding, continue IV\n steroids, HCT goal >21.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735690,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n Ineffective Coping\n Assessment:\n Pt\ns wife and brother in to visit pt throughout day. Pt has 3 small\n children at home.\n Action:\n Social work in to see family. Emotional support provided to pt and\n family by staff.\n Response:\n Family and pt seems to be coping appropriately, very supportive family,\n involved in pt\ns care.\n Plan:\n Continue to provide support as needed, SW aware and involved.\n Hypercalcemia (high Calcium)\n Assessment:\n AM calcium 18.8 (non-ionized). Pt with recent rib fractures related to\n increased calcium levels.\n Action:\n Started on calcitonin salmon SC injection, NS @ 300cc/hr for 2L,\n and lasix. Taken for skeletal survey this afternoon for films of\n skull, long bones and spine. EKG done.\n Response:\n 1100 calcium (non-ionized) down to 15.7. Pt tolerated test well, final\n film reads pending.\n Plan:\n Calcium to be rechecked q6h, monitor for signs and symptoms of\n hypercalcemia, arrhythmias. Follow up skeletal survey results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards, UOP >100cc/hr, clear, yellow. Renal following\n for . Likely related to hypercalcemia.\n Action:\n Treating hypercalcemia as noted above, urine culture sent, started on\n lasix. Ordered for 12 hour urine collection. Started at 1600, due\n to end at 4/13 0400. Collection bottle in room.\n Response:\n Continues to maintain good urine output. Tolerating lasix well,\n afternoon BUN/Cr continuing to climb however renal unimpressed.\n Plan:\n Continue to trend BUN/Cr frequently, monitor UOP, continue 12 hour\n urine collection until 0400.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets (pt\ns baseline HCT40s).\n Bone marrow biopsy done . No obvious signs of bleeding noted.\n Action:\n Drop discussed during , team likely related to disease\n process in bone marrow. Abdominal US and CT torso done to evaluate for\n presence of lymphadenopthy.\n Response:\n CT results supporting atypical myeloma diagnosis. Started on IV\n steroids.\n Plan:\n Continue to monitor HCT, monitor for signs of bleeding, continue IV\n steroids, HCT goal >21.\n"
},
{
"category": "Nursing",
"chartdate": "2136-04-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735809,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to have progressive anemia from 44 to 25 and in\n acute renal failure with creatinine 2.2, elevated LFT's, and Ca+ 17.7.\n He was originally admitted to 3 but during fluid resuscitation\n became hypoxic so he was transferred to the MICU.\n Hypercalcemia (high Calcium)\n Assessment:\n PM calcium 14.6 (down from 15.3). HR 80s-90s with occasional PACs.\n Received on 6L NC with RR 20s, breathing shallow and sats 92-94%. Pt\n very lethargic but oriented and cooperative.\n Action:\n Given calcitonin salmon SC injection\n NS IVF finished and now NS to KVO.\n 40mg IVP lasix.\n Labs checked q6hour.\n Pt placed on home CPAP nasal prongs with 10L O2 running in.\n Response:\n Am calcium 13.7\n Chest CT wet read more consistent with atypical myeloma.\n Skeletal survey final read still pending.\n Tolerated CPAP with RR 20s and sats 88-96%\n Plan:\n Calcium checked q6hour, next due at 1100.\n Admin meds per order.\n Home CPAP at night.\n F/u with official read from CT and skeletal survey.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending up. Renal following for . Likely related to\n hypercalcemia.\n Action:\n Treating hypercalcemia as noted above\n 12 hour urine collection sent for testing\n Labs trended.\n Response:\n Tolerating IVP lasix well\n UOP >100cc/hr, clear, yellow\n Am BUN/Cr 93/3.6 (from 62/3.4)\n Plan:\n Continue to trend labs.\n Monitor UOP.\n f/u with 12 hour collection results.\n Anemia/thrombocytopenia\n Assessment:\n On admission pt noted to have low Hct from baseline of 40. plt low as\n well.\n Action:\n Labs trended.\n Monitored for s/s of bleeding.\n Response:\n CT results supporting atypical myeloma diagnosis.\n Hct 23.4 from 24.5.\n Plt 59 from 77.\n VSS, no s/s of bleeding.\n Plan:\n Continue to monitor HCT, goal >21.\n"
},
{
"category": "Physician ",
"chartdate": "2136-04-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 735821,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 08:00 AM\n ULTRASOUND - At 10:30 AM\n abdominal\n TRANSTHORACIC ECHO - At 02:00 PM\n - CT torso (prelim): No obvious LAD; multiple diffuse lytic lesions\n consistent with myeloma; evidence of lung dx in bases concerning for\n atypical infection\n - US abdomen: Not a good study for assessing LAD; no nodes seen\n - Skeletal survey: final report pending\n - Renal recs: 12-hour urine collection for protein/albumin/creatinine;\n check UA and UCx; may need renal bx if function continues to worsen\n - Onc recs: Start dexamethasone 40 mg IV daily x 4 days; plan for\n transfer to when stable for further treatment\n - Became somewhat somnolent toward evening (as in early AM) but still\n able to answer Qs appropriately after being roused. Wife felt this was\n consistent with recent baseline. Maintained on home CPAP overnight.\n Allergies:\n Iodine; Iodine Containing\n Anaphylaxis;\n Last dose of Antibiotics:\n Azithromycin - 11:30 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:47 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 07:02 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: 37.1\nC (98.8\n HR: 85 (80 - 98) bpm\n BP: 129/61(75) {103/49(63) - 158/65(84)} mmHg\n RR: 26 (25 - 38) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 4,618 mL\n 570 mL\n PO:\n 420 mL\n 500 mL\n TF:\n IVF:\n 4,198 mL\n 70 mL\n Blood products:\n Total out:\n 7,090 mL\n 1,680 mL\n Urine:\n 7,090 mL\n 1,680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,472 mL\n -1,110 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 90%\n ABG: ///31/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), radiates to axilla, posterior chest, III/VI\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n very scattered at bases, Diminished: )\n Abdominal: Soft, Tender: RUQ, , Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not\n assessed, somewhat drowsy\n Labs / Radiology\n 59 K/uL\n 8.1 g/dL\n 169 mg/dL\n 3.6 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 93 mg/dL\n 93 mEq/L\n 137 mEq/L\n 23.4 %\n 10.7 K/uL\n [image002.jpg]\n 02:29 PM\n 03:47 AM\n 05:02 AM\n 10:42 AM\n 05:07 PM\n 10:37 PM\n 04:55 AM\n WBC\n 7.4\n 10.7\n Hct\n 24.5\n 23.4\n Plt\n 77\n 59\n Cr\n 2.6\n 3.1\n 3.4\n 3.4\n 3.4\n 3.6\n TCO2\n 34\n Glucose\n 121\n 123\n 169\n Other labs: PT / PTT / INR:14.2/23.6/1.2, ALT / AST:95/102, Alk Phos /\n T Bili:68/0.4, Fibrinogen:653 mg/dL, Lactic Acid:1.3 mmol/L, LDH:1494\n IU/L, Ca++:13.7 mg/dL, Mg++:1.9 mg/dL, PO4:6.3 mg/dL\n TTE: The left atrium is elongated. The right atrium is moderately\n dilated. The estimated right atrial pressure is 10-20mmHg. Left\n ventricular wall thicknesses and cavity size are normal. Left\n ventricular systolic function is hyperdynamic (EF>75%). A mid-cavitary\n and outflow tract gradient is identified without dynamic resting LVOT\n obstruction (high output state). There is no ventricular septal defect.\n Right ventricular chamber size and free wall motion are normal. There\n is abnormal septal motion/position. The aortic valve leaflets (3) are\n mildly thickened. There is no valvular aortic stenosis. The increased\n transaortic velocity is likely related to high cardiac output. No\n aortic regurgitation is seen. The mitral valve leaflets are mildly\n thickened. Trivial mitral regurgitation is seen. There is moderate\n pulmonary artery systolic hypertension. There is no pericardial\n effusion\n CT Chest/Abd (WET READ):\n Multiple lucent lesions through all osseous structurs most consistent\n with\n myeloma. No lymphadenopathy. Diffuse ground glass/nodular lung\n opacities-?\n atypical infection. Perhaps a component of superimposed pulmonary\n edema.\n Assessment and Plan\n 47M with a history asthma, recent dental infection, recent rib\n fracures, now presents with progressive malaise in setting of\n hypercalcemia, renal failure, hyperuricemia, and abnormal differential\n which is highly suggestive of a new malignancy diagnosis. Would favor\n multiple myeloma as most likely, although lymphoma/leukemia are in\n differential. Altered mental status, renal failure and\n thrombocytopenia c/w TTP but no schistocytes on smear excluding dx.\n Overall constellation of symptoms is likely explained by severe\n hypercalcemia.\n .\n # Hypercalcemia: Suspected malignancy given the degree of\n hypercalcemia. Admission calcium is 17.7 with an ionized calcium of\n 2.13. Not on HCTZ, not taking vitamin D, and not taking calcium.\n Preliminary read of BM biopsy suggests anaplastic myeloma. PTH = 8,\n SPEP/UPEP, vitamin D 25 and 1,25, B2 globulin and kappa/lambda levels\n pending.\n - continue IVF with normal saline at 200cc/hr\n - Furosemide 80mg q 12 hours based on nephrology recommendations\n - Trend , electrolytes\n - One dose pamidronate on \n - Calcitonin -> written for 3 doses\n - Trend calcium Q8H for now\n - f/u ACE Level\n - F/U final heme report\n - Check EKG this AM for changes\n .\n # Respiratory Status/volume: Increasing O2 requirement in setting of\n volume resuscitation. Likely pulmonary edema. Potentially underlying\n valvular disease given murmur on exam. Lasix as needed. Got 20mg IV\n lasix on floor -> unclear what was to that dose, but lasix naive.\n Increased SOB overnight\n unable to tolerate BiPAP. Currently O2 sats\n ~90%. require intubation if O2 sats fall, increased work of\n breathing. ? Infiltrates on CXR.\n - lasix PRN\n - Contiue fluticasone, albuterol inhalers\n - Trend CXR\n - f/u blood cultures (NGTD)\n - check sputum cx\n - continue antibiotics for presumed CAP, ceftriaxone/azithromycin\n .\n # Hyperuricemia: Likely due to cell turn over given elevated LDH, in\n setting of dehydration. Complicated by and likely contributing to\n .\n - continue allopurinol 100mg daily\n - serum pH remains alkalemic so will defer bicarbonate infusion.\n - trend pH\n - follow \n .\n # Acute kidney injury: Likely combination of hypercalcemia,\n hyperuricemia as a component of tumor lysis, and poor POs. If tumor is\n of plasma cell origin, immunoglobulins may also play a role. Continues\n to make good urine.\n - Renal following\n will F/U recs; if creatinine worsens, will likely\n require renal biopsy\n - require HD for calcium, uric acid, possible tumor lysis\n - Moderate UEos, etiology unclear. Stopping all nonessential meds\n - Lasix 80 mg IV BID or PRN\n - Check urine albumin, creatinine, total protein\n - will continue IVF with goal TBB even\n .\n # Likely cancer diagnosis: Labs pending as above. PSA = 0.3. ESR, CRP\n elevated. EBV Antibody Panel, CMV IgG/IgM Antibody Panel, and\n Toxoplasma IgG/IgM Antibody Panel pending given atypical lymphocytes on\n smear all ordered. Will likely need treatment for underlying malignancy\n soon\n prelim Bx suggests anaplastic myeloma.\n - Heme onc following\n appreciate recs; will obtain final reads on\n imaging to eval for lymphadenopathy. CT scan concerning for multiple\n lytic lesions but no LAD\n - Continue dexamethasone x 4 days\n - f/u Skeletal survey\n .\n # Anemia: Likely due to a bone marrow process. No evidence of TTP or\n intravascular hemolysis. Elevated haptoglobin and ferritin.\n - Likely marrow failure\n - Type and screen up to date, cross match one unit as will likely need\n blood after IVFs given\n - Transfuse for H/H < \n - Guaiac stools.\n .\n # Hypertension: Continue to follow. Treat accordingly.\n .\n # Asthma:\n - Albuterol and ipratropium nebs Q6H PRN\n .\n # OSA\n - will continue home CPAP machine and settings\n .\n # FEN: IVF as above, replete electrolytes, NPO for now, but ADAT\n # Prophylaxis:\n -pneumoboots\n -Bowel regimen, PPI\n -Pain management with tylenol PRN\n # Access: peripherals\n # Communication: Patient\n # Code: full\n # Disposition: ICU for now, transition to when clinically\n stable for oncology services.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 10:00 AM\n 18 Gauge - 08:21 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": "2136-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 736053,
"text": "47M with history of asthma, chronic low back pain, two recent rib\n fractures, recent dental abscess who presented to ED for malaise. Per\n pt has not been feeling well for the past 2 weeks with progressive\n severe fatigue, night sweats, and subjective fevers. The last 3 days\n he has had increasing dyspnea on exertion, convinced by wife to go to\n . In ED he was found to behave progressive anemia from 44 to 25 and\n in acute renal failure with creatinine 2.2, elevated LFT's, and Ca+\n 17.7. He was originally admitted to 3 but during fluid\n resuscitation became hypoxic so he was transferred to the MICU.\n \n CT torso, skeletal survey, ECHO, abdominal US\n Ineffective Coping\n Assessment:\n Pt\ns wife and brother in to visit pt throughout day. Pt has 3 small\n children at home.\n Action:\n Social work in to see family. Emotional support provided to pt and\n family by staff.\n Response:\n Family and pt seems to be coping appropriately, very supportive family,\n involved in pt\ns care.\n Plan:\n Continue to provide support as needed, SW aware and involved.\n Hypercalcemia (high Calcium)\n Assessment:\n Calcium continues to trend downward, this AM 13.7 (non-ionized). Pt\n with recent rib fractures related to increased calcium levels.\n Action:\n This AM completed calcitonin salmon SC injection, ordered for NS @\n 200cc/hr for 2L, and lasix. Skeletal survey films of skull, long\n bones and spine pending. EKG done. Calcium rechecked at 1400.\n results pending.\n Response:\n Final read of skeletal survey pending. Calcium trending down\n appropriately. EKG showing no changes.\n Plan:\n Calcium to be rechecked q6h, next due at , monitor for signs and\n symptoms of hypercalcemia, arrhythmias. Follow up skeletal survey\n results.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr trending upwards, UOP >100cc/hr, clear, yellow. Renal following\n for . Likely related to hypercalcemia induced vasoconstriction to\n renal vasculature.\n Action:\n NS 2 200cc/hr to flush kidneys, lasix.\n Response:\n Continues to maintain good urine output. Tolerating lasix well,\n afternoon BUN/Cr continuing to climb however renal unimpressed. Per\n discussion with renal kidney function expected to improve over time and\n as calcium levels decrease.\n Plan:\n Continue to trend BUN/Cr frequently, monitor UOP. Renal team\n suggesting kidney biopsy if no improvement over next few days.\n Anemia/thrombocytopenia\n Assessment:\n AM labs revealing decreased HCT and platelets. Bone marrow biopsy done\n . No obvious signs of bleeding noted. Stool guiac positive\n however pt with known hemorrhoids. CT done . ECHO from \n showing EF >55%.\n Action:\n Drop discussed during , team likely related to disease\n process in bone marrow.\n Response:\n CT results supporting atypical myeloma diagnosis. Started on IV\n steroids.\n Plan:\n Continue to monitor HCT, monitor for signs of bleeding, continue IV\n steroids, HCT goal >21\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-16 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1130001,
"text": " 11:35 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: assess for lymphadenopathy, lesions\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with newly diagnosed malignancy, hypercalcemia, please perform\n without contrast\n REASON FOR THIS EXAMINATION:\n assess for lymphadenopathy, lesions\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: ARHb MON 4:32 PM\n Multiple lucent lesions through all osseous structurs most consistent with\n myeloma. No lymphadenopathy. Diffuse ground glass/nodular lung opacities-?\n atypical infection. Perhaps a component of superimposed pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with suspicion for malignancy. Evaluate for\n lymphadenopathy or bone lesions.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the chest, abdomen, and pelvis were\n obtained with multiplanar reformatted images.\n\n CT CHEST WITHOUT CONTRAST: No pathologically enlarged axillary, mediastinal,\n or hilar lymph nodes are observed. Small precarinal and subcarinal lymph\n nodes measure up to 8 mm in short axis which does not meet CT criteria for\n pathologic enlargement. The heart and great vessels are unremarkable and\n there is no evidence of pericardial or pleural effusion. There is diffuse\n ground-glass opacity throughout the lungs bilaterally, sparing the subpleural\n lung, with a more nodular pattern predominating in the upper lobes. The\n airways are patent to the subsegmental level bilaterally.\n\n CT ABDOMEN WITHOUT CONTRAST: The liver, spleen, and adrenal glands appear\n unremarkable. Wall thickening along the body and fundus of the gallbladder\n spares the gallbladder neck. Non-contrast evaluation of the kidneys reveals a\n 7-mm nonobstructing right interpolar stone. Intra-abdominal loops of large\n and small bowel are of normal caliber and there is no pneumoperitoneum or free\n fluid. Atherosclerotic calcifications involve the abdominal aorta, otherwise\n of normal caliber.\n\n CT PELVIS WITHOUT CONTRAST: The rectum and sigmoid colon are unremarkable. A\n Foley is present within the bladder.\n\n Bone windows reveal innumerable small lucent lesions throughout all visualized\n osseous structures. A healing right seventh rib fracture is noted\n anterolaterally. No vertebral compression deformities are observed.\n\n IMPRESSION:\n (Over)\n\n 11:35 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: assess for lymphadenopathy, lesions\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Findings most consistent with multiple myeloma with innumerable lucent\n lesions seen throughout all visualized osseous structures.\n 2. Diffuse ground glass and partially nodular opacities throughout both lungs\n is a nonspecific finding, though raises concern for an atypical infection;\n pulmonary edema alone is felt less likely.\n 3. No lymphadenopathy.\n\n Findings discussed with Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-16 00:00:00.000",
"description": "SKELETAL SURVEY (INCLUD LONG BONES)",
"row_id": 1130003,
"text": " 11:41 AM\n SKELETAL SURVEY (INCLUD LONG BONES) Clip # \n Reason: Please evaluate for lytic lesions\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with worsening respiratory status and possible new multiple\n myeloma.\n REASON FOR THIS EXAMINATION:\n Please evaluate for lytic lesions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Man with worsening respiratory status and possible new multiple\n myeloma.\n\n COMPARISON: Torso CT from today.\n\n Images of the skull, both humeri, thoracic, and lumbar spine and both femurs\n were obtained. The patient is supine.\n\n No lytic lesions are noted in the imaged bones.\n\n There is a shallow area of endosteal scalloping along the lateral cortex of\n the left femoral diaphysis, of equivocal clinical significance. (This lies at\n a site approximately 25.3 cm below the articular surface of the femoral head).\n Otherwise, no lytic lesion is detected radiographically. Two small sclerotic\n foci are noted in the proximal femur, likely bone islands. NO fractures are\n detected.\n\n There are mild degenerative changes of the thoracic and lumbar spine, with\n more moderate discogenic degenerative change at L3/4.\n\n Aortic calcification noted.\n\n Of note, the partially imaged lungs show diffuse airspace abnormalities, which\n are better evaluated on the contemporaneous CT.\n\n IMPRESSION:\n\n 1. No obvious lucent lesions identified radiographically. However, the torso\n CT obtained the same day shows innumerable small lytic foci which are\n consistent with myeloma. Please see report of that exam. Subtle scalloping\n along left femoral diaphysis lateral cortex is of equivocal clinical\n significance.\n\n 2. Diffuse pulmonary parenchymal opacities which require further evaluation.\n Again, please see contemporaneous CT report.\n\n 3. Degenerative changes in the spine.\n\n 4. Aortic calcification, unusual in someone of this age. Is there a history of\n diabetes or vasculopathy?\n\n (Over)\n\n 11:41 AM\n SKELETAL SURVEY (INCLUD LONG BONES) Clip # \n Reason: Please evaluate for lytic lesions\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1129860,
"text": " 10:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with worsening respiratory status.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 47-year-old male with worsening respiratory status. Evaluate for\n interval change.\n\n FINDINGS: Comparison is made to the previous study from .\n\n There is unchanged mild cardiomegaly which is stable. There is hazy\n developing densities seen at the lung bases, which are slightly more apparent\n than previous. This may represent aspiration or developing infiltrate. The\n lung apices are clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-16 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1129984,
"text": " 10:05 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: NEW DISGNOSIS OF MULTIPLE MYELOMA, LOOK FOR LYMPHADENOPATHY\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with new diagnosis of Multiple myeloma\n REASON FOR THIS EXAMINATION:\n lymphadenopathy\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 47-year-old man with multiple myeloma. Evaluate for\n lymphadenopathy.\n\n COMPARISON: Torso CT, .\n\n FINDINGS: A limited examination of the porta hepatis and peripancreatic\n region was performed. No enlarged lymph nodes are seen.\n\n Incidentally noted, but not fully evaluated, there is a round hypoechoic\n lesion within the left lobe of the liver. This lesion measures 1.3 x 1.5 x\n 1.3 cm.\n\n IMPRESSION:\n 1. No lymphadenopathy identified.\n 2. Left hepatic lesion measuring 1.3 cm, which cannot be further\n characterized with ultrasound. A multiphase CT could be performed for better\n characterization when the patient is better able to tolerate contrast.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130481,
"text": " 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval changes.\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with MM, now here with hypoxia.\n REASON FOR THIS EXAMINATION:\n please eval for interval changes.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hypoxia, evaluation for interval changes.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. Extensive pulmonary edema with cardiomegaly and bilateral diffuse\n partly interstitial and partly alveolar changes. No evidence of pleural\n effusions. No evidence of newly occurred focal parenchymal opacities.\n\n\n"
}
] |
45,344 | 195,325 | 75 yo M with Mantle cell lymphoma (on bendamustine and Rituxan), atrial flutter, tachy-CM (last EF 45-50%), recent UTI and episode of urinary retention, prostate cancer s/p XRT who was recently admitted to for LE edema, who presented from for an evaluation of LE edema, urinary retention and hypotension. # Mantle cell lymphoma. Reportedly improving with current chemo prior to this. However, as hospitalization went on, became clear that pleural effusions and pericardial effusions were malignant in nature. service was following throughout. CT torso on showed worsening lymphoma. As a result, oncology started Dexamethasone 20mg daily to arrest the lymphoma. MRI showed no CNS disease. Persistent pressor requirement and unable to get off vent (had been intubated for pericardiocentesis - see below) with negative infectious work-up raised concern that all problems stemming from overwhelming lymphoma. On after 4 days of steroids with no response oncology met with family who had expressed desires to not have prolonged intubation or life support. Decision was made to pursue comfort-based goals of care and withdraw other medical care. Patient expired on morning of . # Sepsis. Patient admitted initially to ICU on with hypotension, tachycardia, low CVP and elevated SVO2. Source of sepsis is most likely Pseudomonal UTI. Recurrent UTI likely due to stricture from past prostate radiation. No evidence of prostatitis on rectal exam. Of note, he has been hypotensive, even at time of d/c during last admission to 80s. Started on Meropenem for abx and initially on pressors, given fluid boluses. Improved and was able to transfer to oncology floor on . Finished course of meropenem for UTI but later in hospitalization when in MICU7 (see below) more issues with hypotension requiring pressors so placed back on vanco and continued on meropenem empirically for HCAP. | Relatively low limb lead voltage and low precordial voltage.Probable left atrial abnormality with non-specific ST-T wave changes. Trivial mitral regurgitation is seen. There is sustained right atrialcollapse, consistent with low filling pressures or early tamponade. Diffuse low QRS voltages, particularly in the precordial leads.Prior inferior myocardial infarction, age undetermined. There is a moderate sizedpericardial effusion. Echocardiographic signsof tamponade may be absent or less severe in the presence of elevated rightsided pressures.Compared with the prior study (images reviewed) of , there is morepericardial fluid seen and early tamponade physiology is present. Significant, accentuated respiratoryvariation in mitral/tricuspid valve inflows, c/w impaired ventricular filling.Echocardiographic signs of tamponade may be absent in the presence of elevatedright sided pressures.GENERAL COMMENTS: Resting tachycardia (HR>100bpm). Trivial MR.PERICARDIUM: Very small pericardial effusion. There is a very smallpericardial effusion. Cannot exclude prior anteroseptal myocardial infarction.Compared to the previous tracing of the findings are similar. There is a moderate sized pericardial effusion. The mitral valve leaflets are mildlythickened. Cannot exclude underlying inferior wall myocardialinfarction. Trivial mitralregurgitation is seen. There issignificant, accentuated respiratory variation in mitral/tricuspid valveinflows, consistent with impaired ventricular filling. Diffuse low voltageand right bundle-branch block without diagnostic interim change. Grossly preserved biventricular systolic function.Compared with the prior study (images reviewed) of , the findingsarppear similar, although inferior/inferolateral hypokinesis is notappreciated on today's focused study. Right ventricular chamber size and free wall motion are normal.Trace aortic regurgitation is seen. QRS complexshows right bundle-branch block, left axis deviation consistent with leftanterior fascicular block. Left atrial abnormality. Left atrial abnormality. Right ventricular function.Height: (in) 69Weight (lb): 210BSA (m2): 2.11 m2BP (mm Hg): 85/53HR (bpm): 96Status: InpatientDate/Time: at 08:44Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded. Mild global left ventricular systolic dysfunction.Compared with the prior study (images reviewed) of , pericardialeffusion is larger and LV systolic function is less vigorous, albeit at afaster heart rate. Suboptimal image quality -ventilator. No echocardiographic signs oftamponade.GENERAL COMMENTS: Suboptimal image quality as the patient was difficult toposition. Wide complex tachycardia which is probably sinus tachycardia/atrialtachycardia conducting with right bundle-branch block, left anterior fascicularblock. Otherwise, noapparent diagnostic interim change.TRACING #2 PATIENT/TEST INFORMATION:Indication: Pericardial effusion.Weight (lb): 215BP (mm Hg): 119/61HR (bpm): 116Status: InpatientDate/Time: at 09:02Test: Portable TTE (Focused views)Doppler: Limited Doppler and no color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Overall normal LVEF (>55%).TRICUSPID VALVE: Indeterminate PA systolic pressure.PERICARDIUM: Moderate pericardial effusion. Bilateral pleural effusions.Conclusions:Due to suboptimal technical quality, a focal wall motion abnormality cannot befully excluded. Poor R waveprogression. PATIENT/TEST INFORMATION:Indication: CHF, Hypotension, TachycardiaHeight: (in) 69Weight (lb): 211BSA (m2): 2.12 m2BP (mm Hg): 95/58HR (bpm): 117Status: InpatientDate/Time: at 15:32Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Mild global LV hypokinesis.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.MITRAL VALVE: Trivial MR.PERICARDIUM: Moderate pericardial effusion. No echocardiographic signs oftamponade.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Low amplitude P wave as recorded on . Thereare no echocardiographic signs of tamponade.IMPRESSION: Moderate-sized pericardial effusion without evidence of tamponadephysiology. Supraventricular tachycardia which may be sinus with a P-R intervalof about 150, although atrial tachycardia is not excluded. Sinus rhythm. Sinus rhythm. Sinus rhythm. Suboptimal image quality - body habitus. Left pleural effusion.Conclusions:There is mild global left ventricular hypokinesis (LVEF = 50-55%). Otherwise, no diagnostic interim change.TRACING #1 Pericardial effusion. PATIENT/TEST INFORMATION:Indication: Echo guided imaging in cath lab for pericardial tap attemptHeight: (in) 69Weight (lb): 210BSA (m2): 2.11 m2BP (mm Hg): 105/60HR (bpm): 130Status: InpatientDate/Time: at 14:48Test: Portable TTE (Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Conclusions:IMPRESSION: Limited views during attempted pericardiocentesis. Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Rightventricular chamber size and free wall motion are normal. Right bundle-branch block. Right bundle-branch block. Suboptimalimage quality - body habitus. Sustained RA diastolic collapse, c/wlow filling pressures or early tamponade. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Clinical correlation is suggested to further assess sinusversus non-sinus mechanism, etc. Ascites.Conclusions:Overall left ventricular systolic function is normal (LVEF>55%). There are no echocardiographic signs of tamponade.IMPRESSION: Very small pericardial effusion, without any evidence ofhemodynamic significance. The pulmonaryartery systolic pressure could not be determined. No change fromprior. Overall left ventricular systolic function is normal(LVEF>55%). Comparedto the previous tracing of the limb leads are correctly attached.The rate has increased. Comparedto the previous tracing of heart rate is faster. QRS duration isslightly wider. On priorecho there may have been pressure/volume overload of the right ventricle.Findings discussed with Dr. at 0945 on day of study. Effusion echo dense, c/w blood,inflammation or other cellular elements. The effusion is echo dense, consistent with blood,inflammation or other cellular elements. | 9 | [
{
"category": "Echo",
"chartdate": "2172-06-12 00:00:00.000",
"description": "Report",
"row_id": 105384,
"text": "PATIENT/TEST INFORMATION:\nIndication: CHF, Hypotension, Tachycardia\nHeight: (in) 69\nWeight (lb): 211\nBSA (m2): 2.12 m2\nBP (mm Hg): 95/58\nHR (bpm): 117\nStatus: Inpatient\nDate/Time: at 15:32\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 VENTRICLE: Mild global LV hypokinesis.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nMITRAL VALVE: Trivial MR.\n\nPERICARDIUM: Moderate pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - body habitus. Suboptimal image quality -\nventilator. Left pleural effusion.\n\nConclusions:\nThere is mild global left ventricular hypokinesis (LVEF = 50-55%). Right\nventricular chamber size and free wall motion are normal. Trivial mitral\nregurgitation is seen. There is a moderate sized pericardial effusion. There\nare no echocardiographic signs of tamponade.\n\nIMPRESSION: Moderate-sized pericardial effusion without evidence of tamponade\nphysiology. Mild global left ventricular systolic dysfunction.\n\nCompared with the prior study (images reviewed) of , pericardial\neffusion is larger and LV systolic function is less vigorous, albeit at a\nfaster heart rate.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2172-06-15 00:00:00.000",
"description": "Report",
"row_id": 105220,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nWeight (lb): 215\nBP (mm Hg): 119/61\nHR (bpm): 116\nStatus: Inpatient\nDate/Time: at 09:02\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and no color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements. Sustained RA diastolic collapse, c/w\nlow filling pressures or early tamponade. Significant, accentuated respiratory\nvariation in mitral/tricuspid valve inflows, c/w impaired ventricular filling.\nEchocardiographic signs of tamponade may be absent in the presence of elevated\nright sided pressures.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). Ascites.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). The pulmonary\nartery systolic pressure could not be determined. There is a moderate sized\npericardial effusion. The effusion is echo dense, consistent with blood,\ninflammation or other cellular elements. There is sustained right atrial\ncollapse, consistent with low filling pressures or early tamponade. There is\nsignificant, accentuated respiratory variation in mitral/tricuspid valve\ninflows, consistent with impaired ventricular filling. Echocardiographic signs\nof tamponade may be absent or less severe in the presence of elevated right\nsided pressures.\n\nCompared with the prior study (images reviewed) of , there is more\npericardial fluid seen and early tamponade physiology is present. On prior\necho there may have been pressure/volume overload of the right ventricle.\n\nFindings discussed with Dr. at 0945 on day of study.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2172-06-15 00:00:00.000",
"description": "Report",
"row_id": 105219,
"text": "PATIENT/TEST INFORMATION:\nIndication: Echo guided imaging in cath lab for pericardial tap attempt\nHeight: (in) 69\nWeight (lb): 210\nBSA (m2): 2.11 m2\nBP (mm Hg): 105/60\nHR (bpm): 130\nStatus: Inpatient\nDate/Time: at 14:48\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nIMPRESSION: Limited views during attempted pericardiocentesis. No change from\nprior.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2172-06-04 00:00:00.000",
"description": "Report",
"row_id": 104722,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion. Right ventricular function.\nHeight: (in) 69\nWeight (lb): 210\nBSA (m2): 2.11 m2\nBP (mm Hg): 85/53\nHR (bpm): 96\nStatus: Inpatient\nDate/Time: at 08:44\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nPERICARDIUM: Very small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus. Bilateral pleural effusions.\n\nConclusions:\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nTrace aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Trivial mitral regurgitation is seen. There is a very small\npericardial effusion. There are no echocardiographic signs of tamponade.\n\nIMPRESSION: Very small pericardial effusion, without any evidence of\nhemodynamic significance. Grossly preserved biventricular systolic function.\n\nCompared with the prior study (images reviewed) of , the findings\narppear similar, although inferior/inferolateral hypokinesis is not\nappreciated on today's focused study.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2172-06-15 00:00:00.000",
"description": "Report",
"row_id": 308756,
"text": "Wide complex tachycardia which is probably sinus tachycardia/atrial\ntachycardia conducting with right bundle-branch block, left anterior fascicular\nblock. Diffuse low QRS voltages, particularly in the precordial leads.\nPrior inferior myocardial infarction, age undetermined. Poor R wave\nprogression. Cannot exclude prior anteroseptal myocardial infarction.\nCompared to the previous tracing of the findings are similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2172-06-12 00:00:00.000",
"description": "Report",
"row_id": 308757,
"text": "Supraventricular tachycardia which may be sinus with a P-R interval\nof about 150, although atrial tachycardia is not excluded. QRS complex\nshows right bundle-branch block, left axis deviation consistent with left\nanterior fascicular block. Cannot exclude underlying inferior wall myocardial\ninfarction. Relatively low limb lead voltage and low precordial voltage.\nProbable left atrial abnormality with non-specific ST-T wave changes. Compared\nto the previous tracing of heart rate is faster. QRS duration is\nslightly wider. Clinical correlation is suggested to further assess sinus\nversus non-sinus mechanism, etc.\n\n"
},
{
"category": "ECG",
"chartdate": "2172-06-11 00:00:00.000",
"description": "Report",
"row_id": 308758,
"text": "Sinus rhythm. Low amplitude P wave as recorded on . Diffuse low voltage\nand right bundle-branch block without diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2172-06-04 00:00:00.000",
"description": "Report",
"row_id": 308759,
"text": "Sinus rhythm. Left atrial abnormality. Right bundle-branch block. Compared\nto the previous tracing of the rate has increased. Otherwise, no\napparent diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2172-06-03 00:00:00.000",
"description": "Report",
"row_id": 308760,
"text": "Sinus rhythm. Left atrial abnormality. Right bundle-branch block. Compared\nto the previous tracing of the limb leads are correctly attached.\nThe rate has increased. Otherwise, no diagnostic interim change.\nTRACING #1\n\n"
}
] |
6,252 | 196,542 | 50M w/ a PMH of EtOH abuse and psychiatric disorder p/w fatigue, anorexia, found to have metastatic lunch cancer to liver, pancreas and abdomen. . # METASTATIC SMALL CELL LUNG CANCER: The patient initially presented with hepatomegaly and was found to have innumerous nodules as well as a pancreatic head mass. Hepatology was consulted and a percutaneous liver biopsy was performed which was consistent with a neuroendocrine small cell lung primary. Oncology was consulted. Chest CT confirmed the presence of a spiculated lung mass and mediastinal lymphadenopathy. Bone scan was performed and is pending. Tumor markers CEA and CA -9 were elevated, but AFP normal; 5-HIAA and chromogrannin are pending. He underwent EGD and colonoscopy which was unrevealing. Due to the metastatic disease, his liver functions slowly worsened and he developed signs of hepatic encephalopathy; the patient was given lactulose titrated to 4 bowel movements per day with improvement in his symptoms. Hepatitis panel negative for A/B/C viruses. MELD 13, score/discriminant function is 16. Given the new diagnosis and worsening of his liver function, the Oncology team hoped to initiate chemotherapy as an inpatient. . On the morning of , the patient developed worsening mental status changes, tachypnea and increasing abdominal distansion and tenderness. CXR was unrevealing, however, ABG revealed a lactated of 8. He was started on broad spectrum antibiotics for suspicion of SBP, or other abdominal source of infection; he was transferred to the . Upon arrival to the , his respiratory status further deteriorated and he was intubated. He was continued on Vancomycin, Zosyn, and flagyl for evolving sepsis. On the morning of , the patient further deteriorated, and required 3 pressors to maintain his blood pressure. . A family meeting was held at approximately 10:00 AM ; at that meeting his parents requested that the goals of care be changed to comfort measures only, given his underlying metastatic disease and overall poor prognosis. Supportive care was withdrawn. The patient passed away quietly at 1410pm. An autopsy was requested by his mother, . | Multiple loops of small bowel in the mid abdomen with wall edema, a non- specific finding. CT OF THE ABDOMEN WITH IV CONTRAST: There is minor atelectasis at the bases. Distal to this area the sigmoid colon is mildly prominent with multiple areas of caliber narrowing probably representing areas of peristalsis. Stable appearance of mediastinal lymphadenopathy and left upper lobe spiculated mass. There appear to be multiple prominent periportal lymph nodes that are unchanged compared to the previous study. 9:03 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: ? FINAL REPORT INDICATION: Distended abdomen. SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPHS: There is a moderate amount of stool seen throughout the colon along with air extending into the rectum. There is a focal area of decreased caliber of the large bowel at the splenic flexure that may represent an area of peristalsis. Within the limits of the study, the superior mesenteric artery and superior mesenteric vein appear patent. There are multiple small mesenteric and retroperitoneal lymph nodes that do not meet CT criteria for pathologic enlargement. (Over) 9:03 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: ? Dilated ascending colon and transverse colon with a focal area of caliber narrowing at the splenic flexure that may represent an area of peristalsis. Mediastinal lymphadenopathy and left upper lobe mass are unchanged. It demonstrates gas-filled nonspecific bowel loops. CT OF THE PELVIS WITH IV CONTRAST: The prostate, seminal vesicles, bladder, sigmoid and rectum are unremarkable. Alternatively, if this is a mass of pancreatic origin, this would be more consistent with a neuroendocrine tumor, given the widespread hepatic involvement and absence of pancreatic ductal dilatation. Small ascites and pelvic free fluid. Mild pulmonary edema is unchanged in the short interval with new right lower lobe discoid atelectasis. COMPARISON: Chest dated and CT abdomen dated . IMPRESSION: ETT at inferior clavicular edge and OG tube in stomach. Assess for partial small-bowel obstruction. Lack of progession of oral contrast from CT study of one day prior is suggestive of ileus. if ascites, mark for paracentesis. Hepatic veins and portal vein appear grossly patent. There is a stable small pericardial effusion. The cardiac and mediastinal contours, remarkable for adenopathy, is unchanged. There is dilatation of the cecum, ascending colon, and transverse colon. There is a small amount of low-density ascites in the pelvis. A collapsed gallbladder is may reflect hepatic dysfunction. SBO Admitting Diagnosis: HEPATITIS Field of view: 46 Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter within a decompressed bladder. Stable small pericardial effusion. TECHNIQUE: Unenhanced MDCT of the chest from thoracic inlet to upper abdomen was obtained with subsequent 1.25 and 5mm collimation axial and 5 mm coronal reformats reviewed. Moderate, predominantly apical, centrilobular and paraseptal emphysema is noted. IMPRESSION: Known mediastinal lymphadenopathy and left hilar mass, better appreciated on recent CT examination, with no focal superimposed infiltrate identified. pt to be electively intubated b/cause of altered ms sepsis. once intubated ptr will need sedative gtts.gi: abd with increased ascites and hypoactive bowel sounds. multiple studies pt now with sm cell lung ca with mets to liver.pt was to be d/c'd home and to undergo outpt paliative chemo but this am pt with increased confusion and agitation requiring 1:1 pt observer. On the supine view, air filled ascending and transverse colon loops of bowel are seen as seen on the CT study of at 9:22 p.m. High NGT placement discussed with Dr . Assess for acute infiltrate or edema. will follow fluid balance closely.id: afberile but with elevated lactal and abg results pt is to be septic. Bilateral adrenal enlargement is present : low density in left adrenal is probably adenoma or hyperplasia, but mixed density of the right might represent either adrenal hyperplasia (related to paraneoplastic, ectopic ACTH production ) or metastasis. UPRIGHT PORTABLE CHEST RADIOGRAPH FINDINGS: Right paratracheal and mediastinal lymphadenopathy along with left hilar mass are better appreciated on recent CT examination. will follow hemodynamics and electrolytes repleting lytes as needed.lactate prior to transfer =8.4 and presently down to 7.3.resp: pt arrived on o2 at 2l/m nc and rr in the 30's. rr in the 30's and requiring higher amts of o2 though abg on 2l/m nc=7.44/30/92 and lactate=8.4. Nursing Discharge Note 0700-1530Patient unstable, requiring 3 pressors: vasopressin,levophed, & neosynephrine IV this morning. Known liver enlargement DUE TO METASTASES. REASON FOR THIS EXAMINATION: Please evalute for cholangitis. (Over) 8:16 AM CT CHEST W/O CONTRAST Clip # Reason: please evaluate for metastatic lesions in lungs Admitting Diagnosis: HEPATITIS FINAL REPORT (Cont) 4. was medicated with halol 2.5 mg ivp x2 for severe agitation with good effect.cv: pt with hr in the 80-90's and sbp has ranged form 110-130's. The area was prepped and draped in a sterile fashion, and local anesthesia was provided with 1% lidocaine administered subcutaneously. Also acidotic requiring 2 amps HCO3 IV & continued w/ HCO3 drip, vent settings @ 90-100% FiO2/.500 Vt/RR20-30/ PEEP5-8 on CMV --still remaining acidotic from metabolic source.Patient's family made aware of grave situation & patient made comfortmeasures only. | 22 | [
{
"category": "Radiology",
"chartdate": "2182-04-18 00:00:00.000",
"description": "BONE SCAN",
"row_id": 961484,
"text": "BONE SCAN Clip # \n Reason: 50YR OLD MAN W/NEW DIAGNOSIS METASTATIC SMALL CELL LUNG CA\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 22.5 mCi Tc-m MDP ();\n HISTORY: metastatic small cell lung cancer\n\n INTERPRETATION:\n\n Whole body images of the skeleton were obtained in anterior and posterior\n projections demonstrating linear uptake in the lateral proximal one-third of the\n left femur in a cortical or periosteal distribution. There is also suggestion\n of a contour deformity at this level suggestion a prior injury. No other focal\n uptake.\n\n\n The kidneys and urinary bladder are visualized, the normal route of tracer\n excretion.\n\n IMPRESSION: The pattern of uptake in the proximal left femur suggests prior\n injury, but should be correlated with radiographs of this region.\n\n\n , M.D.\n , M.D. Approved: 10:53 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": "2182-04-19 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 961719,
"text": " 9:03 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ? PE, RESP DISTRESS, ? SBO\n Admitting Diagnosis: HEPATITIS\n Field of view: 46 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with metastatic lung cancer, now intubated for respiratory\n distress\n REASON FOR THIS EXAMINATION:\n Please do CTA with PE protocol to r/o PE. Please evaluate for SBO, bowel\n necrosis, or peritoneal carcinomatosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic lung cancer, now intubated for respiratory distress.\n Please evaluate for small-bowel obstruction, bowel necrosis, pulmonary\n embolism, or peritoneal carcinomatosis.\n\n COMPARISON: Chest dated and CT abdomen dated .\n\n TECHNIQUE: MDCT-acquired images of the chest, abdomen and pelvis were\n obtained.\n\n CTA OF THE CHEST: The image is limited by motion. There is no evidence of\n pulmonary embolism within the limits of this study. Mediastinal\n lymphadenopathy and left upper lobe mass are unchanged. Emphysematous changes\n of the lungs are again seen. The aorta appears intact. There is enhancing\n opacity in the lower lobes posteriorly bilaterally that is new compared to the\n previous study suggestive of atelectasis, however pneumonia cannot be\n excluded. There is a linear right lower lobe opacity that is more prominent\n compared to the previous study, also suggestive of atelectasis. Patient is\n intubated with ET tube terminating above the carina. There is a stable small\n pericardial effusion.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver is diffusely enlarged and\n heterogeneous, not significantly changed compared to the prior study. Hepatic\n veins and portal vein appear grossly patent. Kidneys enhance homogeneously.\n There is dilatation of the cecum, ascending colon, and transverse colon. There\n is a focal area of decreased caliber of the large bowel at the splenic flexure\n that may represent an area of peristalsis. Distal to this area the sigmoid\n colon is mildly prominent with multiple areas of caliber narrowing probably\n representing areas of peristalsis. There is fluid in the rectum and sigmoid\n colon. The appendix is normal. There are several loops of small bowel in the\n mid abdomen that demonstrate mild wall thickening. No pneumatosis of the\n large or small bowel lumen are seen. No portal venous gas is seen. There\n appear to be multiple prominent periportal lymph nodes that are unchanged\n compared to the previous study. There are multiple small mesenteric and\n retroperitoneal lymph nodes that do not meet CT criteria for pathologic\n enlargement. There is no intra-abdominal free air. Within the limits of the\n study, the superior mesenteric artery and superior mesenteric vein appear\n patent. Enlarged bilateral adrenal glands are unchanged.\n (Over)\n\n 9:03 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ? PE, RESP DISTRESS, ? SBO\n Admitting Diagnosis: HEPATITIS\n Field of view: 46 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter within a\n decompressed bladder. The rectum is not completely imaged, and is filled with\n fluid and air. No significant pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: There are degenerative changes with no suspicious lytic or\n sclerotic lesions.\n\n IMPRESSION:\n 1. Study limited by motion, however no evidence of pulmonary embolism.\n 2. Interval development of enhancing consolidation in the posterior lower\n lobes bilaterally, consistent with atelectasis, with infectious process\n difficult to exclude.\n 3. Stable small pericardial effusion.\n 4. NG tube terminates above the GE junction.\n 5. Stable appearance of mediastinal lymphadenopathy and left upper lobe\n spiculated mass.\n 6. Unchanged enlarged, heterogeneous liver\n 7. Stable appearance of enlarged adrenal glands bilaterally.\n 8. Dilated ascending colon and transverse colon with a focal area of caliber\n narrowing at the splenic flexure that may represent an area of peristalsis. No\n evidence of small-bowel obstruction.\n 9. Multiple loops of small bowel in the mid abdomen with wall edema, a non-\n specific finding.\n 10. Small ascites and pelvic free fluid.\n\n The above findings were discussed with Dr. , caring for the\n patient in the intensive care unit at approximately 10:20 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-19 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 961706,
"text": " 5:23 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for SBO.\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with distended abdomen and elevated lactate.\n REASON FOR THIS EXAMINATION:\n Please evaluate for SBO.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Distended abdomen. Please evaluate for small bowel obstruction.\n\n Single portable radiograph is markedly limited and mostly nondiagnostic. It\n demonstrates gas-filled nonspecific bowel loops. Repeat exam is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961728,
"text": " 11:52 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval placement of NG\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with metastatic lung CA, respiratory distress, now intubated\n REASON FOR THIS EXAMINATION:\n eval placement of NG\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic lung cancer with respiratory distress, now intubated, an\n NG tube placed, for evaluation of NG tube.\n\n Portable radiograph with field of view projecting over the lower chest and\n upper abdomen demonstrates an NG tube with its tip in the proximal stomach.\n It's side hole is above or at the GE junction, therefore the tube needs to be\n advanced further into the stomach. Doboff tube tip in the stomach. Findings\n discussed with Dr on at 11:20 am.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-09 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 960246,
"text": " 7:12 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: assess for partial SBO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with abd distention, no BM x 1 week\n REASON FOR THIS EXAMINATION:\n assess for partial SBO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old male with abdominal distention and no bowel movements\n for one week. Assess for partial small-bowel obstruction.\n\n SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPHS: There is a moderate amount of stool\n seen throughout the colon along with air extending into the rectum. There are\n no distended loops of small bowel. There is no evidence of free air below the\n diaphragms. Oral contrast is seen within the stomach. Osseous structures are\n unremarkable.\n\n IMPRESSION:\n\n No evidence of small bowel obstruction or free air. Moderate amount of stool\n throughout the colon.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-10 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 960304,
"text": " 8:51 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please perform liver U/S with full doppler exam. if ascites\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with h/o EtOH abuse, p/w hepatomegaly, anorexia; hepatology\n would like u/s for further characterization\n REASON FOR THIS EXAMINATION:\n please perform liver U/S with full doppler exam. if ascites, mark for\n paracentesis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old man with history of alcohol abuse and hepatomegaly,\n for further characterization of the liver.\n\n COMPARISON: CT scan from .\n\n RIGHT UPPER QUADRANT ULTRASOUND: There is enlargement of the liver. There\n are innumerable diffuse nodules throughout the liver measuring between 5 mm\n and up to 1.5-2 cm in size. There is no intrahepatic biliary ductal\n dilatation, or dilatation of the common bile duct. The gallbladder is\n contracted. No free fluid is seen. In the region of the head of the pancreas,\n there is a 2.3 cm hypoechoic mass. There is no evidence of pancreatic ductal\n dilatation.\n\n IMPRESSION:\n 1) Innumerable nodules throughout an enlarged liver, ranging from 5 mm to 1.5\n cm, in the absence of other findings of decompensated liver disease, is is\n more consistent with widespread metastatic disease in the liver. A collapsed\n gallbladder is may reflect hepatic dysfunction.\n 2) 2.3 cm mass in the region of the head of the pancreas. This may represent\n an enlarged peripancreatic lymph node. Alternatively, if this is a mass of\n pancreatic origin, this would be more consistent with a neuroendocrine tumor,\n given the widespread hepatic involvement and absence of pancreatic ductal\n dilatation.\n\n Further evaluation of this with US-guided biopsy of the hepatic nodules is\n recommended. These findings were discussed with Dr. at 10:30\n a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-09 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 960253,
"text": " 9:05 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: H/O ETOH ABUSE, FEELING OF ABD MASS ON EXAM.\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with h/o EtOH abuse, p/w anorexia, fatigue, \"abdominal mass\" -\n on exam has non-tender hepatomegaly. Labs notable for incr bilirubin,\n transaminases and alk phos\n REASON FOR THIS EXAMINATION:\n assess for hepatomegaly, pancreatic mass, other biliary abnormality, SBO\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AEBc TUE 9:57 PM\n Findings c/w severe hepatitis, including ascites, although no CT evidence of\n cirrhosis; stranding about pancreatic head suggestive of pancreatitis; no\n biliary obstruction; periportal lymphadenopathy, non-specific but often seen\n with infectious hepatitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 50-year-old man with alcohol abuse, anorexia, fatigue and\n abdominal mass with non-tender hepatomegaly.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial CT images of the abdomen and pelvis were obtained with oral\n and intravenous contrast and sagittal and coronal reconstructions were also\n performed.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is minor atelectasis at the bases.\n The liver is markedly enlarged with a heterogeneous appearance, suggesting\n hepatitis or perhaps an infiltrative liver disease. A more well-defined 5 mm\n hypodensity in the left lobe is too small to characterize. There is no intra-\n or extra-hepatic biliary ductal dilatation. There is periportal\n lymphadenopathy, with a node up to 15 mm in shortest dimension. The main\n portal vein appears patent. The pancreas, spleen and adrenal glands are\n unremarkable. Ascites is present.\n\n Stomach, small and large bowel are unremarkable. The gallbladder is\n contracted with wall thickening and edema, which can be seen in hepatitis. The\n contour of the liver is not particularly suggestive of cirrhosis.\n\n CT OF THE PELVIS WITH IV CONTRAST: The prostate, seminal vesicles, bladder,\n sigmoid and rectum are unremarkable. There is a small amount of low-density\n ascites in the pelvis.\n\n BONE WINDOWS: There are no suspicious lytic or blastic lesions.\n\n IMPRESSION: Marked hepatomegaly with heterogeneity of the liver and ascites,\n as well as periportal lymphadenopathy and gallbladder wall edema. The\n appearance is most consistent with hepatitis or other infiltrative liver\n disease.\n\n (Over)\n\n 9:05 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: H/O ETOH ABUSE, FEELING OF ABD MASS ON EXAM.\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961713,
"text": " 7:27 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess for ET tube placement, as well as OG tube placement\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with metastatic lung CA, respiratory distress, now intubated\n and OG tube placed\n REASON FOR THIS EXAMINATION:\n assess for ET tube placement, as well as OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubated with history of metastatic lung disease, please assess\n ET tube.\n\n FINDINGS: Portable chest radiograph was compared to four hours prior and\n demonstrates interval intubation with ETT terminate along the inferior\n clavicular margin, while the enteric tube lies in the stomach. Mild pulmonary\n edema is unchanged in the short interval with new right lower lobe discoid\n atelectasis. The cardiac and mediastinal contours, remarkable for adenopathy,\n is unchanged.\n\n IMPRESSION: ETT at inferior clavicular edge and OG tube in stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 960916,
"text": " 4:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for mass, herniation, bleed\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with liver masses and mental status change\n REASON FOR THIS EXAMINATION:\n eval for mass, herniation, bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT CONTRAST\n\n INDICATION: 50-year-old man with liver masses and mental status change.\n\n COMPARISON: Head CT and head MR and \n respectively.\n\n TECHNIQUE: Head CT without intravenous contrast.\n\n FINDINGS: There is no acute intracranial hemorrhage, mass effect, or shift of\n normally midline structures. There is no hydrocephalus. The density values\n of the brain parenchyma are within normal limits. The -white matter\n differentiation is preserved.\n\n The imaged paranasal sinuses and mastoid air cells are well aerated.\n Surrounding soft tissues and osseous structures are unremarkable.\n\n There is persistent prominence of the sulci and ventricles, consistent with\n age-related involutional change.\n\n IMPRESSION: No evidence of intracranial hemorrhage, no change from .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961695,
"text": " 3:45 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evalaute for pneumonia.\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with known malignancy, now increased respiratory rate and\n altered mental status now with rapildy worsening respiratory distress.\n REASON FOR THIS EXAMINATION:\n Please evalaute for pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known malignancy with increased respiratory rate.\n\n Portable chest radiograph is compared to two hours prior without significant\n short-term interval change, remarkable for mild pulmonary edema. The exam is\n otherwise unchanged.\n\n IMPRESSION: Mild pulmonary edema without airspace consolidation.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-20 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 961744,
"text": " 5:10 AM\n PORTABLE ABDOMEN Clip # \n Reason: assess for bowel perforation\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with lung ca, newly diagnosed with mets to liver, and acute\n respiratory distress and hypoxia, intubated\n REASON FOR THIS EXAMINATION:\n assess for bowel perforation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old man with lung cancer with mets to the liver with\n respiratory distress and hypoxia. Assess for bowel perforation.\n\n On the single portable abdominal study without indication as to supine or\n upright, no free air is identified. Gas-filled loops of ascending and\n transverse colon are seen. Lack of progession of oral contrast from CT study\n of one day prior is suggestive of ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961745,
"text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for free air\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with metastatic lung CA to liver, intubated, now with acute\n resp. distress, tense abdomen, breathing over vent\n REASON FOR THIS EXAMINATION:\n eval for free air\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic lung cancer to the liver with acute respiratory distress\n and dense abdomen, evaluate for free air.\n\n Limited views of the abdomen demonstrate no free air in the visualized fields\n of view. On the supine view, air filled ascending and transverse colon loops\n of bowel are seen as seen on the CT study of at 9:22 p.m.\n High NGT placement discussed with Dr .\n\n IMPRESSION: No free air under the diaphragm. Findings likely due to ileus as\n oral contrast has not progressed in the interval.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-16 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 961125,
"text": " 8:16 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: please evaluate for metastatic lesions in lungs\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with newly diagnosed endocrine tumor, hepatomegaly\n REASON FOR THIS EXAMINATION:\n please evaluate for metastatic lesions in lungs\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation for metastatic lesions in lung in a\n patient with newly diagnosed endocrine tumor.\n\n COMPARISON: Abdominal CT from .\n\n TECHNIQUE: Unenhanced MDCT of the chest from thoracic inlet to upper abdomen\n was obtained with subsequent 1.25 and 5mm collimation axial and 5 mm coronal\n reformats reviewed.\n\n FINDINGS: Spiculated left upper lobe mass, 2.8 x 2.4 cm in diameter involves\n aortopulmonary window and hilus, occluding the apicoposterior bronchus of the\n left upper lobe . Large AP window mass, 3.4 x 2.5 cm could be either part of\n the primary tumor or represent a metastatic nodal spread, also involving the\n right and left lower paratracheal lymph nodes, 9.5 mm in diameter and an 11 mm\n left hilar lymph node . Left upper lobe volume is slightly decreased but no\n discrete atelectasis is present.\n\n Moderate, predominantly apical, centrilobular and paraseptal emphysema is\n noted. Right lower lobe areas of atelectasis are new and might be related to\n high position of the right hemidiaphragm.\n\n The imaged portion of the upper abdomen includes a markedly enlarged\n heterogeneous liver with known hypodense areas most likely metastases.\n Bilateral adrenal enlargement is present : low density in left adrenal is\n probably adenoma or hyperplasia, but mixed density of the right might\n represent either adrenal hyperplasia (related to paraneoplastic, ectopic ACTH\n production ) or metastasis.\n The heart size is normal. The small pericardial effusion has increased since\n .\n\n There are no bone lesions suspicious for malignancy. Left rib fractures are\n healed A small amount of perihepatic ascites is unchanged.\n\n IMPRESSION:\n 1. Large spiculated left upper lobe lung mass which radiologically most\n likely representing primary lung tumor with extensive mediastinal involvement.\n\n 2. Increased pericardial effusion.\n\n 3. New right lower lobe atelectasis.\n\n (Over)\n\n 8:16 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: please evaluate for metastatic lesions in lungs\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Known liver enlargement DUE TO METASTASES.\n\n 5. Bilateral adrenal enlargement which may be either due to bilateral\n hyperplasia from ectopic ACTH production or metastases.\n\n 6. Moderate emphysema.\n\n 7. Old rib fractures.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-19 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 961692,
"text": " 3:30 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: LIVER METS ASSESS FOR CHOLANGITIS\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with h/o EtOH abuse, p/w hepatomegaly, anorexia; now with\n elevated bili and elevated lactate.\n REASON FOR THIS EXAMINATION:\n Please evalute for cholangitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of alcohol abuse and hepatomegaly, now with elevated\n bilirubin and elevated lactate. Please evaluate for cholangitis.\n\n FINDINGS: Comparison made to ultrasound from and CT scan from .\n\n Enlargement of the liver, with innumerable diffuse nodules throughout the\n liver is unchanged. There is no biliary ductal dilatation. The common duct\n measures 3 mm. There is no ascites. Gallbladder remains contracted. The\n main portal vein is patent, with appropriate antegrade flow. However, as in\n previous exam, portal venous flow is relatively slow, approximately 10 cm/sec.\n\n IMPRESSION:\n 1. Unchanged appearance of innumerable small nodules throughout the liver,\n most consistent with widespread metastatic disease.\n 2. No evidence of biliary ductal dilatation, or other secondary findings to\n suggest cholangitis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-11 00:00:00.000",
"description": "BX-NEEDLE LIVER BY RADIOLOGIST",
"row_id": 960466,
"text": " 7:47 AM\n BX-NEEDLE LIVER BY RADIOLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: LIVER NODULES ,PLEASE BIOPSY NODULE\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n FINAL ADDENDUM\n Please note that the Indication should read: \"50-year-old man with\n hepatomegaly and multiple liver nodules, for biopsy.\"\n\n\n 7:47 AM\n BX-NEEDLE LIVER BY RADIOLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: LIVER NODULES ,PLEASE BIOPSY NODULE\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with hepatomegaly, multiple nodules seen by ultrasound, concern\n for malignancy. also mass vs node at pancreatic head\n REASON FOR THIS EXAMINATION:\n biopsy nodule\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiomegaly and multiple liver nodules for biopsy.\n\n ULTRASOUND-GUIDED TARGETED LIVER BIOPSY: Prior to initiation of procedure,\n written informed consent was obtained. A preprocedure timeout was performed.\n\n Ultrasound was used to identify a nodule for biopsy within the right lobe of\n the liver. The area was prepped and draped in a sterile fashion, and local\n anesthesia was provided with 1% lidocaine administered subcutaneously. Under\n direct ultrasound guidance, an 18 gauge needle was used to obtain a core\n biopsy. Three successful passes were made. The patient tolerated the\n procedure well, and there were no immediate complications.\n\n Dr. , attending radiologist, was present and supervising throughout the\n procedure.\n\n IMPRESSION: Successful ultrasound-guided targeted liver biopsy of a right\n liver lobe nodule.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961667,
"text": " 12:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: edema or infiltrate\n Admitting Diagnosis: HEPATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with known malignancy, now increased respiratory rate and\n altered mental status\n REASON FOR THIS EXAMINATION:\n edema or infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old male with no malignancy, with increased respiratory rate\n and altered mental status. Assess for acute infiltrate or edema.\n\n Comparison is made to prior radiograph dated , and prior CT\n chest dated .\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n FINDINGS:\n Right paratracheal and mediastinal lymphadenopathy along with left hilar mass\n are better appreciated on recent CT examination. No acute infiltrates are\n identified. Cardiac silhouette is within normal limits, and there is no\n evidence of pulmonary edema or pneumothorax. Left costophrenic angle appears\n sharp; however, right costophrenic angle was not included on current\n radiograph. Slight gaseous distension of the bowel is noted.\n\n Please note that the examination is slightly limited due to low lung volumes,\n as patient would not hold still for film due to confused.\n\n IMPRESSION:\n Known mediastinal lymphadenopathy and left hilar mass, better appreciated on\n recent CT examination, with no focal superimposed infiltrate identified.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-19 00:00:00.000",
"description": "Report",
"row_id": 1344466,
"text": "review of systems:\nd:neuro: pt arrived confused -disorented x3. calm when left alone but with any stimulation or nursing care pt becomes agitated ,swinging at nurses. 1:1 pt observer at the bedside and bil soft wrist restraints applied to maintain both pt and nursing staff safety. was medicated with halol 2.5 mg ivp x2 for severe agitation with good effect.\n\ncv: pt with hr in the 80-90's and sbp has ranged form 110-130's. k+ upon arrival to micu=3.3 and ordered to receive 40 meq kcl in 500cc's d5w as ordered. will follow hemodynamics and electrolytes repleting lytes as needed.lactate prior to transfer =8.4 and presently down to 7.3.\n\nresp: pt arrived on o2 at 2l/m nc and rr in the 30's. o2 sats at that time 90%. even with increasing the flow of the o2 his sats were 89-91%. pt then placed on 100% cool neb mask and abg 7.45/31/141/0/22. pt to be electively intubated b/cause of altered ms sepsis. once intubated ptr will need sedative gtts.\n\ngi: abd with increased ascites and hypoactive bowel sounds. ultrasound done at bedside and results are pending . pt will be kept npo till ms improves and pt is extubated. will consider other means of providing nutrition.\n\ngu: foley cath in place with adequate hourly uo. bun=37 and creat=1.0. pt was given 1.5 liters of ns before transfer to and than an additional liter. will follow fluid balance closely.\n\nid: afberile but with elevated lactal and abg results pt is to be septic. he has received zosyn and vancomycin. will follow all culture data results.\n\nsocial: disucssion held with pt's mother while he was on 2 and pt remains a full code. will continue with present medical management and keep family well informed on a daily basis\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-20 00:00:00.000",
"description": "Report",
"row_id": 1344467,
"text": "Nsg.notes 1900hrs-0700hrs\n1st day in ICU\n\n50 yo man,a case of GERD,paranosis,schizophrenic,bipolar features,heavy tobacco use,admitted with fatigue,anorexia,\nabd.pain,wt.loss and liver mass noted by pcp, as sm cell carcinoma metastasis to liver.\n\nEvents:Pt confused ,agitated,disoriented ,vital signs remains stable,decided to intubate and ventilate at the early shift.At 1900hrs premedications given and intubated with ET tube no:8 ,fixed at no:22 ,and connected to ventilator.AC mode,Fio2 100% (see carevue for details ) sump tube also inserted and post CXR taken and tube placement confirmed.later resident decided to remove sump and to insert NG tube and done.2115hrs oral contrast given and taken for cat scan.2210hrs back from cat scan.NG tube in place and resident planned to put sump through other nostril,so both tubes are in place now,CXR repeated and tube placement confirmed.oral lactulose given and all other oral meds held.verbal report of cat scan: no obstruction,minimal ascites ,large liver mass.2400 hrs: Rt.radial artery canulated and connected to monitor for arterial BP,blood gas done ,Fio2 reduced to 50%after ABG. At 0100hra BP 105/55 ,map >65,for fluid bolus if map< 60.k remains low,3.6 in night,40meq kcl on,to repeat in the morning.D5w with NaHC03 150meq is on.\n\nNeuro: sedated with Inj.fentanyl 200mcg/hr and versed 2mg/hr.pupils 2mm size and brisk reacting to light.gag and cough reflex intact.cat scan done.\n\nResp:On ventilator,AC mode,RR 16,PEEP 5,TV 500,Fio2 50%.spo2 100% air entry equal and adequate bilaterally,clear,CXR taken pm and am.\n\nCVS:HR 95-110/min,NST,no ectopics noted.vital signs stable.A-line and peripheral lines in.peripheral pulse strong palpable.\n\nGU: sump and NG tube in place ,may remove NG tube in the morning,nil by mouth .abdomen distended and bowel sounds not present.\n\nGI:Urine output adequate on foleys catheter,bladder pressure 13cm of H20.icteric and clear.\n\nIntegu:T max 98.8,skin intact,position changed ,all nursing care attended,body washed.\n\nAccess:Two peripheral lines on Lt.hand and one on Rt.hand,patent,no swelling or redness noted,dressing intact.A-line on Rt.Radial artery,site looks clean .\n\nSocial: Sedated,no visitors during the shift,discussed with healthcare proxy and code status DNR.\n\nPLAN:To continue ventilation and treatment,to remove NG tube,NPO,DC'd oral meds execpt lactulose,monitor Lactate and K and replacement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-20 00:00:00.000",
"description": "Report",
"row_id": 1344468,
"text": "0600hrs Nsg: notes contd.....\n\nArterial BP dropped to 75-90/40-55 mm of Hg,spo2 90-93%.NBP >100/55 MM OF Hg. seen by resident.lactated ringers 500ml bolus given and inj.phenylephrine 4.3mcg/kg/mt started.resident inserting central line (procedure on),To be started with vassopressin infusion once after the central line position confirmed with CXR.ARTERIAL BP STILL REMAINS 84/44 mm of Hg,NBP 97/49 mm of Hg.Fio2 increased back to 100% and spo2 improved 97%.ALL OTHER INVASIVE LINES ARE PATENT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-20 00:00:00.000",
"description": "Report",
"row_id": 1344469,
"text": "Resp Care\nIntubated last evening for severe resp distress. Currently ventilated on a/c 500 x 16 +5 100%, overbreathing into 30s and discoordinate with the vent. Transported to and from ct scan without incident. Resp status appears to be worsening this morning with increased work of breathing, desaturating down to 80s.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-20 00:00:00.000",
"description": "Report",
"row_id": 1344470,
"text": "Nursing Discharge Note 0700-1530\nPatient unstable, requiring 3 pressors: vasopressin,levophed, & neosynephrine IV this morning. Also acidotic requiring 2 amps HCO3 IV & continued w/ HCO3 drip, vent settings @ 90-100% FiO2/.500 Vt/RR20-30/ PEEP5-8 on CMV --still remaining acidotic from metabolic source.\nPatient's family made aware of grave situation & patient made comfort\nmeasures only. Pressors D/C'ed @ 1120. Patient extubated @ 1400. Patient expired @ 1410.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-19 00:00:00.000",
"description": "Report",
"row_id": 1344465,
"text": "altered resp status\nD: briefly this a 51 yo male with pmh significant for gerd,etoh abuse,paranoid schizophrenia who presented to ed on with c/o fatigue,anorexia,and abd pain and weight loss and liver mass noted by pcp. multiple studies pt now with sm cell lung ca with mets to liver.pt was to be d/c'd home and to undergo outpt paliative chemo but this am pt with increased confusion and agitation requiring 1:1 pt observer. rr in the 30's and requiring higher amts of o2 though abg on 2l/m nc=7.44/30/92 and lactate=8.4. transfered to for furher monitoring and tx. pt with nkda\n\n\n"
}
] |
24,847 | 193,772 | 58 year-old female with morbid obesity, osteoarthritis, history of asthma, OSA, LE edema, who now presents with dyspnea on exertion and hypoxia: . ##Dyspnea/hypoxia: This was felt to be a combination of CHF, asthma, and obesity hypoventilation syndrome. The patient was diuresed almost 18L and improved dramatically. She had no leukocytosis, fever, productive cough, or clear consolidation on CXR suggestive of pneumonia. She ruled out for a PE with a CTA. She did have some wheezing on exam to suggest an asthma flare and was treated with a short course of tapered steroids as well as nebulizers RTC. She was discharged to complete her short taper as well as started on Advair. Her hypoxia was also felt to be likely in part due to obesity hypoventilation syndrome and she was placed on Bipap at night. She tolerated this well and will follow up for a formal sleep study and be fitted for BiPap at home. . ## Pulmonary HTN: the echo showed that the pt's PASP was markedly elevated at 52. She will follow up in the pulmonary clinic for formal PFT's and will likely be referred for further testing including possible Swan Ganz cathter with NO trial. . ## Hypertension: She was continued on norvasc and lisinopril with good BP control. . ## osteoarthritis: She was continued with ibuprofen prn. . | PATIENT/TEST INFORMATION:Indication: Shortness of breath.Height: (in) 65Weight (lb): 450BSA (m2): 2.79 m2BP (mm Hg): 117/55HR (bpm): 80Status: InpatientDate/Time: at 14:00Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LS c faint exp wheezes in upper lobes this AM & diminished BS @ bases, BS have now been clear in upper lobes since OOB to chair. NEB RX AS ORDERED AND PRN WHEEZING. FINAL REPORT HISTORY: Shortness of breath and hypoxia. Overallnormal LVEF (>55%).AORTA: Normal aortic root diameter.AORTIC VALVE: Aortic valve not well seen.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. PT RECEIVING TOLERATING WELL AND BACK ON AEROSOL MASK AT 36/%.CV: NSR NO ECTOPY. Pt has fairly clear BS in upper lobes and diminished BS @ bases @ this time. ABD OBESE, GOOD BOWEL SOUNDS, NO STOOL.GU: PT USES COMMODE TO VOID. Again demonstrated is perihilar haziness, vascular indistinctness, and patchy opacities throughout both lungs, consistent with congestive heart failure which is not significantly changed since the prior examination. ABDOMEN OBESE, SOFT, + BOWEL SOUNDS.GU: OOB TO COMMODE TO VOID. HS BS 103, NO RX.GI: TOLERATING LIQUIDS. 11:22 AM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # Reason: PE? Pt denies dizzyness or lightheadedness c transfer from bed to commode to ambulating short distances in room.GU: Pt net output 800ml thus far today c teams I&O goal of net negative 1 liter. Dynamic interatrialseptum.LEFT VENTRICLE: Normal LV wall thickness. FiO2 successfully weaned down over the coarse of the day, now resting comfortably c sats in the mid-90's and a nl RR c no SOB/dyspnea on 40% FiO2 hi-flow mask. The mediastinum is not well evaluated, though the contour of the aortic knob is within normal limits. The heart, great vessels, and paracardium appear grossly normal. Pt ruled out for PE today s/p CT scan and therefore Heparin gtt d/c'ed. HAS NOT VOIDED SINCE BEFORE GOING TO BED LAST NIGHT.SKIN: NO ISSUES.ACCESS: PT HAS RIGHT EJ, AND LEFT ANTECUB. Consider myocardial ischemia. Team to assess whether pt has OSA tonight and may initiate BiPap if needed.CV: Hemodynamically stable and afebrile. CT CHEST W/O & W/IV CONTRAST: This examination is technically suboptimal due to patient body habitus. LUE AC 20# gauge PIV and R EJ 18# gauge both patent c excellent blood return noted.MS: Pleasant/cooperative/conversant/MAE/AAO times three and in NAD. Resp CarePt receiving albuterol/atrovnet neb q4. IMPRESSION: No significant interval change in congestive heart failure. Bs generally diminished but with occasional scatter wheezing The left ventricular cavitysize is normal. POOR VENOUS ACCESS D/T SIZE. The airways are patent to the level of the subsegmental bronchi bilaterally. Overall left ventricular systolic function is probably normal(LVEF>55%). NSR c rare VEA. BP WITHIN NORMAL LIMITS. Compared to the previous tracingof probably no significant change.TRACING #2 The left atrium is mildly dilated.2.The right atrium is moderately dilated.3. AP UPRIGHT VIEW OF THE CHEST: The study is limited by patient's body habitus. Noprevious tracing available for comparison.TRACING #1 Superimposed pneumonia not excluded. Normal LV cavity size. GOOD RESPONSE TO LASIX IV AT .SOCIAL: NO VISITORS OR PHONE CALLS.PLAN: AGGRESSIVE PULM HYGIENE. There is patchy opacity involving both lungs throughout consistent with congestive failure. MOVES WELL INDEPENDENTLY.CV: NSR WITHOUT ECTOPY. Please see STAT med sheet for KCL & Magnesium Sulfate repletion data.MS: Pleasant, cooperative, conversant, AAO times three, MAE in NAD. Trace pitting LE edema noted. LUNGS DIMISHED IN BASES, FAINT EXPIRATORY WHEEZE AT TIMES. Pt reports feeling much better now than @ time of admission s/p diuresis of nearly five liters. Nursing Progress Note.RESP: Pt received on 100% NRB c nl sats/RR/resp effort this AM. IMPRESSION: Evidence of congestive failure. BILATERAL LOWER EXTREMITY ULTRASOUND: scale, color, and Doppler son of both common femoral, both superficial femoral, and both popliteal veins were performed. R EJ 18 gauge PIV and a L AC PIV are in place for IV therapy. Left ventricular wall thicknesses are normal. No aoritic regurgitation seen.5.The mitral valve appears structurally normal with trivial mitralregurgitation.6.There is no pericardial effusion. Pt able to take PO meds s diff.GU: 40mg IV Lasix therapy in place c pt currently net output 3.0 liters today. Droplet isolation precautions in place until pt negative for H.Flu. SHALLOW RESPIRATIONS WHEN ASLEEP WITH DROP IN SATS TO 87% AT TIMES WITH MASK ON. Pt has very poor peripheral access, placement of a double lumen PIC placement broached c team. Pt reports resp fxn greatly improved s/p Lasix therapy. IMPRESSION: No evidence of deep venous thrombosis in the lower extremities bilaterally. Probable small bilateral pleural effusions are present. Pt s c/o CP. Pt placed on droplet precautions 2nd URI sx that mostly subsided one week ago, a nasal viral swab was subsequently sent for analysis today(resultsare currently pending). Good strong cough noted, prod of sm amounts of light tan sec. CONTINUE HEPARIN GTT PER SLIDING SALE ORDER TO EMPIRICALLY RX FOR PULM EMBOLUS. PROPER LEAD PLACEMENT DIFFICULT D/T SIZE. A superimposed pneumonia cannot be excluded. The imaged portions of the upper abdomen reveal no gross abnormalities. NURSING PROGRESS NOTE:NEURO: PT ALERT AND ORIENTED AND VERY PLEASANT. The pt will be kept in MICU-B overnight for initiation of Bipap positive pressure ventilation therapy this evening.CV: Hemodynamically stable and afebrile. Non-specific ST-T wave changes. Non-specific ST-T wave changes. NSR c no ectopy. No contraindications for IV contrast FINAL REPORT CLINICAL HISTORY: 58-year-old female with dyspnea, hypoxia, and cough. Nonionic contrast was used due to rapid bolus infusion required for the CTA technique. | 12 | [
{
"category": "Nursing/other",
"chartdate": "2183-01-25 00:00:00.000",
"description": "Report",
"row_id": 1585343,
"text": "Nursing Progress Note.\n\nRESP: Pt received on 50% hi flow venti mask this AM c fluctuating sats/RR while asleep(periods of slow/shallow breathing c transitory drop in sats to 80's followed by more rapid/deeper breaths c nl sats). Pt 2 weaned down to 36% when awake c nl sats/RR/resp effort all day. LS c faint exp wheezes in upper lobes this AM & diminished BS @ bases, BS have now been clear in upper lobes since OOB to chair. Pt ruled out for PE today s/p CT scan and therefore Heparin gtt d/c'ed. Good strong cough noted, prod of sm amounts of light tan sec. Pt s c/o dyspnea/SOB all day including short walks in room c walker. DFA antigen test for Influenza A&B negative and pt returned to isolation precautions. The pt will be kept in MICU-B overnight for initiation of Bipap positive pressure ventilation therapy this evening.\n\nCV: Hemodynamically stable and afebrile. NSR c rare VEA. Pt s c/o CP. Repeat labs values @ 14:20 all WNL. LUE AC 20# gauge PIV and R EJ 18# gauge both patent c excellent blood return noted.\n\nMS: Pleasant/cooperative/conversant/MAE/AAO times three and in NAD. Pt reports knee pain greatly diminished c addition of 800mg PO Ibuprofen dosing therapy today. Pt denies dizzyness or lightheadedness c transfer from bed to commode to ambulating short distances in room.\n\nGU: Pt net output 800ml thus far today c teams I&O goal of net negative 1 liter. The pt is currently net output nearly five liters since transfer from EW. Pt voiding on commode.\n\nSOC: No calls/visitors received thus far today. The pt is a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-01-26 00:00:00.000",
"description": "Report",
"row_id": 1585344,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT ALERT AND ORIENTED AND VERY PLEASANT. MOVES QUITE WELL FROM CHAIR TO COMMODE TO BED. C/O KNEE PAIN AND WAS MEDICATED WITH 800MG IBUPROFEN.\n\nRESP: PT ON 36%HIGH FLOW MASK AND MAINTAINED O2 SAT'S IN THE HIGH 90'S. AT BED TIME PT WENT ON BIPAP AND WAS ABLE TO SLEEP COMFORTABLY FOR SEVERAL HOURS. PT RECEIVING TOLERATING WELL AND BACK ON AEROSOL MASK AT 36/%.\n\nCV: NSR NO ECTOPY. BP WITHIN NORMAL LIMITS. AFEBRILE.\n\nGI: PT TAKING SIPS OF WATER/ICE CHIPS. ABD OBESE, GOOD BOWEL SOUNDS, NO STOOL.\n\nGU: PT USES COMMODE TO VOID. HAS NOT VOIDED SINCE BEFORE GOING TO BED LAST NIGHT.\n\nSKIN: NO ISSUES.\n\nACCESS: PT HAS RIGHT EJ, AND LEFT ANTECUB. BOTH PATENT.\n\nSOCIAL: FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-01-24 00:00:00.000",
"description": "Report",
"row_id": 1585340,
"text": "Nursing Progress Note.\n\nRESP: Pt received on 100% NRB c nl sats/RR/resp effort this AM. Pt c exp wheezing appreciated this AM while in bed, which improved s/p nebs/OOB to chair. Pt c bibasilar crackles appreciated by team this AM. IV 40mg Furosemide dosing in place v pt currently net output 3 liters today. Pt has fairly clear BS in upper lobes and diminished BS @ bases @ this time. FiO2 successfully weaned down over the coarse of the day, now resting comfortably c sats in the mid-90's and a nl RR c no SOB/dyspnea on 40% FiO2 hi-flow mask. Pt able to communicate in full sentences all day s SOB. Pt also able to transfer out of bed to chair to commode s assistance s c/o SOB/dyspnea. Pt reports resp fxn greatly improved s/p Lasix therapy. Pt placed on droplet precautions 2nd URI sx that mostly subsided one week ago, a nasal viral swab was subsequently sent for analysis today(resultsare currently pending). Team to assess whether pt has OSA tonight and may initiate BiPap if needed.\n\nCV: Hemodynamically stable and afebrile. NSR c no ectopy. Heparin gtt in place, rate decreased by 300units/hr @ noontime 2nd PTT value of 103 per Heparin infusion nomogram. Next PTT to be drawn/sent @ 18:00 and will calibrate infusion rate as needed. Trace pitting LE edema noted. R EJ 18 gauge PIV and a L AC PIV are in place for IV therapy. Pt has very poor peripheral access, placement of a double lumen PIC placement broached c team. Elevated FS value of 153 @ lunchtime discussed c team, RISS order set subsequently placed. EKG obtained @ BS this AM and provided to team. BS Echo also performed @ BS today, results are currently pending. Team to discuss pts case c Cardiology to eval whether she would be a good candidate for angiography to r/o PE and assess pulm fxn. Please see STAT med sheet for KCL & Magnesium Sulfate repletion data.\n\nMS: Pleasant, cooperative, conversant, AAO times three, MAE in NAD. Pt reports feeling much better now than @ time of admission s/p diuresis of nearly five liters. Pt denies all forms &/or types of pain. Pt OOB to chair/commode c supervision only.\n\nGI: Pt had a good breakfast this AM but was made NPO before lunchtime pending possible angio imaging study. Pt able to take PO meds s diff.\n\nGU: 40mg IV Lasix therapy in place c pt currently net output 3.0 liters today. She is approx 5 liters net output since admit to -ER. Urine is clear, yellow and dilute.\n\nSOC: No calls/visitors received thus far today. The pt is a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments. Droplet isolation precautions in place until pt negative for H.Flu.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-01-25 00:00:00.000",
"description": "Report",
"row_id": 1585341,
"text": "NEURO: ALERT AND ORIENTED TO TIME, PLACE AND EVENTS. MAE, FOLLOWS COMMANDS. PLEASANT AND COOPERATIVE.\n\nPULM: 50% FACE MASK, SATS 96-99%, DESATS QUICKLY TO 75 WHEN OFF 02. SHALLOW RESPIRATIONS WHEN ASLEEP WITH DROP IN SATS TO 87% AT TIMES WITH MASK ON. LUNGS DIMISHED IN BASES, FAINT EXPIRATORY WHEEZE AT TIMES. STRONG COUGH EFFORT. DROPLET PRECAUTIONS FOR ? INFLUENZA. OOB IN CHAIR MOST OF SHIFT FOR OPTIMAL LUNG EXPANSION. MOVES WELL INDEPENDENTLY.\n\nCV: NSR WITHOUT ECTOPY. PROPER LEAD PLACEMENT DIFFICULT D/T SIZE. SEE CAREVUE FOR Q1H VS. HEPARIN GTT AT 2250 UNITS/HR, LAST PTT ~98. REPEAT PTT AT 0500. POOR VENOUS ACCESS D/T SIZE. HEPARIN GTT VIA REJ LINE. PALPABLE PEDAL PULSES.\n\nENDO: AC AND HS FSBS. HS BS 103, NO RX.\n\nGI: TOLERATING LIQUIDS. ABDOMEN OBESE, SOFT, + BOWEL SOUNDS.\n\nGU: OOB TO COMMODE TO VOID. GOOD RESPONSE TO LASIX IV AT .\n\nSOCIAL: NO VISITORS OR PHONE CALLS.\n\nPLAN: AGGRESSIVE PULM HYGIENE. NEB RX AS ORDERED AND PRN WHEEZING. CONTINUE HEPARIN GTT PER SLIDING SALE ORDER TO EMPIRICALLY RX FOR PULM EMBOLUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-01-25 00:00:00.000",
"description": "Report",
"row_id": 1585342,
"text": "Resp Care\n\nPt receiving albuterol/atrovnet neb q4. Tolerated well. Remains pm 40% high flow neb. Bs generally diminished but with occasional scatter wheezing\n"
},
{
"category": "Echo",
"chartdate": "2183-01-24 00:00:00.000",
"description": "Report",
"row_id": 79077,
"text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath.\nHeight: (in) 65\nWeight (lb): 450\nBSA (m2): 2.79 m2\nBP (mm Hg): 117/55\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 14:00\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: Moderately dilated RA. Dynamic interatrial\nseptum.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%).\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor apical views.\n\nConclusions:\nTechnically difficult study. Limited views obtained.\n\n1. The left atrium is mildly dilated.\n2.The right atrium is moderately dilated.\n3. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Overall left ventricular systolic function is probably normal\n(LVEF>55%). No wall motion abnormalities seen but the views are limited.\n4.The aortic valve is not well seen. No aoritic regurgitation seen.\n5.The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n6.There is no pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-01-25 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 857951,
"text": " 11:22 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: PE?\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with dyspnea, hypoxia, cough, bilateral opacities on CXR,\n unclear etiology, AFEBRILE. Assess for PE vs. Pneumonia\n REASON FOR THIS EXAMINATION:\n PE?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 58-year-old female with dyspnea, hypoxia, and cough.\n\n TECHNIQUE: Multidetector CT images of the chest were obtained prior to and\n following the administration of 150 cc of Optiray. Nonionic contrast was used\n due to rapid bolus infusion required for the CTA technique.\n\n Coronal and sagittal reformations were created.\n\n COMPARISON: Unavailable.\n\n CT CHEST W/O & W/IV CONTRAST: This examination is technically suboptimal due\n to patient body habitus. Allowing for this, the opacified pulmonary arterial\n tree does not demonstrate any filling defects indicative of a central or\n segmental pulmonary embolus. The heart, great vessels, and paracardium appear\n grossly normal. Assessment of lung fields reveals no concerning areas of\n parenchymal opacification. There are minor dependent atelectatic changes. No\n pleural effusions are identified. The airways are patent to the level of the\n subsegmental bronchi bilaterally.\n\n The imaged portions of the upper abdomen reveal no gross abnormalities. The\n osseous structures are notable for multilevel degenerative changes of the\n thoracic spine.\n\n Sagittal and coronal images were reviewed and confirm the above findings.\n\n IMPRESSION: No evidence of pulmonary embolism or pneumonia in this\n technically suboptimal study.\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-01-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 857763,
"text": " 5:44 PM\n CHEST (PA & LAT) Clip # \n Reason: assess for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with fever cough\n REASON FOR THIS EXAMINATION:\n assess for pneumonia\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Fever and cough. Assess for pneumonia.\n\n COMPARISON: No prior studies are available for comparison.\n\n Upright AP and lateral chest performed at the bedside: The patient has a\n large body habitus. The heart is probably enlarged, in spite of technique.\n The mediastinum is not well evaluated, though the contour of the aortic knob\n is within normal limits. There is patchy opacity involving both lungs\n throughout consistent with congestive failure. A superimposed pneumonia cannot\n be excluded. There is likely bilateral effusions.\n\n IMPRESSION:\n\n Evidence of congestive failure. Superimposed pneumonia not excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-01-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 857802,
"text": " 3:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: compare with prior\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with fever cough\n\n REASON FOR THIS EXAMINATION:\n compare with prior\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever and cough.\n\n COMPARISON: at 17:53.\n\n AP UPRIGHT VIEW OF THE CHEST: The study is limited by patient's body habitus.\n The heart is enlarged. Again demonstrated is perihilar haziness,\n vascular indistinctness, and patchy opacities throughout both lungs,\n consistent with congestive heart failure which is not significantly changed\n since the prior examination. Probable small bilateral pleural effusions are\n present. No pneumothorax is seen. The soft tissues and osseous structures\n are unremarkable.\n\n IMPRESSION: No significant interval change in congestive heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-01-24 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 857798,
"text": " 12:59 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: asses for DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with SOB, hypoxia\n REASON FOR THIS EXAMINATION:\n asses for DVT\n ______________________________________________________________________________\n WET READ: DFDdp FRI 4:20 AM\n\n no dvt in bilateral lower ext.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath and hypoxia.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: scale, color, and Doppler\n son of both common femoral, both superficial femoral, and both popliteal\n veins were performed. Normal color flow, compressibility, wave forms, and\n augmentation were demonstrated in all these veins. No intraluminal thrombus\n was present.\n\n IMPRESSION: No evidence of deep venous thrombosis in the lower extremities\n bilaterally.\n\n"
},
{
"category": "ECG",
"chartdate": "2183-01-24 00:00:00.000",
"description": "Report",
"row_id": 191603,
"text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing\nof probably no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2183-01-23 00:00:00.000",
"description": "Report",
"row_id": 191604,
"text": "Sinus rhythm. Non-specific ST-T wave changes. Consider myocardial ischemia. No\nprevious tracing available for comparison.\nTRACING #1\n\n"
}
] |
43,322 | 110,565 | He was admitted to the Trauma service. Orthopedics was consulted and he was taken to the operating room for intramedullary nail left femur and closed treatment of pelvic ring fracture with manipulation. His metatarsal fracture was managed non operatively. On he was noted with tachypnea/dyspnea and drop in his hematocrit; a CTA of his chest was done which was positive for PE. He was started on a heparin drip and transferred to the Trauma ICU. He was later started on Coumadin and the Heparin drip was stopped. His last INR on was 2.7 (Goal INR ). He required multiple blood transfusions during his hospital course due to acute blood loss from his injuries. His last hematocrit was 25 on . On he was taken back to the operating room by Orthopedics for open reduction and internal fixation, unstable ring, with orthogonal plate; an IVC filter was placed at that time by Trauma surgery. He was noted to complain of left shoulder pain and underwent an MRI which showed a partial thickness intrasubstance tear of the infraspinatus at the myotendinous junction and no full-thickness rotator cuff tears. This will be re-evaluated at his follow up orthopedic appointment. He was eventually transferred back to the regular nursing unit. His pain was controlled using IV narcotics initially and then he was changed to oral narcotics prn with adequate control. He is on an aggressive bowel regimen and is moving his bowels. Physical and Occupational therapy were consulted and have recommended rehab after his acute hospital stay. | Albuterol 0.083% Neb Soln 7. Albuterol 0.083% Neb Soln 7. Albuterol 0.083% Neb Soln 7. Pt noted to have: R femur fx, R acetabular frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx, T7-10 SP frx, right ribs frx. edu re: Role of PT, , WB status, therex, ROM, RN comm re: pt. edu re: Role of PT, , WB status, therex, ROM, RN comm re: pt. Metoprolol Tartrate 23. Metoprolol Tartrate 23. infiltrate on CT chest vs. consolidatioin around PE, abx started for hosp. cont heparin gtt. cont heparin gtt. Pt noted to have: R femur fx, R acetabular frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx, T7-10 SP frx, right ribs frx Chief complaint: s/p trauma PMHx: PMH:PMH: HTN, GERD PSH: : HCTZ, omeprazole, ASA Pulmonary Embolism (PE), Acute Assessment: Pt on heparin gtt at 1650units/hr. developed SOB and tachycardia found to have PE. developed SOB and tachycardia found to have PE. Lidocaine 1% 21. Lidocaine 1% 21. R Knee ROM 0-90 deg. R Knee ROM 0-90 deg. Pt noted to have: R femur fx, R acetabular frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx, T7-10 SP frx, right ribs frx Chief complaint: pain PMHx: HTN, GERD Current medications: 1. Rising troponins secondary to demand ischemia and right ventricular strain, no h/x of CAD, MI, currently on heparin gtt for PE. 02 sats mid /high 90's on non-rebreather, will titrate down to nasal cannula if possible. 02 sats mid /high 90's on non-rebreather, will titrate down to nasal cannula if possible. Ipratropium Bromide Neb 17. Pt noted to have: R femur fx, R acetabular frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx, T7-10 SP frx, right ribs frx Chief complaint: s/p trauma PMHx: PMH:PMH: HTN, GERD PSH: : HCTZ, omeprazole, ASA Pulmonary Embolism (PE), Acute Assessment: -On 5L NC with O2 sats 96-100% (will immediately desat to 80s on room air) -Lungs clear and diminished bibasilar, strong (occasionally) productive cough -low grade temp 100 max -PTT subtheraputic on 1450 u/hr Action: -IS and C/DB encouraged -heparin gtt increased to 1650u/hr -vanco, cipro, and cefapime for presumed pneumonia -tylenol atc Response: -resp status stable continues on course of abx for pna -PTT therapeutic on 1650 u/hr Heparin -reaches 750 on IS Plan: -Goal PTT >55 -wean supplemental O2 as tolerated -f/u am CXR -f/u cxs from Pain control (acute pain, chronic pain) Assessment: -Reports pain in both LEs (L>R) as achey at rest . Negative for CAD, MI, currently on heparin gtt for PE. Albuterol 0.083% Neb Soln 7. Pt noted to have: R femur fx, R acetabular frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx, T7-10 SP frx, right ribs frx Chief complaint: s/p trauma PMHx: PMH:PMH: HTN, GERD PSH: : HCTZ, omeprazole, ASA Pt noted to have: R femur fx, R acetabular frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx, T7-10 SP frx, right ribs frx. Pt noted to have: R femur fx, R acetabular frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx, T7-10 SP frx, right ribs frx Chief complaint: pain PMHx: HTN, GERD Current medications: 1. Pt noted to have: R femur fx, R acetabular frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx, T7-10 SP frx, right ribs frx Chief complaint: s/p trauma PMHx: PMH:PMH: HTN, GERD PSH: : HCTZ, omeprazole, ASA Pulmonary Embolism (PE), Acute Assessment: Pt on heparin gtt at 1650units/hr. Pt noted to have: R femur fx, R acetabular frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx, T7-10 SP frx, right ribs frx Chief complaint: s/p trauma PMHx: PMH:PMH: HTN, GERD PSH: : HCTZ, omeprazole, ASA Pulmonary Embolism (PE), Acute Assessment: Pt on heparin gtt at 1650units/hr. Sinus tachycardia, rate 128. TITLE: 58M MCC driver denies LOC. TITLE: 58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx, T7-10 SP frx, right ribs frx Chief complaint: s/p trauma PMHx: PMH:PMH: HTN, GERD PSH: : HCTZ, omeprazole, ASA Pulmonary Embolism (PE), Acute Assessment: -On 5L NC with O2 sats 97-100% (will immediately desat to 80s on room air) -Lungs clear and diminished bibasilar, strong (occasionally) productive cough -afebrile -PTT subtheraputic on 1450 u/hr Action: -IS and C/DB encouraged -heparin gtt increased to 1650u/hr -vanco, cipro, and cefapime for presumed pneumonia Response: -resp status stable continues on course of abx for pna Plan: -Goal PTT >55 -wean supplemental O2 as tolerated -f/u am CXR Pain control (acute pain, chronic pain) Assessment: -Reports pain in both LEs (L<R) as achey at rest , and pain becomes sharp with turning and dressing changes Action: Response: Plan: Comminuted left femoral diaphyseal fracture. Left femoral head gamma nail is incompletely imaged. Right lower lobe is probably still collapsed and there is an indeterminate but no larger than moderate right pleural effusion. There is an equivocal joint effusion, minimal degenerative spurring, and possible posterior tibial cyst. The heart and the great vessels appear unremarkable, except for some atherosclerotic calcifications of the coronary arteries. Suspected fracture of the right acetabulum. IMPRESSION: Non-displaced fracture of the right second metatarsal. FINDINGS: Since the previous study,the moderate right pleural effusion is unchanged with fluid in the right horizontal fissure and right lower lobe atelectasis. OSSEOUS FINDINGS: Note is made of a fracture at the right acetabulum with a small ossific fragment appearing is a loose body within the joint space. CT CHEST WITHOUT IV CONTRAST: Airways are patent up to the subsegmental levels bilaterally. There is a comminuted fracture in the mid shaft of the left femur incompletely demonstrated on these views. Right jugular line ends in the mid SVC. Mild degenerative changes are present at the first MTP joint, with subchondral sclerosis and osteophytes. Partial thickness intrasubstance tear of the infraspinatus at the myotendinous junction. indeterminate small to moderate right pleural effusion. Mild-to-moderate acromioclavicular osteoarthritis with proliferative change and subchondral cyst formation is noted. CT PELVIS WITHOUT CONTRAST: The bladder is decompressed, with a Foley in situ. Adjacent right lower lobe atelectasis and minimal atelectasis of the left lung base. In the foot, there is a nondisplaced fracture through the proximal shaft of the second metatarsal. Note is made of mild degenerative change at the hip joints bilaterally with subchondral sclerosis and osteophyte formation. FINAL REPORT HISTORY: Bilateral lower extremity edema status post lower extremity trauma with left lower extremity fractures. Small right pleural effusion with Hounsfield units 20, cannot exclude a hemothorax. OSSEOUS STRUCTURES AND SOFT TISSUES: Again noted is fracture of the right acetabulum with a bony fragment noted in the joint space and another fragment noted antero inferior tho the femoral head . | 49 | [
{
"category": "Nursing",
"chartdate": "2170-09-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 694132,
"text": "TITLE:\n Pulmonary Embolism (PE), Acute\n Assessment:\n -(+) PE in R upper/ middle lobe and subsegmental pulmonary arteries per\n CTA obtained yesterday evening prior to TSICU adm.\n -received with O2 sats in 60\ns, PaO2 45\n Action:\n -Hep gtt started at 1300 u/hr\n -IS teaching and C/DB encouraged\n -LENIs obtained\n -placed on NRB/ABGs monitored\n -cardiac enzymes cycled-initial trop 0.10\n Response:\n -PTT sub therapeutic so Heparin increased to 1450 u/hr\n -O2 sats 100%, PAo2 now 167.\n -Mentating appropriately\n -LENIs neg.\n Plan:\n -Repeat PTT at 0800 (goal 60-80)\n -ASA daily\n -venodynes\n -last set of cardiac enzymes due at this afternoon.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n -Received from floor with hct 18\n -tachy up to , no ectopy\n Action:\n -4 units of PRBCs transfused\n -seriel hcts obtained\n Response:\n -hct 25.5 after 4 units RBCs\n -HR 90\ns NSR , BP stable.\n Plan:\n -repeat hct 24/ ? transfuse additional units\n -? CT to determine source of bleeding\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n -febrile up to 102.3\n -WBC 11\n Action:\n -vanco/ cefipime/ cipro initiated\n -2 sets of blood cxs and sputum sent\n -anti pyretic measures-fan, cool bath, tylenol provided\n Response:\n -temp down to 98.7 after midnight\n Plan:\n -f/u cxs\n -continue course of abx\n Pain control (acute pain, chronic pain)\n Assessment:\n -describes\nsharp gassy pain\n in abd as a . Also experiences\n sharp pain in both LE\ns during turns as .\n Action:\n -Dilaudid PCA 0.25/6/2.5 explained and provided to pt\n -Tylenol Q8\n Response:\n -pt reports pain is\nwell controlled\n Plan:\n -consider longer acting PO analgesia once diet is resumed\n -Continue Dilaudid PCA\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 694137,
"text": "TITLE:\n Pulmonary Embolism (PE), Acute\n Assessment:\n -(+) PE in R upper/ middle lobe and subsegmental pulmonary arteries per\n CTA obtained yesterday . R pleural effusion/? Hemothorax evening prior\n to TSICU adm.\n -received with O2 sats in 60\ns, PaO2 45\n Action:\n -Hep gtt started at 1300 u/hr\n -IS teaching and C/DB encouraged\n -LENIs obtained\n -placed on NRB/ABGs monitored\n -cardiac enzymes cycled-initial trop 0.10\n Response:\n -PTT sub therapeutic so Heparin increased to 1450 u/hr\n -O2 sats 100%, PAo2 now 167.\n -Mentating appropriately\n -LENIs neg.\n Plan:\n -Repeat PTT at 0800 (goal 60-80)\n -ASA daily\n -venodynes\n -last set of cardiac enzymes due at this afternoon.\n -repeat CXR this am\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n -Received from floor with hct 18\n -tachy up to , no ectopy\n Action:\n -4 units of PRBCs transfused\n -seriel hcts obtained\n Response:\n -hct 25.5 after 4 units RBCs\n -HR 90\ns NSR , BP stable.\n Plan:\n -repeat hct 24/ ? transfuse additional units\n -? CT to determine source of bleeding\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n -febrile up to 102.3\n -WBC 11\n Action:\n -vanco/ cefipime/ cipro initiated\n -2 sets of blood cxs and sputum sent\n -anti pyretic measures-fan, cool bath, tylenol provided\n Response:\n -temp down to 98.7 after midnight\n Plan:\n -f/u cxs\n -continue course of abx\n Pain control (acute pain, chronic pain)\n Assessment:\n -describes\nsharp gassy pain\n in abd as a . Also experiences\n sharp pain in both LE\ns during turns as .\n Action:\n -Dilaudid PCA 0.25/6/2.5 explained and provided to pt\n -Tylenol Q8\n -Repositoned to promote comfort\n Response:\n -pt reports pain is\nwell controlled\n Plan:\n -consider longer acting PO analgesia once diet is resumed\n -Continue Dilaudid PCA\n"
},
{
"category": "Rehab Services",
"chartdate": "2170-09-20 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 694276,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: / 959.9\n Reason of referral: Eval and treat\n History of Present Illness / Subjective Complaint: Pt. is 58 y.o. male\n s/p MCC with resulting injuries: L femur fracture s/p ORIF, diastasis\n of pubic symphysis, and L SIJ, R acetabular fracure, R acetabular\n fracture, R 2nd metatarsal fracture, R rib fractures , Spinous\n process fractures T7-T10, and transverse process fractures L3-L5. While\n on the floor pt. developed SOB and tachycardia found to have PE.\n Past Medical / Surgical History: Htn, GERD\n Medications: Famotidine, HYDROmorphone PCA, Metoprolol, Labetalol ,\n Ciprofloxacin, Heparin\n Radiology: Abd CT: 1. Right acetabular and left sacroiliac fractures as\n well as the diaphysis of the pubic symphysis. In addition, there are\n numerous spinal fractures of the spinous processes and transverse\n processes as detailed above. Lastly, note is made of multiple level\n right rib fractures. 2. Small right pleural effusion. 3. Bibasilar\n atelectasis. R foot x-ray: Non-displaced fracture of the right second\n metatarsal, R femur x-ray 1. Diastasis of the pubic symphysis and both\n SI joints. 2. Suspected fracture of the right acetabulum. 3. Comminuted\n left femoral diaphyseal fracture.\n Labs:\n 24.2\n 8.2\n 112\n 7.1\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with assist, R LE: WBAT, L LE: TDWB\n Social / Occupational History: Married, lives with wife. Wife was also\n involved in MCC and sustained injuries. Works full-time, desk job.\n Step-son lives with family\n Living Environment: 2 level home, + FOS to bedroom\n Prior Functional Status / Activity Level: PTA\n Objective Test\n Arousal / Attention / Cognition / Communication: A&O x 3, and\n cooperative\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 106\n 146/76\n 26\n 96 on 5L\n Rest\n /\n Sit\n 120\n 180/78\n 30\n 88 on 5L\n Activity\n 120\n 156/78\n 30\n 88-94\n Stand\n /\n Recovery\n 108\n 134/69\n 24\n 96 on 5L\n Total distance walked:\n Minutes:\n Pulmonary Status: BS dimished throuhgout, shallow breathing pattern\n Integumentary / Vascular: R IJ line, R anterior leg dressing, foley\n catheter, L a-line, L LE bandages c/d/i\n Sensory Integrity: sensation grossly intact to LT\n Pain / Limiting Symptoms: Pain , mainly in L LE, and ant. thigh\n Posture: WNL\n Range of Motion\n Muscle Performance\n Bilat. UEs: WFL throughout, bilats. LEs: WFL except L Knee ext: 0 deg,\n flex: 70 deg\n bilat. UEs: throughout, R LE: > throughout, L hip flex: 3-/5, L\n quads: 3-/5, DF: \n Motor Function: no abnormal movement patterns noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Squat-pivot bed to chair to R with max A x2\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n T\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: S to sit EOB\n Education / Communication: Pt. edu re: Role of PT, , WB status,\n therex, ROM, RN comm re: pt. status, method of transfer\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Balance, Impaired\n 3.\n Gait, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Transfers, Impaired\n 6.\n Joint Mobility, Impaired\n Clinical impression / Prognosis: Pt. is 58 y.o. male s/p MCC with\n multiple fractures, includ L femur fx s/p ORIF and pelvic separation\n that p/w above impairments associated with fracture. Pt. appears to be\n functioning below baseline, requiring maximum assistance to maintain\n TDWB, and would benefit from continued PT. Pt. limited today by poor\n pain control and SOB. At this point recommend rehab placement upon d/c,\n but expect quick fucntionally progress based on age and PLOF.\n Goals\n Time frame: 1 week\n 1.\n supine to sit with mod A\n 2.\n sit to stand with max A\n 3.\n stand-pivot with mod A\n 4.\n Amb 5 ft with SW with mod A\n 5.\n R Knee ROM 0-90 deg.\n 6.\n Verbalize understanding of WB restrictions and HEP\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: x/wk\n Therex, ROM, transfers, gait-training with SW, dispo planning\n Nsg recs: Squat-pivot bed to chair to R with 2 assist\n Facetime: 15:50-16:30\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Rehab Services",
"chartdate": "2170-09-20 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 694277,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: / 959.9\n Reason of referral: Eval and treat\n History of Present Illness / Subjective Complaint: Pt. is 58 y.o. male\n s/p MCC with resulting injuries: L femur fracture s/p ORIF, diastasis\n of pubic symphysis, and L SIJ, R acetabular fracure, R acetabular\n fracture, R 2nd metatarsal fracture, R rib fractures , Spinous\n process fractures T7-T10, and transverse process fractures L3-L5. While\n on the floor pt. developed SOB and tachycardia found to have PE.\n Past Medical / Surgical History: Htn, GERD\n Medications: Famotidine, HYDROmorphone PCA, Metoprolol, Labetalol ,\n Ciprofloxacin, Heparin\n Radiology: Abd CT: 1. Right acetabular and left sacroiliac fractures as\n well as the diaphysis of the pubic symphysis. In addition, there are\n numerous spinal fractures of the spinous processes and transverse\n processes as detailed above. Lastly, note is made of multiple level\n right rib fractures. 2. Small right pleural effusion. 3. Bibasilar\n atelectasis. R foot x-ray: Non-displaced fracture of the right second\n metatarsal, R femur x-ray 1. Diastasis of the pubic symphysis and both\n SI joints. 2. Suspected fracture of the right acetabulum. 3. Comminuted\n left femoral diaphyseal fracture.\n Labs:\n 24.2\n 8.2\n 112\n 7.1\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with assist, R LE: WBAT, L LE: TDWB\n Social / Occupational History: Married, lives with wife. Wife was also\n involved in MCC and sustained injuries. Works full-time, desk job.\n Step-son lives with family\n Living Environment: 2 level home, + FOS to bedroom\n Prior Functional Status / Activity Level: PTA\n Objective Test\n Arousal / Attention / Cognition / Communication: A&O x 3, and\n cooperative\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 106\n 146/76\n 26\n 96 on 5L\n Rest\n /\n Sit\n 120\n 180/78\n 30\n 88 on 5L\n Activity\n 120\n 156/78\n 30\n 88-94\n Stand\n /\n Recovery\n 108\n 134/69\n 24\n 96 on 5L\n Total distance walked:\n Minutes:\n Pulmonary Status: BS dimished throuhgout, shallow breathing pattern\n Integumentary / Vascular: R IJ line, R anterior leg dressing, foley\n catheter, L a-line, L LE bandages c/d/i\n Sensory Integrity: sensation grossly intact to LT\n Pain / Limiting Symptoms: Pain , mainly in L LE, and ant. thigh\n Posture: WNL\n Range of Motion\n Muscle Performance\n Bilat. UEs: WFL throughout, bilats. LEs: WFL except L Knee ext: 0 deg,\n flex: 70 deg\n bilat. UEs: throughout, R LE: > throughout, L hip flex: 3-/5, L\n quads: 3-/5, DF: \n Motor Function: no abnormal movement patterns noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Squat-pivot bed to chair to R with max A x2\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n T\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: S to sit EOB\n Education / Communication: Pt. edu re: Role of PT, , WB status,\n therex, ROM, RN comm re: pt. status, method of transfer\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Balance, Impaired\n 3.\n Gait, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Transfers, Impaired\n 6.\n Joint Mobility, Impaired\n Clinical impression / Prognosis: Pt. is 58 y.o. male s/p MCC with\n multiple fractures, includ L femur fx s/p ORIF and pelvic separation\n that p/w above impairments associated with fracture. Pt. appears to be\n functioning below baseline, requiring maximum assistance to maintain\n TDWB, and would benefit from continued PT. Pt. limited today by poor\n pain control and SOB. At this point recommend rehab placement upon d/c,\n but expect quick fucntionally progress based on age and PLOF.\n Goals\n Time frame: 1 week\n 1.\n supine to sit with mod A\n 2.\n sit to stand with max A\n 3.\n stand-pivot with mod A\n 4.\n Amb 5 ft with SW with mod A\n 5.\n R Knee ROM 0-90 deg.\n 6.\n Verbalize understanding of WB restrictions and HEP\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: x/wk\n Therex, ROM, transfers, gait-training with SW, dispo planning\n Nsg recs: Squat-pivot bed to chair to R with 2 assist\n Facetime: 15:50-16:30\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 694255,
"text": "Pulmonary Embolism (PE), Acute\n Assessment:\n Pt on heparin gtt at 1450units/hr. PTT within goal range. 5L NC with\n sat in the mid 90s. Pt denies SOB and HR in the 90s to low 100s. LENIs\n negative from last night.\n Action:\n -Incentive spirometry encouraged, CDB\n -Heparin gtt and PTT checked every 6 hrs.\n -Trans thoracic Echo performed\n -CT of torso\n Response:\n PTT remains in goal range. TTE shows normal RV function. Pt still\n oxygenating well and denies any WOB\n Plan:\n Possible transfer to the floor. Trauma and ICU team discussed IVC\n filter and denies wanting it placed. ?Heparin gtt discontinue since pt\n has normal RV function per Dr. . Monitor Resp status and VS\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt HCt stable at 24 today. Pt HR in the 90s- low 100s. Good peripheral\n pulses and normal capillary refill.\n Action:\n -CT of torso and abdomen to look for ?active bleeding sites\n -HCt checked every 4 hrs\n Response:\n CT scan shows no areas of active bleeding and Hct remains stable.\n Plan:\n Monitor RBC count and transfuse as needed.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of some rib pain with coughing and deep breathing. With\n movement left leg pain is significant. Pain from , but pt says\n it is\ntolerable\n Action:\n -Dilaudid PCA encouraged.\n -Position changes and elevation of left leg performed\n -Physical Therapy worked with the pt and got him OOB with weight\n bearing on right and touch down on left leg\n Response:\n Pt finds relief with PCA and denies wanting any further breakthrough\n pain medication\n Plan:\n See Nursing Care Plan in Chart\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 694115,
"text": "TITLE:\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 694116,
"text": "TITLE:\n Pulmonary Embolism (PE), Acute\n Assessment:\n -(+) PE per CTA obtained yesterday evening\n -received with O2 sats in 60\ns, PaO2 45\n Action:\n -Hep gtt started at 1300 u/hr\n -IS teaching and C/DB encouraged\n -LENIs obtained\n -placed on NRB/ABGs monitored\n Response:\n -PTT sub therapeutic so Heparin increased to 1450 u/hr\n -O2 sats 100%, PAo2 also in 100s.\n -Mentating appropriately\n Plan:\n -Repeat PTT at 0800 (goal 60-80)\n -ASA daily\n -venodynes\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n -Received from floor with hct 18\n -tachy up to , no ectopy\n Action:\n -4 units of PRBCs transfused\n -seriel hcts obtained\n Response:\n -hct 25.5 after 4 units RBCs\n Plan:\n -repeat hct and ? transfuse additional units\n -? CT to determine source of bleeding\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n -febrile up to 102.3\n -WBC 11\n Action:\n -vanco/ cefipime/ cipro initiated\n -2 sets of blood cxs and sputum sent\n Response:\n -temp down to 98.7 after midnight\n Plan:\n -f/u cxs\n -continue course of abx\n Pain control (acute pain, chronic pain)\n Assessment:\n -describes\nsharp gassy pain\n in abd as a . Also experiences\n sharp pain in both LE\ns during turns as .\n Action:\n -Dilaudid PCA 0.25/6/2.5 explained and provided to pt\n -\n Response:\n -pt reports pain is\nwell controlled\n Plan:\n -consider longer acting PO analgesia once diet is resumed\n -Continue Dilaudid PCA\n"
},
{
"category": "Physician ",
"chartdate": "2170-09-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 694172,
"text": "TSICU\n HPI:\n 58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n s/p trauma\n PMHx:\n PMH:PMH: HTN, GERD\n PSH:\n : HCTZ, omeprazole, ASA\n Current medications:\n 1000 mL LR 5. Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Calcium\n Gluconate 8. CefePIME 9. CefePIME 10. Ciprofloxacin 11. Ciprofloxacin\n 12. Docusate Sodium 13. Famotidine 14. HYDROmorphone (Dilaudid)\n 15. HYDROmorphone (Dilaudid) 16. HYDROmorphone (Dilaudid) 17. Heparin\n 18. Insulin 19. Ipratropium Bromide Neb 20. Lidocaine 1% 21. Magnesium\n Sulfate 22. Metoprolol Tartrate 23. Ondansetron 24. Potassium Chloride\n 25. Potassium Phosphate 26. Potassium Chloride 27. Senna 28. Sodium\n Chloride 0.9% Flush 29. Sodium Chloride 0.9% Flush 30. Sodium Chloride\n 0.9% Flush 31. Vancomycin 32. Vancomycin\n 24 Hour Events:\n EKG - At 07:30 PM\n ARTERIAL LINE - START 08:14 PM\n ULTRASOUND - At 09:33 PM\n MULTI LUMEN - START 11:17 PM\n FEVER - 102.9\nF - 07:01 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:50 PM\n Cefipime - 09:59 PM\n Ciprofloxacin - 10:30 PM\n Infusions:\n Heparin Sodium - 1,450 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:30 PM\n Famotidine (Pepcid) - 09:16 PM\n Other medications:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.4\nC (102.9\n T current: 37.8\nC (100\n HR: 98 (91 - 139) bpm\n BP: 153/69(95) {124/57(82) - 194/81(347)} mmHg\n RR: 19 (14 - 36) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,535 mL\n 1,047 mL\n PO:\n 50 mL\n Tube feeding:\n IV Fluid:\n 1,303 mL\n 1,029 mL\n Blood products:\n 1,033 mL\n 18 mL\n Total out:\n 2,045 mL\n 340 mL\n Urine:\n 845 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,490 mL\n 707 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SPO2: 95%\n ABG: 7.45/39/167/27/3\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : Right base)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), (Responds to: Verbal\n stimuli), Moves all extremities\n Labs / Radiology\n 159 K/uL\n 7.7 g/dL\n 117 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 106 mEq/L\n 140 mEq/L\n 24.9 %\n 11.2 K/uL\n [image002.jpg]\n 08:28 PM\n 08:34 PM\n 10:15 PM\n 11:55 PM\n 03:34 AM\n 03:47 AM\n WBC\n 11.2\n Hct\n 22.3\n 25.5\n 24.9\n Plt\n 159\n Creatinine\n 1.0\n 0.9\n Troponin T\n 0.10\n TCO2\n 29\n 27\n 28\n Glucose\n 122\n 117\n Other labs: PT / PTT / INR:13.1/43.2/1.1, CK / CK-MB / Troponin\n T:2854/8/0.10, Fibrinogen:729 mg/dL, Lactic Acid:2.0 mmol/L, Ca:7.8\n mg/dL, Mg:2.4 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE, PLEURAL EFFUSION, ACUTE, ANEMIA, ACUTE,\n SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN), FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), TRAUMA, S/P\n Assessment and Plan: NEURO: AxOx3\n Neuro checks Q:4\n Pain:Dilaudid PCA\n CVS: Tachycardia resolving with transfusion; will continue to check\n serial hcts. Rising troponins secondary to demand ischemia and right\n ventricular strain, no h/x of CAD, MI, currently on heparin gtt for PE.\n Goal 55-75.\n PULM: RUL/ML PE. 02 sats mid /high 90's on non-rebreather, will titrate\n down to nasal cannula if possible. cont heparin gtt with goal of\n 40-50. Spiking fevers, abx started, sputum cx sent. LENI's no evidence\n of DVT, c/u final read (attending read positive for PE, atalectasias,\n pleural effusion and lobe infiltrate)\n GI: clears/ADAT\n RENAL: good UOP Cr 0.9 - stable\n HEME: transfused 4 U PRBC- hct 19-25, cont q4 hour checks until\n stabilizes, transfuse prn. The reason of bleed unnecessary. We will\n send patient to CTA to establish source of bleed.\n ENDO: RISS sugars well controlled\n ID: Fevers; infiltrate on CT chest, abx started for hosp. acquired PNA;\n Vanc/Cefepime/Cipro. f/u Cultures. Mucomyst and bicarbs for renal\n protection for another CTA\n TLD: R IJ 3x, PIV x3, L rad a-line, foley\n IVF: KVO\n CONSULTS: ortho trauma, trauma\n BILLING DIAGNOSIS:\n ICU CARE:intensive\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: boots\n DVT - therapeutic heparin\n STRESS ULCER - pepcid\n VAP BUNDLE - none\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:01 PM\n Arterial Line - 08:14 PM\n 20 Gauge - 08:54 PM\n Multi Lumen - 11:17 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: none\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 34\n"
},
{
"category": "Physician ",
"chartdate": "2170-09-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 694157,
"text": "TSICU\n HPI:\n 58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n s/p trauma\n PMHx:\n PMH:PMH: HTN, GERD\n PSH:\n : HCTZ, omeprazole, ASA\n Current medications:\n 1000 mL LR 5. Acetaminophen 6. Albuterol 0.083% Neb Soln 7. Calcium\n Gluconate 8. CefePIME 9. CefePIME 10. Ciprofloxacin 11. Ciprofloxacin\n 12. Docusate Sodium 13. Famotidine 14. HYDROmorphone (Dilaudid)\n 15. HYDROmorphone (Dilaudid) 16. HYDROmorphone (Dilaudid) 17. Heparin\n 18. Insulin 19. Ipratropium Bromide Neb 20. Lidocaine 1% 21. Magnesium\n Sulfate 22. Metoprolol Tartrate 23. Ondansetron 24. Potassium Chloride\n 25. Potassium Phosphate 26. Potassium Chloride 27. Senna 28. Sodium\n Chloride 0.9% Flush 29. Sodium Chloride 0.9% Flush 30. Sodium Chloride\n 0.9% Flush 31. Vancomycin 32. Vancomycin\n 24 Hour Events:\n EKG - At 07:30 PM\n ARTERIAL LINE - START 08:14 PM\n ULTRASOUND - At 09:33 PM\n MULTI LUMEN - START 11:17 PM\n FEVER - 102.9\nF - 07:01 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:50 PM\n Cefipime - 09:59 PM\n Ciprofloxacin - 10:30 PM\n Infusions:\n Heparin Sodium - 1,450 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:30 PM\n Famotidine (Pepcid) - 09:16 PM\n Other medications:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.4\nC (102.9\n T current: 37.8\nC (100\n HR: 98 (91 - 139) bpm\n BP: 153/69(95) {124/57(82) - 194/81(347)} mmHg\n RR: 19 (14 - 36) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,535 mL\n 1,047 mL\n PO:\n 50 mL\n Tube feeding:\n IV Fluid:\n 1,303 mL\n 1,029 mL\n Blood products:\n 1,033 mL\n 18 mL\n Total out:\n 2,045 mL\n 340 mL\n Urine:\n 845 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,490 mL\n 707 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SPO2: 95%\n ABG: 7.45/39/167/27/3\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : Right base)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), (Responds to: Verbal\n stimuli), Moves all extremities\n Labs / Radiology\n 159 K/uL\n 7.7 g/dL\n 117 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 106 mEq/L\n 140 mEq/L\n 24.9 %\n 11.2 K/uL\n [image002.jpg]\n 08:28 PM\n 08:34 PM\n 10:15 PM\n 11:55 PM\n 03:34 AM\n 03:47 AM\n WBC\n 11.2\n Hct\n 22.3\n 25.5\n 24.9\n Plt\n 159\n Creatinine\n 1.0\n 0.9\n Troponin T\n 0.10\n TCO2\n 29\n 27\n 28\n Glucose\n 122\n 117\n Other labs: PT / PTT / INR:13.1/43.2/1.1, CK / CK-MB / Troponin\n T:2854/8/0.10, Fibrinogen:729 mg/dL, Lactic Acid:2.0 mmol/L, Ca:7.8\n mg/dL, Mg:2.4 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE, PLEURAL EFFUSION, ACUTE, ANEMIA, ACUTE,\n SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN), FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), TRAUMA, S/P\n Assessment and Plan: NEURO: AxOx3\n Neuro checks Q:4\n Pain:Dilaudid PCA\n CVS: Tachycardia resolving with transfusion; will continue to check\n serial hcts. Rising troponins ? demand ischemia, no hx of CAD, MI,\n currently on heparin gtt for PE. Goal 55-75.\n PULM: RUL/ML PE. 02 sats mid /high 90's on non-rebreather, will titrate\n down to nasal cannula if possible. cont heparin gtt. Spiking fevers,\n abx started, sputum cx sent. LENI's no evidence of DVT, c/u final read\n GI: clears/ADAT\n RENAL: good UOP Cr 0.9 - stable\n HEME: transfused 4 U PRBC- hct 19-25, cont q4 hour checks until\n stabilizes, transfuse prn\n ENDO: RISS sugars well controlled\n ID: Fevers; infiltrate on CT chest, abx started for hosp. acquired PNA;\n Vanc/Cefepime/Cipro. f/u Cx\n TLD: R IJ 3x, PIV x3, L rad a-line, foley\n IVF: LR @100\n CONSULTS: ortho trauma, trauma\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS: boots\n DVT - therapeutic heparin\n STRESS ULCER - pepcid\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: pending\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:01 PM\n Arterial Line - 08:14 PM\n 20 Gauge - 08:54 PM\n Multi Lumen - 11:17 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2170-09-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 694385,
"text": "TSICU\n HPI:\n 58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n pain\n PMHx:\n HTN, GERD\n Current medications:\n 1. 2. 3. 4. 1000 mL LR 5. Acetaminophen 6. Albuterol 0.083% Neb Soln 7.\n Calcium Gluconate 8. CefePIME\n 9. Ciprofloxacin 10. Docusate Sodium 11. Famotidine 12. HYDROmorphone\n (Dilaudid) 13. HYDROmorphone (Dilaudid)\n 14. Heparin 15. Insulin 16. Ipratropium Bromide Neb 17. Labetalol 18.\n Magnesium Sulfate 19. Metoprolol Tartrate\n 20. Ondansetron 21. Potassium Chloride 22. Potassium Phosphate 23.\n Senna 24. Sodium Chloride 0.9% Flush\n 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush 27.\n Vancomycin\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:41 PM\n Cefipime - 09:19 PM\n Ciprofloxacin - 09:49 PM\n Infusions:\n Heparin Sodium - 1,650 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:47 PM\n Hydromorphone (Dilaudid) - 03:28 AM\n Other medications:\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (101\n T current: 38.3\nC (101\n HR: 107 (86 - 110) bpm\n BP: 117/65(84) {117/62(83) - 170/85(111)} mmHg\n RR: 40 (13 - 44) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 5,213 mL\n 793 mL\n PO:\n 1,390 mL\n 200 mL\n Tube feeding:\n IV Fluid:\n 3,806 mL\n 593 mL\n Blood products:\n 18 mL\n Total out:\n 1,345 mL\n 345 mL\n Urine:\n 1,345 mL\n 345 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,868 mL\n 449 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: 7.47/37/138/26/4\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: No(t) Absent, 2+), (Pulse - Dorsalis pedis:\n Present)\n Right Extremities: (Edema: 2+), (Pulse - Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 130 K/uL\n 7.1 g/dL\n 111 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 10 mg/dL\n 107 mEq/L\n 139 mEq/L\n 20.8 %\n 5.9 K/uL\n [image002.jpg]\n 10:15 PM\n 11:55 PM\n 03:34 AM\n 03:47 AM\n 08:00 AM\n 08:36 AM\n 12:52 PM\n 08:00 PM\n 02:41 AM\n 03:38 AM\n WBC\n 7.1\n 5.9\n Hct\n 25.5\n 24.9\n 24.1\n 24.2\n 20.8\n Plt\n 112\n 130\n Creatinine\n 0.9\n 1.0\n 0.8\n Troponin T\n 0.25\n 0.17\n TCO2\n 27\n 28\n 28\n Glucose\n 117\n 121\n 122\n 122\n 111\n Other labs: PT / PTT / INR:12.7/67.5/1.1, CK / CK-MB / Troponin\n T:/0.17, Fibrinogen:729 mg/dL, Lactic Acid:2.0 mmol/L, Ca:7.1\n mg/dL, Mg:2.0 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, BALANCE, IMPAIRED, GAIT,\n IMPAIRED, KNOWLEDGE, IMPAIRED, TRANSFERS, IMPAIRED, JOINT MOBILITY,\n IMPAIRED, PULMONARY EMBOLISM (PE), ACUTE, PLEURAL EFFUSION, ACUTE,\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), TRAUMA, S/P\n Assessment and Plan: 58M MCC driver denies LOC. Pt noted to have: R\n femur fx, R acetabular frx, L sacroiliac frx, diastasis of pubic\n symphysis, L L3-5 TP frx, T7-10 SP frx, right ribs frx. tx to icu\n for decreasing hct, sats, PE\n Neurologic: Neuro checks Q: 4 hr, AxOx3\n Neuro checks Q:4\n Pain:Dilaudid PCA, comfortable\n Cardiovascular: Full anticoagulation, Tachycardia resolved with\n transfusion; will continue to check serial hcts. Rising troponins ?\n demand ischemia but trended back down this am, no hx of CAD, MI,\n currently on heparin gtt for PE. Goal 55-75. rechecking ce in am.\n -echo w/o e/o RV strain\n Pulmonary: RUL/ML PE. 02 sats high 90s on nc. cont heparin gtt.\n Spiking fevers, abx started, sputum cx sent but unusable. LENI's no\n evidence of DVT, c/u final read\n Gastrointestinal / Abdomen: clears/ADAT\n Nutrition: Advance diet as tolerated\n Renal: good UOP Cr 0.9 - stable\n Hematology: transfused 4 U PRBC - hct stable at 24 all day,\n dropped to 20.8 this am, will transfuse 1 unit & now check \n Endocrine: RISS sugars well controlled\n Infectious Disease: AF, had fevers , ? infiltrate on CT chest vs.\n consolidatioin around PE, abx started for hosp. acquired PNA;\n Vanc/Cefepime/Cipro. f/u Cx\n Lines / Tubes / Drains: R IJ 3x, PIV x3, L rad a-line, foley\n Wounds:\n Imaging:\n Fluids: LR 50\n Consults: Trauma surgery, Ortho\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:01 PM\n Arterial Line - 08:14 PM\n Multi Lumen - 11:17 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\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:\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 694370,
"text": "TITLE:\n 58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n s/p trauma\n PMHx:\n PMH:PMH: HTN, GERD\n PSH:\n : HCTZ, omeprazole, ASA\n Pulmonary Embolism (PE), Acute\n Assessment:\n -On 5L NC with O2 sats 96-100% (will immediately desat to 80\ns on room\n air)\n -Lungs clear and diminished bibasilar, strong (occasionally) productive\n cough\n -low grade temp 100 max\n -PTT subtheraputic on 1450 u/hr\n -HR 80\ns-110 (with turning) NSR/ST\n Action:\n -IS and C/DB encouraged\n -heparin gtt increased to 1650u/hr\n -vanco, cipro, and cefapime for presumed pneumonia\n -tylenol atc\n Response:\n -resp status stable continues on course of abx for pna\n -PTT therapeutic at 67.5.\n -reaches 750 on IS\n Plan:\n -Goal PTT >55\n -Next PTT due at 0900\n -wean supplemental O2 as tolerated\n -f/u am CXR\n -f/u cxs from \n Pain control (acute pain, chronic pain)\n Assessment:\n -Reports pain in both LE\ns (L>R) as achey at rest . Pain becomes\n sharp with turning and dressing changes up to an on pain scale.\n Also reports occasional\ngas pain\n in abd. + flatus.\n -Hyperdynamic to 180\ns systolic with movement or while guests visiting\n Action:\n -Dilaudid PCA at 0.25/6/2.5\n -on bowel regimen\n -deep breathing encouraged during turns/care\n Response:\n -pt reports that pain is controlled fairly well though says that\n turning in bed isn\nt becoming easier as he would have though and that\n it feels almost more painful than in previous days.\n Plan:\n -Consider starting pt on PO Dilaudid now that he is taking full liquids\n -encourage ROM/repositioning/PT following\n Nursing care plan for additionall measure\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n -Hct down to 20 from 24, plts 130\n -Good cap refill/CSM in both LE\n Action:\n -1 unit or PRBCs transfused\n Response:\n -unknown source of bleeding\n Plan:\n -consider monitoring hcts Q6?\n -transfuse as indicated\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-21 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 694472,
"text": "58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n s/p trauma\n PMHx:\n PMH:PMH: HTN, GERD\n PSH:\n : HCTZ, omeprazole, ASA\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt on heparin gtt at 1650units/hr. PTT within goal range. 5L NC with\n sat in the mid 90s. Pt denies SOB and HR in the 80s- low 100s. LENIs\n negative yesterday. Pt drops in the mid 80s on Room air.\n Action:\n -Incentive spirometry encouraged, CDB\n -Heparin gtt changed to 1550 and PTT checked every 6 hrs.\n Response:\n PTT remains in goal range. Pt still oxygenating well and denies any\n WOB\n Plan:\n Transfer to the floor. Trauma and ICU team discussed IVC filter and\n denies wanting it placed. Monitor Resp status and VS.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt HCt dropped last night from 24 to 20. Pt HR in the 80s- low 100s.\n Good peripheral pulses and normal capillary refill.\n Action:\n -CT of torso and abdomen yesterday shows no active bleeding areas\n -HCt checked every 6 hrs\n -transfused pt with 3 units of PRBCs\n Response:\n Hct increased to 26.5 with 3 more units of blood. Old pin sites and\n wounds from ORIF on left leg has some serosanguinous oozing. Team\n feels this is the result of the Hct drop\n Plan:\n Monitor RBC count q6hr and transfuse as needed.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of some rib pain with coughing and deep breathing. With\n movement bilateral leg pain is significant. Pain from \n Action:\n -Dilaudid PCA discontinued and percocet prn order for pain management\n -Tramadol added prn\n -Position changes and elevation of left leg performed\n -Physical Therapy consulted\n Response:\n Pt resting comfortably with pain medication changes.\n Plan:\n See Nursing Care Plan in Chart\n Demographics\n Attending MD:\n E.\n Admit diagnosis:\n FEMUR FX\n Code status:\n Height:\n Admission weight:\n 109 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: DVT (RLE DVT 5 yrs ago tx with 3mos coumadin)\n GERD\n Surgery / Procedure and date: ORIF L femur\n RIJ CVL placed in TSICU\n LENI's neg\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:140\n D:83\n Temperature:\n 97.6\n Arterial BP:\n S:167\n D:78\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 110 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 2,731 mL\n 24h total out:\n 1,185 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 09:21 AM\n Potassium:\n 4.7 mEq/L\n 09:21 AM\n Chloride:\n 111 mEq/L\n 09:21 AM\n CO2:\n 25 mEq/L\n 09:21 AM\n BUN:\n 11 mg/dL\n 09:21 AM\n Creatinine:\n 0.8 mg/dL\n 09:21 AM\n Glucose:\n 143\n 02:00 PM\n Hematocrit:\n 26.5 %\n 01:23 PM\n Finger Stick Glucose:\n 107\n 02:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with: patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: CC609\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 694290,
"text": "Pulmonary Embolism (PE), Acute\n Assessment:\n Pt on heparin gtt at 1450units/hr. PTT within goal range. 5L NC with\n sat in the mid 90s. Pt denies SOB and HR in the 90s to low 100s. LENIs\n negative from last night.\n Action:\n -Incentive spirometry encouraged, CDB\n -Heparin gtt and PTT checked every 6 hrs.\n -Trans thoracic Echo performed\n -CT of torso\n Response:\n PTT remains in goal range. TTE shows normal RV function. Pt still\n oxygenating well and denies any WOB\n Plan:\n Possible transfer to the floor. Trauma and ICU team discussed IVC\n filter and denies wanting it placed. ?Heparin gtt discontinue since pt\n has normal RV function per Dr. . Monitor Resp status and VS\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt HCt stable at 24 today. Pt HR in the 90s- low 100s. Good peripheral\n pulses and normal capillary refill.\n Action:\n -CT of torso and abdomen to look for ?active bleeding sites\n -HCt checked every 4 hrs\n Response:\n CT scan shows no areas of active bleeding and Hct remains stable.\n Plan:\n Monitor RBC count and transfuse as needed.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of some rib pain with coughing and deep breathing. With\n movement left leg pain is significant. Pain from , but pt says\n it is\ntolerable\n Action:\n -Dilaudid PCA encouraged.\n -Position changes and elevation of left leg performed\n -Physical Therapy worked with the pt and got him OOB with weight\n bearing on right and touch down on left leg\n Response:\n Pt finds relief with PCA and denies wanting any further breakthrough\n pain medication\n Plan:\n See Nursing Care Plan in Chart\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 694353,
"text": "TITLE:\n 58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n s/p trauma\n PMHx:\n PMH:PMH: HTN, GERD\n PSH:\n : HCTZ, omeprazole, ASA\n Pulmonary Embolism (PE), Acute\n Assessment:\n -On 5L NC with O2 sats 96-100% (will immediately desat to 80\ns on room\n air)\n -Lungs clear and diminished bibasilar, strong (occasionally) productive\n cough\n -low grade temp 100 max\n -PTT subtheraputic on 1450 u/hr\n Action:\n -IS and C/DB encouraged\n -heparin gtt increased to 1650u/hr\n -vanco, cipro, and cefapime for presumed pneumonia\n -tylenol atc\n Response:\n -resp status stable continues on course of abx for pna\n -PTT therapeutic at 67.5.\n -reaches 750 on IS\n Plan:\n -Goal PTT >55\n -Next PTT due at 0900\n -wean supplemental O2 as tolerated\n -f/u am CXR\n -f/u cxs from \n Pain control (acute pain, chronic pain)\n Assessment:\n -Reports pain in both LE\ns (L>R) as achey at rest . Pain becomes\n sharp with turning and dressing changes up to an on pain scale.\n Also reports occasional\ngas pain\n in abd. + flatus.\n Action:\n -Dilaudid PCA at 0.25/6/2.5\n -on bowel regimen\n -deep breathing encouraged during turns/care\n Response:\n -pt reports that pain is controlled fairly well though says that\n turning in bed isn\nt becoming easier as he would have though and that\n it feels almost more painful than in previous days.\n Plan:\n -Consider starting pt on oxycodone or percocet now that he is taking\n full liquids\n -encourage ROM/repositioning/PT following\n Nursing care plan for additionall measure\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n -Hct down to 20 from 24, plts 130\n -Good cap refill/CSM in both LE\n Action:\n -\n Response:\n -unknown source of bleeding\n Plan:\n -consider monitoring hcts Q6?\n -transfuse as indicated\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 694351,
"text": "TITLE:\n 58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n s/p trauma\n PMHx:\n PMH:PMH: HTN, GERD\n PSH:\n : HCTZ, omeprazole, ASA\n Pulmonary Embolism (PE), Acute\n Assessment:\n -On 5L NC with O2 sats 96-100% (will immediately desat to 80\ns on room\n air)\n -Lungs clear and diminished bibasilar, strong (occasionally) productive\n cough\n -low grade temp 100 max\n -PTT subtheraputic on 1450 u/hr\n Action:\n -IS and C/DB encouraged\n -heparin gtt increased to 1650u/hr\n -vanco, cipro, and cefapime for presumed pneumonia\n -tylenol atc\n Response:\n -resp status stable continues on course of abx for pna\n -PTT therapeutic on 1650 u/hr Heparin\n -reaches 750 on IS\n Plan:\n -Goal PTT >55\n -wean supplemental O2 as tolerated\n -f/u am CXR\n -f/u cxs from \n Pain control (acute pain, chronic pain)\n Assessment:\n -Reports pain in both LE\ns (L>R) as achey at rest . Pain becomes\n sharp with turning and dressing changes up to an on pain scale.\n Also reports occasional\ngas pain\n in abd. + flatus.\n Action:\n -Dilaudid PCA at 0.25/6/2.5\n -on bowel regimen\n -deep breathing encouraged during turns/care\n Response:\n -pt reports that pain is controlled fairly well though says that\n turning in bed isn\nt becoming easier as he would have though and that\n it feels almost more painful than in previous days.\n Plan:\n -Consider starting pt on oxycodone or percocet now that he is taking\n full liquids\n -encourage ROM/repositioning/PT following\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n -Hct down to 20 from 24, plts 130\n Action:\n -\n Response:\n -unknown source of bleeding\n Plan:\n -consider monitoring hcts Q6?\n -transfuse as indicated\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 694356,
"text": "TITLE:\n 58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n s/p trauma\n PMHx:\n PMH:PMH: HTN, GERD\n PSH:\n : HCTZ, omeprazole, ASA\n Pulmonary Embolism (PE), Acute\n Assessment:\n -On 5L NC with O2 sats 96-100% (will immediately desat to 80\ns on room\n air)\n -Lungs clear and diminished bibasilar, strong (occasionally) productive\n cough\n -low grade temp 100 max\n -PTT subtheraputic on 1450 u/hr\n -HR 80\ns-110 (with turning) NSR/ST\n Action:\n -IS and C/DB encouraged\n -heparin gtt increased to 1650u/hr\n -vanco, cipro, and cefapime for presumed pneumonia\n -tylenol atc\n Response:\n -resp status stable continues on course of abx for pna\n -PTT therapeutic at 67.5.\n -reaches 750 on IS\n Plan:\n -Goal PTT >55\n -Next PTT due at 0900\n -wean supplemental O2 as tolerated\n -f/u am CXR\n -f/u cxs from \n Pain control (acute pain, chronic pain)\n Assessment:\n -Reports pain in both LE\ns (L>R) as achey at rest . Pain becomes\n sharp with turning and dressing changes up to an on pain scale.\n Also reports occasional\ngas pain\n in abd. + flatus.\n -Hyperdynamic to 180\ns systolic with movement or while guests visiting\n Action:\n -Dilaudid PCA at 0.25/6/2.5\n -on bowel regimen\n -deep breathing encouraged during turns/care\n Response:\n -pt reports that pain is controlled fairly well though says that\n turning in bed isn\nt becoming easier as he would have though and that\n it feels almost more painful than in previous days.\n Plan:\n -Consider starting pt on oxycodone or percocet now that he is taking\n full liquids\n -encourage ROM/repositioning/PT following\n Nursing care plan for additionall measure\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n -Hct down to 20 from 24, plts 130\n -Good cap refill/CSM in both LE\n Action:\n -\n Response:\n -unknown source of bleeding\n Plan:\n -consider monitoring hcts Q6?\n -transfuse as indicated\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 694360,
"text": "TITLE:\n 58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n s/p trauma\n PMHx:\n PMH:PMH: HTN, GERD\n PSH:\n : HCTZ, omeprazole, ASA\n Pulmonary Embolism (PE), Acute\n Assessment:\n -On 5L NC with O2 sats 96-100% (will immediately desat to 80\ns on room\n air)\n -Lungs clear and diminished bibasilar, strong (occasionally) productive\n cough\n -low grade temp 100 max\n -PTT subtheraputic on 1450 u/hr\n -HR 80\ns-110 (with turning) NSR/ST\n Action:\n -IS and C/DB encouraged\n -heparin gtt increased to 1650u/hr\n -vanco, cipro, and cefapime for presumed pneumonia\n -tylenol atc\n Response:\n -resp status stable continues on course of abx for pna\n -PTT therapeutic at 67.5.\n -reaches 750 on IS\n Plan:\n -Goal PTT >55\n -Next PTT due at 0900\n -wean supplemental O2 as tolerated\n -f/u am CXR\n -f/u cxs from \n Pain control (acute pain, chronic pain)\n Assessment:\n -Reports pain in both LE\ns (L>R) as achey at rest . Pain becomes\n sharp with turning and dressing changes up to an on pain scale.\n Also reports occasional\ngas pain\n in abd. + flatus.\n -Hyperdynamic to 180\ns systolic with movement or while guests visiting\n Action:\n -Dilaudid PCA at 0.25/6/2.5\n -on bowel regimen\n -deep breathing encouraged during turns/care\n Response:\n -pt reports that pain is controlled fairly well though says that\n turning in bed isn\nt becoming easier as he would have though and that\n it feels almost more painful than in previous days.\n Plan:\n -Consider starting pt on PO Dilaudid now that he is taking full liquids\n -encourage ROM/repositioning/PT following\n Nursing care plan for additionall measure\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n -Hct down to 20 from 24, plts 130\n -Good cap refill/CSM in both LE\n Action:\n -\n Response:\n -unknown source of bleeding\n Plan:\n -consider monitoring hcts Q6?\n -transfuse as indicated\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-21 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 694420,
"text": "58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n s/p trauma\n PMHx:\n PMH:PMH: HTN, GERD\n PSH:\n : HCTZ, omeprazole, ASA\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-21 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 694421,
"text": "58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n s/p trauma\n PMHx:\n PMH:PMH: HTN, GERD\n PSH:\n : HCTZ, omeprazole, ASA\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt on heparin gtt at 1650units/hr. PTT within goal range. 5L NC with\n sat in the mid 90s. Pt denies SOB and HR in the 80s- low 100s. LENIs\n negative yesterday. Pt drops in the mid 80s on Room air.\n Action:\n -Incentive spirometry encouraged, CDB\n -Heparin gtt and PTT checked every 6 hrs.\n Response:\n PTT remains in goal range. Pt still oxygenating well and denies any\n WOB\n Plan:\n Transfer to the floor. Trauma and ICU team discussed IVC filter and\n denies wanting it placed. Monitor Resp status and VS.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt HCt dropped last night from 24 to 20. Pt HR in the 80s- low 100s.\n Good peripheral pulses and normal capillary refill.\n Action:\n -CT of torso and abdomen yesterday shows no active bleeding areas\n -HCt checked every 6 hrs\n -transfused pt with one unit of PRBCs\n Response:\n Pt Hct elevated appropriately with transfusion. Old pin sites and\n wounds from ORIF on left leg has some serosanguinous oozing. Team\n feels this is the result of the Hct drop\n Plan:\n Monitor RBC count and transfuse as needed.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of some rib pain with coughing and deep breathing. With\n movement bilateral leg pain is significant. Pain from \n Action:\n -Dilaudid PCA encouraged.\n -Tramadol added prn\n -Position changes and elevation of left leg performed\n -Physical Therapy consulted\n Response:\n Pt resting comfortably with pain medication changes. ?adding long\n acting po pain meds, such as oxycodone\n Plan:\n See Nursing Care Plan in Chart\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-21 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 694446,
"text": "58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n s/p trauma\n PMHx:\n PMH:PMH: HTN, GERD\n PSH:\n : HCTZ, omeprazole, ASA\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt on heparin gtt at 1650units/hr. PTT within goal range. 5L NC with\n sat in the mid 90s. Pt denies SOB and HR in the 80s- low 100s. LENIs\n negative yesterday. Pt drops in the mid 80s on Room air.\n Action:\n -Incentive spirometry encouraged, CDB\n -Heparin gtt and PTT checked every 6 hrs.\n Response:\n PTT remains in goal range. Pt still oxygenating well and denies any\n WOB\n Plan:\n Transfer to the floor. Trauma and ICU team discussed IVC filter and\n denies wanting it placed. Monitor Resp status and VS.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt HCt dropped last night from 24 to 20. Pt HR in the 80s- low 100s.\n Good peripheral pulses and normal capillary refill.\n Action:\n -CT of torso and abdomen yesterday shows no active bleeding areas\n -HCt checked every 6 hrs\n -transfused pt with 3 units of PRBCs\n Response:\n Old pin sites and wounds from ORIF on left leg has some serosanguinous\n oozing. Team feels this is the result of the Hct drop\n Plan:\n Monitor RBC count and transfuse as needed.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of some rib pain with coughing and deep breathing. With\n movement bilateral leg pain is significant. Pain from \n Action:\n -Dilaudid PCA discontinued and percocet prn order for pain management\n -Tramadol added prn\n -Position changes and elevation of left leg performed\n -Physical Therapy consulted\n Response:\n Pt resting comfortably with pain medication changes.\n Plan:\n See Nursing Care Plan in Chart\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 694338,
"text": "TITLE:\n 58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n s/p trauma\n PMHx:\n PMH:PMH: HTN, GERD\n PSH:\n : HCTZ, omeprazole, ASA\n Pulmonary Embolism (PE), Acute\n Assessment:\n -On 5L NC with O2 sats 97-100% (will immediately desat to 80\ns on room\n air)\n -Lungs clear and diminished bibasilar, strong (occasionally) productive\n cough\n -afebrile\n -PTT subtheraputic on 1450 u/hr\n Action:\n -IS and C/DB encouraged\n -heparin gtt increased to 1650u/hr\n -vanco, cipro, and cefapime for presumed pneumonia\n Response:\n -resp status stable continues on course of abx for pna\n Plan:\n -Goal PTT >55\n -wean supplemental O2 as tolerated\n -f/u am CXR\n Pain control (acute pain, chronic pain)\n Assessment:\n -Reports pain in both LE\ns (L<R) as achey at rest , and pain\n becomes sharp with turning and dressing changes\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2170-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 694392,
"text": "TITLE:\n 58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n s/p trauma\n PMHx:\n PMH:PMH: HTN, GERD\n PSH:\n : HCTZ, omeprazole, ASA\n Pulmonary Embolism (PE), Acute\n Assessment:\n -On 5L NC with O2 sats 96-100% (will immediately desat to 80\ns on room\n air)\n -Lungs clear and diminished bibasilar, strong (occasionally) productive\n cough\n -l temp 101 max\n -PTT subtheraputic on 1450 u/hr\n -HR 80\ns-110 (with turning) NSR/ST\n Action:\n -IS and C/DB encouraged\n -heparin gtt increased to 1650u/hr\n -vanco, cipro, and cefapime for presumed pneumonia\n -tylenol atc and additional cooling measures provided\n Response:\n -resp status stable continues on course of abx for pna\n -PTT therapeutic at 67.5.\n -reaches 750 on IS\n Plan:\n -Goal PTT >55\n -Next PTT due at 0900\n -wean supplemental O2 as tolerated\n -f/u am CXR\n -f/u cxs from \n Pain control (acute pain, chronic pain)\n Assessment:\n -Reports pain in both LE\ns (L>R) as achey at rest . Pain becomes\n sharp with turning and dressing changes up to an on pain scale.\n Also reports occasional\ngas pain\n in abd. + flatus.\n -Hyperdynamic to 180\ns systolic with movement or while guests visiting\n Action:\n -Dilaudid PCA at 0.25/6/2.5\n -on bowel regimen\n -deep breathing encouraged during turns/care\n Response:\n -pt reports that pain is controlled fairly well though says that\n turning in bed isn\nt becoming easier as he would have though and that\n it feels almost more painful than in previous days.\n Plan:\n -Consider starting pt on PO Dilaudid now that he is taking full liquids\n -encourage ROM/repositioning/PT following\n Nursing care plan for additionall measure\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n -Hct down to 20 from 24, plts 130\n -Good cap refill/CSM in both LE\n Action:\n -1 unit or PRBCs to be transfused once blood is available\n Response:\n -unknown source of bleeding\n Plan:\n -consider monitoring hcts Q6?\n -transfuse as indicated\n"
},
{
"category": "Physician ",
"chartdate": "2170-09-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 694400,
"text": "TSICU\n HPI:\n 58M MCC driver denies LOC. Pt noted to have: R femur fx, R acetabular\n frx, L sacroiliac frx, diastasis of pubic symphysis, L L3-5 TP frx,\n T7-10 SP frx, right ribs frx\n Chief complaint:\n pain\n PMHx:\n HTN, GERD\n Current medications:\n 1. 2. 3. 4. 1000 mL LR 5. Acetaminophen 6. Albuterol 0.083% Neb Soln 7.\n Calcium Gluconate 8. CefePIME\n 9. Ciprofloxacin 10. Docusate Sodium 11. Famotidine 12. HYDROmorphone\n (Dilaudid) 13. HYDROmorphone (Dilaudid)\n 14. Heparin 15. Insulin 16. Ipratropium Bromide Neb 17. Labetalol 18.\n Magnesium Sulfate 19. Metoprolol Tartrate\n 20. Ondansetron 21. Potassium Chloride 22. Potassium Phosphate 23.\n Senna 24. Sodium Chloride 0.9% Flush\n 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush 27.\n Vancomycin\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:41 PM\n Cefipime - 09:19 PM\n Ciprofloxacin - 09:49 PM\n Infusions:\n Heparin Sodium - 1,650 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:47 PM\n Hydromorphone (Dilaudid) - 03:28 AM\n Other medications:\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (101\n T current: 38.3\nC (101\n HR: 107 (86 - 110) bpm\n BP: 117/65(84) {117/62(83) - 170/85(111)} mmHg\n RR: 40 (13 - 44) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 5,213 mL\n 793 mL\n PO:\n 1,390 mL\n 200 mL\n Tube feeding:\n IV Fluid:\n 3,806 mL\n 593 mL\n Blood products:\n 18 mL\n Total out:\n 1,345 mL\n 345 mL\n Urine:\n 1,345 mL\n 345 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,868 mL\n 449 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: 7.47/37/138/26/4\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: No(t) Absent, 2+), (Pulse - Dorsalis pedis:\n Present)\n Right Extremities: (Edema: 2+), (Pulse - Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 130 K/uL\n 7.1 g/dL\n 111 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 10 mg/dL\n 107 mEq/L\n 139 mEq/L\n 20.8 %\n 5.9 K/uL\n [image002.jpg]\n 10:15 PM\n 11:55 PM\n 03:34 AM\n 03:47 AM\n 08:00 AM\n 08:36 AM\n 12:52 PM\n 08:00 PM\n 02:41 AM\n 03:38 AM\n WBC\n 7.1\n 5.9\n Hct\n 25.5\n 24.9\n 24.1\n 24.2\n 20.8\n Plt\n 112\n 130\n Creatinine\n 0.9\n 1.0\n 0.8\n Troponin T\n 0.25\n 0.17\n TCO2\n 27\n 28\n 28\n Glucose\n 117\n 121\n 122\n 122\n 111\n Other labs: PT / PTT / INR:12.7/67.5/1.1, CK / CK-MB / Troponin\n T:/0.17, Fibrinogen:729 mg/dL, Lactic Acid:2.0 mmol/L, Ca:7.1\n mg/dL, Mg:2.0 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, BALANCE, IMPAIRED, GAIT,\n IMPAIRED, KNOWLEDGE, IMPAIRED, TRANSFERS, IMPAIRED, JOINT MOBILITY,\n IMPAIRED, PULMONARY EMBOLISM (PE), ACUTE, PLEURAL EFFUSION, ACUTE,\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN), FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), TRAUMA, S/P\n Assessment and Plan: 58M MCC driver denies LOC. Pt noted to have: R\n femur fx, R acetabular frx, L sacroiliac frx, diastasis of pubic\n symphysis, L L3-5 TP frx, T7-10 SP frx, right ribs frx. tx to icu\n for decreasing hct, sats, PE\n Neurologic: Neuro checks Q: 4 hr, AxOx3\n Neuro checks Q:4\n Pain:Dilaudid PCA, but not exactly comfortable. We will start Tramadol\n and Acetominophen. Pain in the legs bilateral\n we will call ortho to\n evaluate the wound. Pain is neuropathic in nature\n we will start\n Neurontin. There is also several chest wall pains secondary to PE or\n rib fracture. We are thinking of epidural tomorrow.\n Cardiovascular: Full anticoagulation, Tachycardia still present; will\n continue to check serial hcts. Rising troponins secondary to demand\n ischemia but trended back down this AM. Negative for CAD, MI,\n currently on heparin gtt for PE. Goal 55-75. rechecking ce in am.\n -echo w/o e/o RV strain\n Pulmonary: RUL/ML PE. 02 sats high 90s on nc. cont heparin gtt.\n Spiking fevers, abx started, sputum cx sent but unusable. LENI's no\n evidence of DVT, c/u final read\n Gastrointestinal / Abdomen: clears/ADAT\n Nutrition: NPO for now since awaiting IVC filter\n Renal: good UOP Cr 0.9 - stable\n Hematology: transfused 4 U PRBC - hct stable at 24 all day,\n dropped to 20.8 this am, will transfuse 1 unit & now check .\n Possible reason is PE, femur broken or sacral but no eviodence of that\n on CT. We will put IVC filter today\n Endocrine: RISS sugars well controlled\n Infectious Disease: AF, had fevers with Tmax of 101. Infiltrate on\n CT chest vs. Consolidation around PE, Abx started for hosp. acquired\n PNA; Vanc/Cefepime/Cipro for 5 days. Incentive spirometry.\n Lines / Tubes / Drains: R IJ 3x, PIV x3, L rad a-line, foley\n Wounds: clean.\n Imaging: none\n Fluids: LR 50\n Consults: Trauma surgery, Ortho\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:01 PM\n Arterial Line - 08:14 PM\n Multi Lumen - 11:17 PM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle: none\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 34min\n"
},
{
"category": "ECG",
"chartdate": "2170-09-18 00:00:00.000",
"description": "Report",
"row_id": 232379,
"text": "Sinus tachycardia. ST-T wave abnormalities are non-specific but clinical\ncorrelation is suggested. Compared to the previous tracing of the same date\nthere is probably no significant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2170-09-17 00:00:00.000",
"description": "Report",
"row_id": 232380,
"text": "Sinus tachycardia. Diffuse ST-T wave abnormalities are non-specific but cannot\nexclude myocardial ischemia. Clinical correlation is suggested. No previous\ntracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2170-09-19 00:00:00.000",
"description": "Report",
"row_id": 232377,
"text": "Sinus tachycardia, rate 128. Non-specific inferolateral repolarization\nchanges. Lead V6 is unavailable for analysis. Compared to the previous tracing\nof rate of sinus tachycardia is faster.\n\n"
},
{
"category": "ECG",
"chartdate": "2170-09-18 00:00:00.000",
"description": "Report",
"row_id": 232378,
"text": "Sinus rhythm. Modest ST-T wave changes are non-specific. Clinical correlation\nis suggested. Compared to the previous tracing of ST-T wave\nabnormalities have decreased.\nTRACING #2\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-17 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1094824,
"text": " 10:44 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: S/P MCC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p MCC, neg LOC\n REASON FOR THIS EXAMINATION:\n eval acute c-spine frx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc TUE 12:45 AM\n no fracture or traumatic malalignment.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Motorcycle collision.\n\n COMPARISON: Comparison is made to CT of the head without contrast.\n\n TECHNIQUE: Axial CT images were acquired through the cervical spine, in the\n absence of intravenous contrast. Coronal and sagittal reformatted images were\n also reviewed.\n\n FINDINGS: There is no fracture or malalignment. There is no prevertebral soft\n tissue swelling. Multilevel degenerative changes are present. At C3-4, there\n is a disc herniation which appears to exert mass effect on the spinal cord. In\n Disc/osteophyte complexes from C4-5 through C6-7 also indent the thecal\n sac, with unclear effect on the spinal cord. Multilevel neural foraminal\n narrowing is present. The imaged lung apices are unremarkable.\n\n IMPRESSION:\n 1. No fracture or malalignment.\n\n 2. Multilevel spondylosis. Disc herniation with mass effect on the spinal\n cord at C3-4, predisposing the patient to cord injury with minor trauma. If\n there is a clinical concern for acute or chronic cord injury, MRI would be\n helpful for further evaluation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1095082,
"text": " 2:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for PE, cardiopulmonary process\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p intramedullary nail left femur POD1 with SOB, tachy.\n REASON FOR THIS EXAMINATION:\n please eval for PE, cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath, first day after intramedullary\n nailing of the left femur.\n\n Portable AP chest radiograph was compared to .\n\n There is new opacity at the right lung base with some elevation of the right\n hemidiaphragm that might represent developing right lower lobe atelectasis.\n The cardiomediastinal silhouette is unchanged. There is no evidence of\n failure, although some distention of the vasculature is noted. No\n pneumothorax or appreciable pleural effusion is seen. This study does not\n confirm or exclude the possibility of pulmonary embolism, that should be\n evaluated by dedicated study if clinically suspected.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-27 00:00:00.000",
"description": "CHEST FLUORO",
"row_id": 1096307,
"text": " 1:11 PM\n CHEST FLUORO; -76 BY SAME PHYSICIAN # \n Reason: IVC FILTER\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: IVC filter.\n\n FINDINGS: Single fluoroscopic image obtained without the radiologist input\n shows placement of an IVC filter just to the right of the upper lumbar spine.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-17 00:00:00.000",
"description": "TRAUMA #3 (PORT CHEST ONLY)",
"row_id": 1094822,
"text": " 10:21 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n COMPARISON: No prior studies available for comparison.\n\n FINDINGS: Single portable AP radiograph of the chest shows the lungs to be\n clear. There is no pneumothorax. Cardiomediastinal and hilar contours are\n unremarkable. Included osseous and soft tissue structures are also\n unremarkable. Note that the image is slightly obscured by the underlying\n trauma board.\n\n IMPRESSION: No acute intrathoracic process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-29 00:00:00.000",
"description": "PELVIS (AP ONLY)",
"row_id": 1096643,
"text": " 4:37 PM\n PELVIS (AP ONLY) Clip # \n Reason: eval pelvis\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with MCC, surgical repair of fractures\n REASON FOR THIS EXAMINATION:\n eval pelvis\n ______________________________________________________________________________\n FINAL REPORT\n PELVIS FILM\n\n HISTORY: Surgical repairs of fractures.\n\n FINDINGS: This is a single frontal view of the pelvis plate and screws\n spanning the symphysis pubis. An intramedullary rod is seen spanning the mid\n shaft femur fracture. The distal fragment has two thirds of the shaft with\n displacement medially. The femur film would be needed to assess for placement\n of this intramedullary rod. The alignment is suboptimal based on this film;\n however, the entire femur is not seen. Acetabular fracture is again\n visualized on the right. Skin staples are seen in the midline.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1094823,
"text": " 10:41 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P MCC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p MCC, neg LOC\n REASON FOR THIS EXAMINATION:\n eval acute brain injury and skull frx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc TUE 12:42 AM\n no acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Motorcycle collision, no loss of consciousness.\n\n COMPARISON: Comparison is made to concurrent CT of the cervical spine.\n\n TECHNIQUE: Axial CT images were acquired through the head in the absence of\n intravenous contrast. Coronal and sagittal reformatted images were also\n reviewed.\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, or mass effect.\n The ventricles and sulci are normal in size and in configuration.\n There is no calvarial fracture. The imaged mastoid air cells and visualized\n paranasal sinuses are also unremarkable.\n\n IMPRESSION: No evidence of acute intracranial abnormalities.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-18 00:00:00.000",
"description": "LO FEMUR (AP & LAT) LEFT IN O.R.",
"row_id": 1094925,
"text": " 2:35 PM\n FEMUR (AP & LAT) LEFT IN O.R.; -76 BY SAME PHYSICIAN # \n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.\n Reason: ORIF LT FEMUR, CHECK HARDWARE AND ALIGNMENT\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MH TUE 3:31 PM\n Multiple steps related to fixation of a left femoral fracture.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left femur, check hardware and alignment.\n\n Fluoroscopic assistance provided to the surgeon in the OR without the\n radiologist present. Thirteen spot views obtained. These demonstrate steps\n related to fixation of a proximal left femoral comminuted fracture, with\n intramedullary rod and interlocking screws. Fluoro time recorded as 276.6\n seconds on the electronic requisition. Correlation with real-time findings\n exam available, conventional radiographs recommended for full assessment.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-18 00:00:00.000",
"description": "L KNEE (2 VIEWS) LEFT",
"row_id": 1094837,
"text": ", E. CC6A 1:52 AM\n KNEE (2 VIEWS) LEFT Clip # \n Reason: eval for placment\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with tibia pihn\n REASON FOR THIS EXAMINATION:\n eval for placment\n ______________________________________________________________________________\n PFI REPORT\n Fracture, mid shaft femur side, left femur. Not well demonstrated on these\n views. No knee joint effusion or fluid level seen on cross-table lateral\n views.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-19 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1095146,
"text": " 11:29 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please confirm position; ? PTX\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p R IJ CVL: placement\n REASON FOR THIS EXAMINATION:\n please confirm position; ? PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the new central venous\n access line has been placed over the right internal jugular vein. The course\n of the line is unremarkable, there is no evidence of complication, notably no\n evidence of pneumothorax. Unchanged probably atelectatic bilateral basal\n opacities. Unchanged moderate cardiomegaly with signs of minimal\n overhydration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-18 00:00:00.000",
"description": "LO FEMUR (AP & LAT) LEFT IN O.R.",
"row_id": 1094926,
"text": ", T. CC6A 2:35 PM\n FEMUR (AP & LAT) LEFT IN O.R.; -76 BY SAME PHYSICIAN # \n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.\n Reason: ORIF LT FEMUR, CHECK HARDWARE AND ALIGNMENT\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n PFI REPORT\n Multiple steps related to fixation of a left femoral fracture.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-20 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1095184,
"text": " 8:07 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: active bleeding?\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with active bleeding from orthopediuc inuries, sig crit drop,\n PE in R mainstem\n REASON FOR THIS EXAMINATION:\n active bleeding?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: To rule out active bleeding in a trauma patient now presenting\n with significant hematocrit drop.\n\n TECHNIQUE: MDCT images of the chest, abdomen and pelvis were acquired without\n administration of oral and IV contrast. Multiplanar coronal and sagittal\n reformats were generated and reviewed.\n\n COMPARISON: CT chest done on and CT abdomen done .\n\n CT CHEST WITHOUT IV CONTRAST: Airways are patent up to the subsegmental\n levels bilaterally. There is a small-to-moderate-sized right pleural effusion\n measuring around 20 Hounsfield units, stable since the prior study done\n yesterday. Again noted is adjacent compressive atelectasis in the right lower\n lobe. The left lung is clear. Also noted in the current study is minimal\n atelectasis in the left lower lobe. The heart and the great vessels appear\n unremarkable, except for some atherosclerotic calcifications of the coronary\n arteries.\n\n CT ABDOMEN WITHOUT CONTRAST: Within the limits of a non contrast study,the\n liver, the spleen, the gallbladder appear unremarkable. Minimal fatty\n infiltration of the pancreas is noted. Stomach, small bowel, and large bowel\n appear unremarkable. There is no intra- abdominal free air or free fluid.\n There is no significant retroperitoneal or mesenteric lymphadenopathy.\n\n CT PELVIS WITHOUT CONTRAST: The bladder is decompressed, with a Foley in\n situ. The distal sigmoid and rectum appear unremarkable. There is no\n significant pelvic lymphadenopathy. There is no pelvic free fluid.\n\n OSSEOUS STRUCTURES AND SOFT TISSUES: Again noted is fracture of the right\n acetabulum with a bony fragment noted in the joint space and another fragment\n noted antero inferior tho the femoral head . Again noted is a widened left\n sacroiliac joint . There is widening of the pubic symphysis now measuring 13\n mm,unchanged since prior study. Again noted is a fracture of the transverse\n process of L5, L3 and L2.Again noted are spinous process fractures visualized\n from T10 to T7. Extensive posterior rib fractures on the right side noted in\n the 7, 8, 9, 10, 11, 12 ribs. Also noted is the lateral fracture of the right\n seventh rib.\n\n (Over)\n\n 8:07 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: active bleeding?\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Also noted is the surgical fixation of the left femoral head,calcific\n densities noted posteriorly in the left gluteus muscle,likely representing\n myositis ossificans.\n\n IMPRESSION:\n 1. No significant hematoma visualized in the chest,abdomen and pelvis.\n Again noted are multiple traumatic fractures involving the right acetabulum,\n left sacroiliac joint and diastasis of the pubic symphysis. Mulitple spinal\n fractures involving the spinous process and the transverse process as\n discussed above. Multiple right-sided rib fractures.\n 2. Small right pleural effusion with Hounsfield units 20, cannot exclude a\n hemothorax. Adjacent right lower lobe atelectasis and minimal atelectasis of\n the left lung base.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-18 00:00:00.000",
"description": "L KNEE (2 VIEWS) LEFT",
"row_id": 1094836,
"text": " 1:52 AM\n KNEE (2 VIEWS) LEFT Clip # \n Reason: eval for placment\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with tibia pihn\n REASON FOR THIS EXAMINATION:\n eval for placment\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MH TUE 12:58 PM\n Fracture, mid shaft femur side, left femur. Not well demonstrated on these\n views. No knee joint effusion or fluid level seen on cross-table lateral\n views.\n ______________________________________________________________________________\n FINAL REPORT\n Hx: fx fixation\n\n LEFT KNEE, TWO VIEWS.\n\n There are mild degenerative changes of the left knee. No obvious fracture is\n identified. No effusion or fat-fluid level is detected. There is mild soft\n tissue swelling in the prepatellar soft tissues.\n\n There is a comminuted fracture in the mid shaft of the left femur\n incompletely demonstrated on these views. An external fixation device is\n present in the proximal tibia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-19 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1095107,
"text": " 4:25 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evaluate for pulmonray embolism\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p MCC, now desat. tachycardic, SOB\n REASON FOR THIS EXAMINATION:\n evaluate for pulmonray embolism\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MBue WED 5:40 PM\n pulmonary embolism involving right upper lobe subsegmental and rml segmental\n and subsegmental pulmonary arteries.\n\n rib fractures of ribs on the right.\n\n indeterminate small to moderate right pleural effusion. hemothorax cannot be\n excluded.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58-year-old man status post trauma, now with desaturations and\n tachycardia.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous helical acquisition through the chest was performed\n with intravenous contrast. Coronal, sagittal, and MIP images of the pulmonary\n arteries were obtained.\n\n FINDINGS: The heart is top normal in size. There is atherosclerotic disease\n of the coronary arteries. There is no mediastinal or hilar lymphadenopathy.\n The airway is patent.\n\n Following contrast administration, there is thrombus noted within the\n pulmonary artery supplying the right middle lobe within the segmental and\n subsegmental branches. Also noted is thrombus within the subsegmental\n branches of the right upper lobe. The remaining branches of the pulmonary\n arteries are patent. The aorta opacifies normally, without evidence of\n dissection. There is a small to moderate-sized right pleural effusion,\n measuring approximately 20 Hounsfield. There is adjacent compressive\n atelectasis. The left lung is clear. There are fractures involving the right\n posterior ribs seven through tenth.\n\n Images of the upper abdomen are unremarkable.\n\n IMPRESSION:\n\n 1. Pulmonary embolus involving the segmental and subsegmental branches\n supplying the right middle lobe and subsegmental branches of the right upper\n lobe.\n\n 2. Posterior rib fractures involving ribs seven through ten on the right.\n (Over)\n\n 4:25 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evaluate for pulmonray embolism\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Small-to-moderate right pleural effusion measuring approximately 20 Hounsfield\n units. Hemothorax cannot entirely be excluded. Adjacent airspace opacity\n likely representing compressive atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-23 00:00:00.000",
"description": "L SHOULDER 2-3 VIEWS NON TRAUMA LEFT",
"row_id": 1095675,
"text": " 3:14 PM\n SHOULDER VIEWS NON TRAUMA LEFT Clip # \n Reason: eval acute injury/frx\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with L shoulder abduction weakness\n REASON FOR THIS EXAMINATION:\n eval acute injury/frx\n ______________________________________________________________________________\n FINAL REPORT\n LEFT SHOULDER ON AT 15:28 HOURS\n\n INDICATION: Left shoulder weakness.\n\n FINDINGS:\n\n There is no evidence for acute fracture or dislocation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-18 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1094826,
"text": " 12:03 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval acute injury\n Field of view: 45 Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p MCC, neg LOC\n REASON FOR THIS EXAMINATION:\n eval acute injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc TUE 12:57 AM\n Numerous fractures involving the right acetabulum, widened pubic symphsis and\n left SI joint. Numerours spinous process and transverse process fractures and\n numerous right rib fractures.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Motorcycle collision, no loss of consciousness.\n\n COMPARISON: Comparison is made to CT of the cervical spine.\n\n TECHNIQUE: Axial CT images were acquired through the torso following\n administration of 100 cc of intravenous Visipaque contrast. Coronal and\n sagittal reformatted images were also reviewed.\n\n CT CHEST WITH CONTRAST: Airways are patent to subsegmental levels bilaterally.\n Note is made of bibasilar atelectasis, most notably on the right. There is a\n trace right pleural effusion. There is no pericardial effusion. The heart\n and great vessels are notable for atherosclerotic calcification of the\n coronary arteries and they are otherwise unremarkable. There is no\n mediastinal or axillary lymphadenopathy.\n\n CT ABDOMEN WITH CONTRAST: The stomach, proximal small bowel, spleen, pancreas,\n liver, adrenal glands, and kidneys are unremarkable. Note is made of\n vicarious excretion of contrast in the otherwise unremarkable gallbladder.\n There is no free gas or fluid in the abdomen. There is no retroperitoneal or\n mesenteric lymphadenopathy. Regional vascular structures are unremarkable.\n\n CT PELVIS WITH CONTRAST: The urinary bladder contains a Foley catheter and a\n small amount of intravesicular air is likely related to instrumentation. The\n prostate, seminal vesicles, rectum, colon, and appendix are unremarkable.\n There is no free fluid in the pelvis. There is no pelvic side sidewall or\n inguinal lymphadenopathy.\n\n OSSEOUS FINDINGS: Note is made of a fracture at the right acetabulum with a\n small ossific fragment appearing is a loose body within the joint space. In\n addition, there is slight widening at the pubic symphysis measuring\n approximately 13 mm. Lastly, there is widening of the left sacroiliac joint.\n Note is made of a left transverse process fracture at L5, L4, and L3. In\n addition, spinous process fractures are visualized from T10, T9, T8, and T7.\n Note is made of extensive right rib fractures, involving the twelfth,\n eleventh, tenth, ninth, eighth, and seventh ribs. In addition, there is a\n (Over)\n\n 12:03 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval acute injury\n Field of view: 45 Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lateral fracture of the right seventh rib (2:46). There is a small amount of\n subcutaneous gas surrounding this last fracture site. There is no\n pneumothorax.\n\n IMPRESSION:\n 1. Right acetabular and left sacroiliac fractures as well as the diaphysis of\n the pubic symphysis. In addition, there are numerous spinal fractures of the\n spinous processes and transverse processes as detailed above. Lastly, note is\n made of multiple level right rib fractures.\n 2. Small right pleural effusion.\n 3. Bibasilar atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-18 00:00:00.000",
"description": "R TIB/FIB (AP & LAT) RIGHT",
"row_id": 1094827,
"text": " 12:15 AM\n TIB/FIB (AP & LAT) RIGHT; ANKLE (AP, MORTISE & LAT) RIGHT Clip # \n FOOT AP,LAT & OBL RIGHT\n Reason: eval frx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p MCC\n REASON FOR THIS EXAMINATION:\n eval frx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Motorcycle collision.\n\n COMPARISON: No prior studies available for comparison.\n\n Two views of the right lower leg; tibia three views of the right foot.\n\n Assessment of the knee is limited, but grossly unremrkable. NO fracture\n is detected in the tibia or fibula. The proximal and distal tibio-fibular\n joints are congruent.\n\n The ankle is within normal limits, except for soft tissue swelling and a\n small medial malleolar spur.\n\n In the foot, there is a nondisplaced fracture through the proximal shaft of\n the second metatarsal. No other fractures and no dislocation is identified.\n Mild degenerative changes are present at the first MTP joint, with subchondral\n sclerosis and osteophytes. Similar changes are present at the first\n interphalangeal joint. There is no radiopaque foreign body or soft tissue\n calcification. Soft tissue swelling noted.\n\n IMPRESSION:\n\n Non-displaced fracture of the right second metatarsal.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-18 00:00:00.000",
"description": "HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW)",
"row_id": 1094828,
"text": " 12:15 AM\n HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW); FEMUR (AP & LAT) LEFT Clip # \n KNEE (2 VIEWS) LEFT\n Reason: eval frx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p MCC\n REASON FOR THIS EXAMINATION:\n eval frx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Motorcycle collision.\n\n COMPARISON: No prior studies available for comparison.\n\n 6 radiographs were obtained, including frontal view of the pelvis as well as 2\n views of the left hip, 2 vws of the left femur, and 2 vws of the left knee. No\n oblique vieww of knee.\n\n Frontal view of the hip is notable for diastasis of the pubic symphysis,\n measuring 15 mm, and both SI joints. Bony fragments seen along the inferior\n aspect of the right hip joint likely reflect a right acetabular fracture. Note\n is made of mild degenerative change at the hip joints bilaterally with\n subchondral sclerosis and osteophyte formation. Small amount of contrast is\n seen within the ureters bilaterally as well as within the urinary bladder,\n which contains a Foley catheter.\n\n There is a comminuted fracture of the left proximal femoral diaphysis, with\n displacement, angulation and over-riding. The left femoral head appears well\n seated within the left acetabulum.\n\n The left knee is grossly unremarkable. There is an equivocal joint effusion,\n minimal degenerative spurring, and possible posterior tibial cyst. No oblique\n view was obtained.\n\n IMPRESSION:\n\n 1. Diastasis of the pubic symphysis and both SI joints.\n 2. Suspected fracture of the right acetabulum.\n 3. Comminuted left femoral diaphyseal fracture.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-27 00:00:00.000",
"description": "O PELVIS (AP, INLET & OUTLET) IN O.R.",
"row_id": 1096304,
"text": " 1:08 PM\n PELVIS (AP, INLET & OUTLET) IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: ORIF SI JOINT\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 58-year-old male ORIF pubic symphysis.\n\n COMPARISON: CT torso .\n\n FINDINGS: Fluoroscopic assistance was provided to the orthopedic surgeon\n without the presence of a radiologist. Ten images were submitted for review\n and demonstrate placement of a malleable plate at the pubic symphysis, with\n close approximation of the symphysis pubis. Left femoral head gamma nail is\n incompletely imaged.\n\n Please refer to the operative note for further details.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-19 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1095139,
"text": " 9:05 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: EVAL FOR DVT, KNOWN PE\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with bilat. LE swelling after trauma (LLE fracture) and history\n of DVT\n REASON FOR THIS EXAMINATION:\n Eval. for DVT\n ______________________________________________________________________________\n WET READ: 1:47 AM\n No right DVT. Technically limited study secondary to patient tolerance on the\n left. Nevertheless no evidence of DVT on othe left, however, note that the\n left popliteal vein was not visualized.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bilateral lower extremity edema status post lower extremity trauma\n with left lower extremity fractures.\n\n COMPARISON: No prior studies available for comparison.\n\n FINDINGS: Note that the study is technically limited secondary to patient\n tolerance in the setting of recent lower extremity fractures. The common\n femoral veins show symmetric waveforms bilaterally with appropriate response\n to Valsalva maneuvers. In the right lower extremity, the common femoral,\n proximal greater saphenous, superficial femoral and popliteal veins all\n compress appropriately with appropriate response to waveform, augmentation and\n wall-to-wall flow on color analysis. A small amount of subcutaneous edema is\n present in the soft tissues of the right calf and the superficial veins of the\n right calf are not identified. On the left, compression was not possible\n secondary to patient tolerance. Nevertheless, the common femoral and proximal\n greater saphenous veins appear patent with wall-to-wall flow. There is\n appropriate respiratory variation in the left common femoral venous waveform.\n The left superficial femoral vein also appears patent with wall-to-wall flow.\n The left popliteal vein is not assessed and the superficial veins of the left\n calf are also not visualized.\n\n IMPRESSION: Limited study secondary to poor patient tolerance with no\n evidence of DVT on the right and grossly normal appearing deep veins of the\n left, however, compression was not possible secondary to patient tolerance in\n the left popliteal vein is not identified secondary to patient positioning.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-25 00:00:00.000",
"description": "L MR SHOULDER W/O CONTRAST LEFT",
"row_id": 1095970,
"text": " 2:18 PM\n MR SHOULDER W/O CONTRAST LEFT Clip # \n Reason: please eval for injury\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with shoulder weakness s/p trauma\n REASON FOR THIS EXAMINATION:\n please eval for injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58-year-old man with shoulder weakness status post trauma.\n\n COMPARISON: Radiographs of the left shoulder .\n\n TECHNIQUE: Multiplanar MRI of the left shoulder was performed on a 1.5 Tesla\n magnet without contrast.\n\n FINDINGS:\n\n Evaluation of the rotator cuff demonstrates circumferential edema in the\n muscle belly of the supraspinatus. The supraspinatus tendon is normal. There\n is edema in the supraspinatus and teres minor muscles. Focal near fluid\n signal intensity at the myotendinous junction of the infraspinatus is in\n keeping with a partial-thickness intrasubstance infraspinatus tear.The\n subscapularis muscle and tendon are normal. Rotator cuff tendon insertions are\n normal. Rotator cuff muscular bulk is normal.\n\n Diffuse subcutaneous edema is seen overlying the acromioclavicular joint and\n posterior shoulder.\n\n The long head of the biceps tendon is normal in signal intensity and is\n normally located in the bicipital groove.\n\n There is no glenohumeral joint effusion. Glenohumeral cartilage is preserved.\n There is no displaced labral tear.\n\n Mild-to-moderate acromioclavicular osteoarthritis with proliferative change\n and subchondral cyst formation is noted.\n\n There is no fluid in the subacromial-subdeltoid bursa. There is no mass in\n the quadrilateral space, suprascapular notch, or spinoglenoid notch.\n\n There is no - deformity or suspicious bone marrow edema.\n\n IMPRESSION:\n\n 1. Edema in the infraspinatus, teres minor, and subscapularis muscles. This\n could be related to trauma, especially given the history. If symptoms\n persist, repeat noncontrast MRI in approximately 2-3 months is suggested to\n evaluate for other causes of muscular edema.\n\n (Over)\n\n 2:18 PM\n MR SHOULDER W/O CONTRAST LEFT Clip # \n Reason: please eval for injury\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Partial thickness intrasubstance tear of the infraspinatus at the\n myotendinous junction. No full-thickness rotator cuff tears.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1095354,
"text": " 5:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with PE and oozing from orthopedic injuries, also with\n infiltrate on R LL\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: History of PE.\n\n FINDINGS: Since the previous study,the moderate right pleural effusion is\n unchanged with fluid in the right horizontal fissure and right lower lobe\n atelectasis. Minor left lower lobe atelectasis has improved. Lungs are\n otherwise clear with no consolidation or pneumothorax. Cardiomediastinal\n silhouette is unchanged with mild distention of the azygos vein. The right\n internal jugular central venous line is in the upper SVC.\n\n IMPRESSION:\n\n Interval change. Stable moderately large right pleural effusion with right\n lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-09-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1095168,
"text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: FOR 5AM: Eval. R effusion\n Admitting Diagnosis: FEMUR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with R effusion - eval for enlargement\n REASON FOR THIS EXAMINATION:\n FOR 5AM: Eval. R effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:45 A.M. \n\n HISTORY: Right pleural effusion, evaluate size.\n\n IMPRESSION: AP chest compared to at 2:30 p.m. read in conjunction\n with the chest CTA at 4:53 p.m.\n\n Right lower lobe is probably still collapsed and there is an indeterminate but\n no larger than moderate right pleural effusion. Distention of the azygos vein\n suggests volume overload accounting for increase in diameter of the heart,\n still normal size. No pneumothorax. Mild atelectasis in the left lower lobe\n improved. Right jugular line ends in the mid SVC.\n\n\n"
}
] |
92,801 | 159,064 | The patient is a 69 yo woman with h/o end-stage NSCLC s/p XRT and radiation and recent tracheal and bilateral mainstem bronchi stents who presented from home with large-volume hemoptysis, now s/p embolization of right and left mainstem bronchus. . #. Hemoptysis: Patient was urgently transferred to the ICU. Her Hct has remained at her baseline of 33, and she had no further episodes of hemoptysis while in the ICU. Interventional pulmonary performed a rigid bronchoscopy, which revealed a large volume of blood in the left lung that coould not be interevened upon. Patient was then taken to IR and right and left bronchial artery embolization was performed using 300-500 embospheres. After the embolization, hematocrits remained stable at 29-33. She had no further episodes of bright red hemoptysis. Her cough was prdocutive of rust-colored sputum and she had no signs/symptoms of active bleeding for the remainder of the admission. In order to help her SOB and thick secretions, she was started on morphine liquid 5 mg as needed, which greatly improved her symptoms. She will be discharged on this medication. She will also be discharged with a letter which explains the prcoedures that were done, what to do for another significant large bleed, the patient's wishes, and emergency contact information. . #. NSCLC: Patient has history of NSCLC, followed by Dr. at the Hematology/ clinic. She is s/p trachial y-stenting in and was supposed to have another round of chemotherapy on . Palliative care was consulted after patient's recovery and it was decided by the patient and patient's family that she would go home with hospice. She will follow-up with her oncologist the day after discharge. . #. COPD: Patient takes Prednisone 10 mg daily, Advair 500/50, Flovent, and Tiotropium daily. Will discontinue patient's flovent and keep her on advair. Symptoms of SOB improved with morphine liquid 5 mg as needed along with albuterol nebulizers PRN. Patient's O2 sats were stable in the mid-ghigh 90s on 2L, and she did not desaturate with ambulation. | Selective arteriogram and embolization of left intercosto-bronchial trunk. A left intercostal bronchial trunk was catheterized. Tracheal and bilateral bronchus stent in place. The microcatheter was removed and arteriogram through the catheter at the origin of the bronchial artery showed marked stasis of flow. Selective arteriogram and embolization of right intercosto-bronchial trunk. TECHNIQUE: CTA chest without and with IV contrast and coronal, sagittal, and oblique reformats. COMPARISON: CT trachea . Using a combination of a Renegade STC microcatheter and Transcend microwire, selective catheterization of the intercostal bronchial trunk was performed. There is diffuse osteopenia. An aortogram was performed. Persistent occlusion of the superior segmental bronchus of the left lower lobe and left upper lobe bronchus. Request for bronchial artery embolization. There are bilateral stents in teh main bronchus, which appear patent. At the aortic arch, there is a contrast outpouching into the aortic wall, likely ulcerated plaque (3:29). Two microcoils were then deployed within the proximal intercostal artery coming off the intercostal bronchial trunk and embolization of the right bronchial artery performed using 300 to 500 micron Embospheres until contrast stasis was achieved. Left subclavian arteriogram. Right intercostal bronchial trunk angiogram reveals a branch supplying the left lung. catheter was then used to select the left bronchial artery. The catheter was then used to select the right intercostal bronchial trunk and selective arteriogram was performed. Catheter and guidewire were then removed. Aortogram demonstrates conventional anatomy. There are moderate atherosclerotic changes in the thoracic aorta; combination of soft and hard plaque. Using fluoroscopic and palpatory guidance, the left common femoral artery was accessed at the level of the mid common femoral head using a micropuncture needle through which a 0.018 guidewire was advanced into the abdominal aorta. There is stable circumferential left pleural thickening with multifocal calcifications suggesting prior pleurodesis. This was used to select the left subclavian artery and a selective left subclavian arteriogram performed. Based on the findings of the arteriogram, it was decided to embolize the right bronchial artery. There is a similar volume loss in the left lung with similar leftward shift of the mediastinal structures. There is a prominent right paratracheal lymph node. Tracheal stent has been placed, terminating approximately 2 cm above the . It was then decided to coil embolize the proximal intercostal branch and embolize the bronchial artery. Right common femoral arterial access. The C2 catheter was exchanged for catheter which was formed over the aortic bifurcation and then advanced into the thoracic aorta. There is ground-glass opacity of the dependent right lower lobe, which could be related to aspiration; however, less apparent to prior. The catheter was then removed over the wire and an angled glide catheter was introduced. The trachea and both main bronchi are stented. Patient presented with hemoptysis. COMPARISON: Chest radiograph . Bronchoscopy revealed bleeding in the left mainstem bronchus. There are multiple supraclavicular lymph nodes, left greater than right, which appear similar. The LLL superior segmental bronchus and LUL bronchus remain occluded. Dr. was paged. Multiple intercostal (Over) 3:02 PM OTHER EMBO Clip # Reason: Please evaluate for LM brochial bleed and embolize as neede Admitting Diagnosis: HEMOPTYSIS Contrast: OPTIRAY Amt: 240 FINAL REPORT (Cont) branches seen arising from the aorta. The microcatheter and wire were removed. Needle was exchanged for a micropuncture sheath and the wire upsized to a 0.035 wire. Hilar, mediastinal, and cardiac silhouettes are suboptimally evaluated due to summation of shadows. Incidental small outpouching in the aortic arch likely ulcerated plaque. Again, using a combination of a Renegade STC microcatheter and a Transcend wire, the bronchial artery was superselectively catheterized and embolization performed using 300 to 500 micron Embospheres until stasis of contrast flow was achieved. Persistent opacities in the left lung, could be aspiration or radiation changes. (Over) 3:02 PM OTHER EMBO Clip # Reason: Please evaluate for LM brochial bleed and embolize as neede Admitting Diagnosis: HEMOPTYSIS Contrast: OPTIRAY Amt: 240 FINAL REPORT (Cont) 4. The pulmonary opacities with air bronchograms and more inferior septal thickening at the left lung may represent post-obstructive pneumonia, radiation changes or aspiration. The right bronchial stent may have migrated superiorly and to the left since the previous study. Selective left intercostal bronchial trunk arteriogram and embolization using 300 to 500 micron Embospheres. There is small left pleural effusion. Right basal atelectasis or aspiration. Sterile dressings were applied. Hazy opacities at the bases could be atelectasis or aspiration, or, on the left, radiation injury. | 4 | [
{
"category": "Radiology",
"chartdate": "2102-01-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1175297,
"text": " 12:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with hemoptysis, known lung CA\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hemoptysis and known lung cancer.\n\n TECHNIQUE: Chest radiograph, portable AP single view.\n\n COMPARISON: Chest radiograph .\n\n FINDINGS: Patient has a known left lung cancer. The trachea and both main\n bronchi are stented. Volume loss in the left lung, marked by elevation of the\n left hemidiaphragm, is primarily due to upper lobe atelectasis. Hazy\n opacities at the bases could be atelectasis or aspiration, or, on the left,\n radiation injury. There is no pneumothorax. Left pleural effusion is small.\n Hilar, mediastinal, and cardiac silhouettes are suboptimally evaluated due to\n summation of shadows.\n\n IMPRESSION:\n 1. Known left lung cancer with persistent left upper lung collapse and hazy\n opacity at the lung base could be from radiation or aspiration.\n 2. Right basal atelectasis or aspiration.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-01-13 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1175301,
"text": " 1:00 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: LUNG CA, HEMOPTYSIS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with nonsmall cell lung ca, now with hemoptysis\n REASON FOR THIS EXAMINATION:\n eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf FRI 2:52 AM\n NO PE.\n Small outpouching in the soft plaque of aortic arch could be small penetrating\n ulcer in the wall; short term CT is recommended for follow up.\n Similar apperance of left opacities could be combination of radiation changes\n and aspiration; cannot exclude superinfection.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Non-small cell lung cancer, now with hemoptysis, evaluate for PE.\n\n TECHNIQUE: CTA chest without and with IV contrast and coronal, sagittal, and\n oblique reformats.\n\n COMPARISON: CT trachea .\n\n FINDINGS: No filling defect in the pulmonary artery to suggest pulmonary\n embolus. There are moderate atherosclerotic changes in the thoracic aorta;\n combination of soft and hard plaque. At the aortic arch, there is a contrast\n outpouching into the aortic wall, likely ulcerated plaque (3:29).\n\n Tracheal stent has been placed, terminating approximately 2 cm above the\n . There are bilateral stents in teh main bronchus, which appear patent.\n There is a similar volume loss in the left lung with similar leftward shift of\n the mediastinal structures. The pulmonary opacities with air bronchograms and\n more inferior septal thickening at the left lung may represent\n post-obstructive pneumonia, radiation changes or aspiration. The LLL superior\n segmental bronchus and LUL bronchus remain occluded. There is ground-glass\n opacity of the dependent right lower lobe, which could be related to\n aspiration; however, less apparent to prior. There is small left pleural\n effusion. There is no pneumothorax. There is underlying emphysema in the\n lungs. There are multiple supraclavicular lymph nodes, left greater than\n right, which appear similar. There is a prominent right paratracheal lymph\n node. There is no pericardial effusion. Heart size is normal. There is\n stable circumferential left pleural thickening with multifocal calcifications\n suggesting prior pleurodesis.\n\n OSSEOUS STRUCTURES: There is a stable compression fracture of T7. There is\n diffuse osteopenia. No suspicious lytic or sclerotic lesion is seen.\n\n IMPRESSION:\n 1. No pulmonary embolus.\n 2. Incidental small outpouching in the aortic arch likely ulcerated plaque.\n (Over)\n\n 1:00 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: LUNG CA, HEMOPTYSIS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Tracheal and bilateral bronchus stent in place.\n 4. Persistent occlusion of the superior segmental bronchus of the left lower\n lobe and left upper lobe bronchus.\n 5. Persistent opacities in the left lung, could be aspiration or radiation\n changes.\n 6. RLL opacities less apparent could be atelectasis or aspiration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-01-13 00:00:00.000",
"description": "EMBO NON NEURO",
"row_id": 1175428,
"text": " 3:02 PM\n OTHER EMBO Clip # \n Reason: Please evaluate for LM brochial bleed and embolize as neede\n Admitting Diagnosis: HEMOPTYSIS\n Contrast: OPTIRAY Amt: 240\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO SEL CATH 1ST ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE EXT UNILAT 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 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 69 year old woman with h/o NSCLC s/p XRT and chemotherapy and recent stent\n placement in the left and right mainstem bronchi in who pw hemoptysis.\n s/p rigid bronch with 250ml of bleeding (BRB)\n REASON FOR THIS EXAMINATION:\n Please evaluate for LM brochial bleed and embolize as needed\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 69-year-old woman with history of NSCLC status post XRT and\n chemotherapy with recent tracheobronchial stent placement. Patient presented\n with hemoptysis. Bronchoscopy revealed bleeding in the left mainstem\n bronchus. Request for bronchial artery embolization.\n\n RADIOLOGISTS: Dr. and Dr. performed the procedure.\n Dr. , the attending radiologist, was present and participated throughout\n the procedure.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n 125 mcg of fentanyl and 3 mg of Versed throughout the total intraservice time\n of 2 hours and 20 minutes, during which the patient's hemodynamic parameters\n were continuously monitored.\n\n PROCEDURE AND FINDINGS:\n\n After explaining the risks, benefits, and alternatives of the procedure,\n written informed consent was obtained. The patient was brought to the\n angiography suite and placed supine on the imaging table. The right groin was\n prepped and draped in the standard sterile fashion. A preprocedure timeout\n and huddle were performed per protocol.\n\n 1. Right common femoral arterial access.\n 2. Aortogram.\n 3. Selective arteriogram and embolization of right intercosto-bronchial\n trunk.\n (Over)\n\n 3:02 PM\n OTHER EMBO Clip # \n Reason: Please evaluate for LM brochial bleed and embolize as neede\n Admitting Diagnosis: HEMOPTYSIS\n Contrast: OPTIRAY Amt: 240\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Selective arteriogram and embolization of left intercosto-bronchial trunk.\n 5. Left subclavian arteriogram.\n\n Using fluoroscopic and palpatory guidance, the left common femoral artery was\n accessed at the level of the mid common femoral head using a micropuncture\n needle through which a 0.018 guidewire was advanced into the abdominal aorta.\n Needle was exchanged for a micropuncture sheath and the wire upsized to a\n 0.035 wire. The micropuncture sheath was then exchanged for a 5\n French -Tip sheath, which was connected to a continuous heparinized\n saline sidearm flush. A 5 French pigtail catheter was then advanced over the\n wire and positioned within the descending thoracic aorta just distal\n to the arch. An aortogram was performed. The bronchial arteries were not\n visualized. The pigtail flush catheter was then exchanged over the wire for a\n C2 Cobra catheter, which was used to direct the wire into the left\n common iliac artery. The C2 catheter was exchanged for catheter\n which was formed over the aortic bifurcation and then advanced into the\n thoracic aorta. The catheter was then used to select the right\n intercostal bronchial trunk and selective arteriogram was performed. Based on\n the findings of the arteriogram, it was decided to embolize the right\n bronchial artery. Using a combination of a Renegade STC microcatheter and\n Transcend microwire, selective catheterization of the intercostal bronchial\n trunk was performed. The microcatheter however could not be selectively\n advanced into the right bronchial artery. It was then decided to coil\n embolize the proximal intercostal branch and embolize the bronchial artery.\n Two microcoils were then deployed within the proximal intercostal artery\n coming off the intercostal bronchial trunk and embolization of the right\n bronchial artery performed using 300 to 500 micron Embospheres until contrast\n stasis was achieved. The microcatheter was removed and arteriogram through\n the catheter at the origin of the bronchial artery showed marked\n stasis of flow.\n\n catheter was then used to select the left bronchial artery. A left\n intercostal bronchial trunk was catheterized. Again, using a combination of a\n Renegade STC microcatheter and a Transcend wire, the bronchial artery was\n superselectively catheterized and embolization performed using 300 to 500\n micron Embospheres until stasis of contrast flow was achieved. The\n microcatheter and wire were removed. The catheter was then removed\n over the wire and an angled glide catheter was introduced. This was\n used to select the left subclavian artery and a selective left subclavian\n arteriogram performed. Catheter and guidewire were then removed. Arterial\n sheath was removed and hemostasis was achieved by digital compression for 20\n minutes. Sterile dressings were applied.\n\n FINDINGS:\n 1. Aortogram demonstrates conventional anatomy. Multiple intercostal\n (Over)\n\n 3:02 PM\n OTHER EMBO Clip # \n Reason: Please evaluate for LM brochial bleed and embolize as neede\n Admitting Diagnosis: HEMOPTYSIS\n Contrast: OPTIRAY Amt: 240\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n branches seen arising from the aorta. Bronchial arteries were not visualized.\n 2. Right intercostal bronchial trunk angiogram reveals a branch supplying the\n left lung. Successful embolization performed using 300 to 500 micron\n Embospheres.\n 3. Selective left intercostal bronchial trunk arteriogram and embolization\n using 300 to 500 micron Embospheres.\n 4. No contributor to the anterior spinal artery is seen.\n 5. No anomalus bronchial arterial supply arising off the left subclavian or\n left internal mammary arterial branch is seen.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n IMPRESSION: Successful right and left bronchial arteriograms and embolization\n using 300 to 500 micron Embospheres.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-01-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1175497,
"text": " 4:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval progression\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with hemoptysis\n REASON FOR THIS EXAMINATION:\n Interval progression\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:21 A.M.\n\n HISTORY: 69-year-old woman with hemoptysis, question interval progression.\n\n IMPRESSION: AP chest compared to :\n\n Greater consolidation in the left lung is probably due to worsening\n aspiration, although new edema is seen in the right lung. Large\n post-treatment atelectasis in the left lung and residual left hilar mass are\n more prominent, probably because of differences in positioning. The right\n bronchial stent may have migrated superiorly and to the left since the\n previous study. Tracheal stent position is unchanged, as is a left bronchial\n stent. Dr. was paged.\n\n\n"
}
] |
12,954 | 127,176 | 61 yo male with a past medical history significant for severe COPD and AS s/p admitted to the CCU for acute shortness of breath. Patient's most recent cardiac cath without evidence of flow-limiting stenoses and without chest pain. Cardiac enzymes negative, such that myocardial infarction was unlikely cause for shortness of breath. Furthermore, pt had preserved ejection fraction and appeared euvolemic without evidence of heart failure. Lastly, porcine aortic valve appeared to be stable without any evidence of failure. However, pt did continue to have atrial fibrillation with rapid ventricular response despite recent titration of procainamide. This was felt to be the most likely etiology for shortness of breath. Therefore, in consultation with EP, patient was uptitrated again on procainamide with good effect in conjunction with beta blocker and diltiazem for rate control. Levels were checked after uptitration and were within therapeutic window. In addition, given severity of COPD, it was felt that empiric treatment with corticosteroid pulse would be helpful, and pt was started again on 125 methylprednisolone along with frequent use of bronchodilators. Course of levofloxacin was completed as planned prior to this hospitalization, though no evidence of pneumonia was found. Of note, pt did have elevation in WBC of unclear etiology to a peak of 34.4. CDiff was negative, though pt did not have diarrhea. Interestingly, as steroids were slowly tapered downward, WBC trended downward also, suggestive of demargination as a source of leukocytosis. Otherwise, no other localizing symptoms or signs of infection were identified, and pt remained afebrile. At the time of discharge, pt continued to require 4-5 liters supplemental O2 consistent with the likely endstage nature of his COPD. Although goals of care discussions were held, no definite plan was made. It did, however, seem that pt had appropriate expectations given the degree of his progressive illness. | ccu nsg progress note.o:hemdy stable-remains on procanimide & diltiazem. ?pulm edema-iv ntg started. Lateral ST-T waveabnormalities. On procainimide/dilt po. gi=tolerating cl liq. dilt po added & gtt dced. w rx sob resolved-diuresed approx 1l. ck sent-neg. Left atrialabnormality. INDICATION: Status post AVR. Regional left ventricular wall motionis normal.3. Respiratory Care NotePt given Albuterol/Atrovent via neb. Trivial MR.TRICUSPID VALVE: Mild [1+] TR. started on resp rx q4hrs & solu-medrol. On neb treatments. IMPRESSION: Evidence of COPD. gu=foley placed. Normal sinus rhythm with occasional ventricular premature beats. signif for sever copd & pna. id=low grade t. abx started. Compared to the previoustracing of lateral ST-T wave abnormalities persist. Sinus rhythmSupraventricular extrasystolesSince previous tracing, rate decreased, no aberration CHEST AP: Cardiac, mediastinal and hilar contours are stable status post median sternotomy. Trivial mitralregurgitation is seen.6. cv=arrived on dolt gtt. resp meds & rxs as ordered. cxr- hyperinflation wo significant sigh chf. rhythm-sr w pas's. The diaphragms are noted to be flattened, consistent with a history of COPD. Pulmonary vasculature is within normal limits. Mild PA systolic hypertension.PERICARDIUM: No pericardial effusion.Conclusions:1. The ascending aorta is mildly dilated.4. Compared to tracing #3, patientis now in sinus rhythm. Anterior ST-T wavechanges. Compared to the previous tracing of the incomplete right bundle-branch block is no longer present. Diffuse non-specificST-T wave changes. ?call-out. Trace aortic regurgitation is seen.5. ON DILTIAZEM AND PROCAINIMAIDE QID.RESP: RESPONSDING TO NEBS Q4 HRS. Clinicalcorrelation is suggested.TRACING #1 There is mild pulmonary artery systolic hypertension.7. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Evaluate for CHF. labs=am sent.a:copd exacerbation w ?chf.p:contin present management. transfered to ccu for rx chf/copd.o:neuro=responsive. The left atrium is mildly dilated.2. Sinus rhythm with occasional ventricular premature beats. AVR leaflets movenormally. becomes dyspneic very easily. Compared with the prior study (images reviewed) of , there is nosignificant change. smoker-stopped .present hx;dced to rehab . breath sounds=sl exp wheezes. pulm=initially very sob. diuresed to lasix given on . mso4 given. The aortic prosthesisleaflets appear to move normally. Cannot rule out myocardial ischemia. Cannot rule out myocardial ischemia. COMPARISON: . The lungs are clear with diffuse emphysematous changes again noted. Comparison with . Compared to the previoustracing of lateral ST-T wave abnormalities have improved andventricular premature beats are no longer present. Sinus rhythm with frequent atrial premature beats. The patient is status post median sternotomy, and the heart and mediastinal structures are unchanged. STABLE BP. Anterior ST-T wave changes are new. had received resp rx & lasix on 6. sats low 90's on nrb. The patient is status post median sternotomy. One view. Sinus tachycardia with PACs some with aberrationT wave changesSince previous tracing, aberration is new CCU followup. Compared to the previous tracing of rapid atrialfibrillation is new.TRACING #1 Mildly dilated ascending aorta.AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Clinical correlation issuggested.TRACING #2 IV STEROIDS TAPERING OFF.LS W/ EX WHEEZE, SCATTERED RHONCHI, AND DIMINISHED BASES. BS diminished throughout with end expiratory wheezes in LLL; after rx there is a slight improvement in aeration bialterally wheezing persists. ew-af w rate to 160-rx w lopressor, dilt, 7 dilt gtt. Shortness of breath.Height: (in) 71Weight (lb): 145BSA (m2): 1.84 m2BP (mm Hg): 110/64HR (bpm): 94Status: InpatientDate/Time: at 15:10Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). T wave inversions in the anterolateral leads suggestive ofpossible anterolateral ischemia. Good appetite, OOB to commode x 3, guaiac neg. s/p AVR in ', admitted for Rapid A-fib.O: Please see carevue for complete objective data.A&O x 3, Monitored in MAT/NSR, rate 90-110's. id appropriate. Normal regional LV systolic function.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. Osseous and soft tissue structures are unchanged. IMPRESSION: No active disease. support as indicated. support as indicated. Assess interval change. 6 developed sob, dyspnea, & decreased sats. o2 requirements decreased-5l nc. Atrial fibrillation with a rapid ventricular response. Atrial fibrillation with a rapid ventricular response. Atrial fibrillation with a rapid ventricular response. The mitral valve leaflets are mildly thickened. cooperative. No acute change. Sinus tachycardia with frequent atrial premature beats. One portable view. The mediastinal and hilar contours are unremarkable. The pulmonary vasculature is normal. Clinicalcorrelation is suggested.TRACING #4 The lungs are hyperexpanded and clear, as before. Increased AVR gradient. Compared to tracing #2,no significant diagnostic change.TRACING #3 There is mild symmetric left ventricular hypertrophy with normal cavitysize and systolic function (LVEF>55%). The heart and mediastinal structures are unremarkable in appearance as before. The heart is normal in size. 3 PIV's, called out to floor. COMPARISON: Comparison is made to prior film dated . IMPRESSION: No acute cardiopulmonary process. Compared to tracing #1,no significant diagnostic change and patient is persistently in rapid atrialfibrillation.TRACING #2 H/O cardiac surgery. The lungs are clear. A bioprosthetic aortic valve prosthesis is present. The lungs remain clear. The bony thorax is grossly intact. The bony thorax is grossly intact. The soft tissues and osseous structures are unremarkable. comfortable night wo co breathing problems.a:stable over night.p:contin present med management. Keep updated on plan. admitted to 6. PATIENT/TEST INFORMATION:Indication: Aortic valve disease. CCU NPN 0700-190061 Y/O MALE ADMITTED W/ COPD FLARE & CHF IN SETTING OF RAPID AFIB.S/P LASIX, NEB TREATMENTS, DILT BOLUSES & GTT (NOW PO, GTT OFF).S/O: NEURO A&OX3CV: MAT W/ RATE > 100 W/ OCC PVC'S. Emtoionally support pt and family. There is no significant interval change. There is no significant interval change. breath sounds went from extrem tight w ex wheezes to wheezes at bases. Voids yellow clr urine. am developed sob w feeling of heart "fluttering". There are no pleural effusions. IMPRESSION: No evidence of pneumonia. The transaortic gradient is higher thanexpected for this type of prosthesis. lives w wife. ccu nsg admit note.61 yo male transfered from 6 to ccu w copd exacerbation w super imposed chf.phm:extensive-see chart. | 19 | [
{
"category": "Echo",
"chartdate": "2138-12-30 00:00:00.000",
"description": "Report",
"row_id": 61943,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. H/O cardiac surgery. Shortness of breath.\nHeight: (in) 71\nWeight (lb): 145\nBSA (m2): 1.84 m2\nBP (mm Hg): 110/64\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 15:10\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: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR leaflets move\nnormally. Increased AVR gradient. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2. There is mild symmetric left ventricular hypertrophy with normal cavity\nsize and systolic function (LVEF>55%). Regional left ventricular wall motion\nis normal.\n3. The ascending aorta is mildly dilated.\n4. A bioprosthetic aortic valve prosthesis is present. The aortic prosthesis\nleaflets appear to move normally. The transaortic gradient is higher than\nexpected for this type of prosthesis. Trace aortic regurgitation is seen.\n5. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n6. There is mild pulmonary artery systolic hypertension.\n7. Compared with the prior study (images reviewed) of , there is no\nsignificant change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2139-01-05 00:00:00.000",
"description": "Report",
"row_id": 114209,
"text": "Sinus tachycardia with PACs some with aberration\nT wave changes\nSince previous tracing, aberration is new\n\n"
},
{
"category": "ECG",
"chartdate": "2139-01-06 00:00:00.000",
"description": "Report",
"row_id": 114210,
"text": "Sinus rhythm\nSupraventricular extrasystoles\nSince previous tracing, rate decreased, no aberration\n\n"
},
{
"category": "ECG",
"chartdate": "2139-01-03 00:00:00.000",
"description": "Report",
"row_id": 114211,
"text": "Atrial fibrillation with a rapid ventricular response. Compared to tracing #2,\nno significant diagnostic change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2139-01-03 00:00:00.000",
"description": "Report",
"row_id": 114212,
"text": "Atrial fibrillation with a rapid ventricular response. Compared to tracing #1,\nno significant diagnostic change and patient is persistently in rapid atrial\nfibrillation.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2139-01-03 00:00:00.000",
"description": "Report",
"row_id": 114213,
"text": "Atrial fibrillation with a rapid ventricular response. Diffuse non-specific\nST-T wave changes. Compared to the previous tracing of rapid atrial\nfibrillation is new.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2139-01-04 00:00:00.000",
"description": "Report",
"row_id": 114214,
"text": "Sinus tachycardia with frequent atrial premature beats. Anterior ST-T wave\nchanges. Cannot rule out myocardial ischemia. Compared to tracing #3, patient\nis now in sinus rhythm. Anterior ST-T wave changes are new. Clinical\ncorrelation is suggested.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2139-01-02 00:00:00.000",
"description": "Report",
"row_id": 114215,
"text": "Sinus rhythm with frequent atrial premature beats. Compared to the previous\ntracing of lateral ST-T wave abnormalities have improved and\nventricular premature beats are no longer present. Clinical correlation is\nsuggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2139-01-01 00:00:00.000",
"description": "Report",
"row_id": 114216,
"text": "Sinus rhythm with occasional ventricular premature beats. Lateral ST-T wave\nabnormalities. Cannot rule out myocardial ischemia. Compared to the previous\ntracing of lateral ST-T wave abnormalities persist. Clinical\ncorrelation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2138-12-29 00:00:00.000",
"description": "Report",
"row_id": 114217,
"text": "Normal sinus rhythm with occasional ventricular premature beats. Left atrial\nabnormality. T wave inversions in the anterolateral leads suggestive of\npossible anterolateral ischemia. Compared to the previous tracing of \nthe incomplete right bundle-branch block is no longer present.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 938387,
"text": " 9:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: sob, eval acute cardiopulm disease\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with copd, sob, raf\n REASON FOR THIS EXAMINATION:\n sob, eval acute cardiopulm disease\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old man with COPD, shortness of breath, rapid atrial\n fibrillation.\n\n COMPARISON: .\n\n CHEST AP: Cardiac, mediastinal and hilar contours are stable status post\n median sternotomy. Pulmonary vasculature is within normal limits. The lungs\n are clear with diffuse emphysematous changes again noted. There are no\n pleural effusions. Osseous and soft tissue structures are unchanged.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 938464,
"text": " 8:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute lung process\n Admitting Diagnosis: RAPID A-FIB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with AF and SOB in CCU\n REASON FOR THIS EXAMINATION:\n eval for acute lung process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Atrial fibrillation. CCU followup.\n\n One portable view. Comparison with . The lungs are hyperexpanded and\n clear, as before. The patient is status post median sternotomy, and the heart\n and mediastinal structures are unchanged. The bony thorax is grossly intact.\n There is no significant interval change.\n\n IMPRESSION: Evidence of COPD. No acute change.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-01-04 00:00:00.000",
"description": "Report",
"row_id": 1432216,
"text": "ccu nsg admit note.\n61 yo male transfered from 6 to ccu w copd exacerbation w super imposed chf.\n\nphm:extensive-see chart. signif for sever copd & pna. just dced to rehab after adm for copd & pna-rxed w steroids & abx.\n\nallergies:multiple.\n\nsocial:retired firefighter. lives w wife. smoker-stopped .\n\npresent hx;dced to rehab . am developed sob w feeling of heart \"fluttering\". ew-af w rate to 160-rx w lopressor, dilt, 7 dilt gtt. admitted to 6. 6 developed sob, dyspnea, & decreased sats. transfered to ccu for rx chf/copd.\n\no:neuro=responsive. appropriate. cooperative.\n pulm=initially very sob. had received resp rx & lasix on 6. sats low 90's on nrb. ?pulm edema-iv ntg started. mso4 given. cxr- hyperinflation wo significant sigh chf. w rx sob resolved-diuresed approx 1l. o2 requirements decreased-5l nc. breath sounds went from extrem tight w ex wheezes to wheezes at bases. started on resp rx q4hrs & solu-medrol.\n cv=arrived on dolt gtt. rhythm-sr w pas's. dilt po added & gtt dced. ck sent-neg.\n gi=tolerating cl liq.\n gu=foley placed. diuresed to lasix given on .\n id=low grade t. abx started.\n labs=am sent.\n\na:copd exacerbation w ?chf.\n\np:contin present management. support as indicated.\n id\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-01-04 00:00:00.000",
"description": "Report",
"row_id": 1432217,
"text": "CCU NPN 0700-1900\n61 Y/O MALE ADMITTED W/ COPD FLARE & CHF IN SETTING OF RAPID AFIB.\nS/P LASIX, NEB TREATMENTS, DILT BOLUSES & GTT (NOW PO, GTT OFF).\n\nS/O: NEURO A&OX3\nCV: MAT W/ RATE > 100 W/ OCC PVC'S. STABLE BP. ON DILTIAZEM AND PROCAINIMAIDE QID.\nRESP: RESPONSDING TO NEBS Q4 HRS. IV STEROIDS TAPERING OFF.\nLS W/ EX WHEEZE, SCATTERED RHONCHI, AND DIMINISHED BASES. O2 SAT 95% ON 3.5-4 LTERS VIA NC.\nGI/GU: TOLERATING PO'S GOOD APP.\nCYU VIA FOLEY\n\nA/P: CALLED OUT TO F6 AWAITING BED, MONITOR HR AND RESP STATUS.\nTAPER STEROIDS, Q4 HR NEBS\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-01-05 00:00:00.000",
"description": "Report",
"row_id": 1432218,
"text": "ccu nsg progress note.\no:hemdy stable-remains on procanimide & diltiazem. breath sounds=sl exp wheezes. resp meds & rxs as ordered. comfortable night wo co breathing problems.\n\na:stable over night.\n\np:contin present med management. support as indicated. ?call-out.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-01-05 00:00:00.000",
"description": "Report",
"row_id": 1432219,
"text": "Respiratory Care Note\nPt given Albuterol/Atrovent via neb. BS diminished throughout with end expiratory wheezes in LLL; after rx there is a slight improvement in aeration bialterally wheezing persists.\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-01-05 00:00:00.000",
"description": "Report",
"row_id": 1432220,
"text": "Nursing Progress Note 0700-1900\nS: \"It is so hard to do anything anymore becuase of my breathing\"\n\n61 yo male c hx of severe COPD, smoker and retired firefighter. s/p AVR in ', admitted for Rapid A-fib.\n\nO: Please see carevue for complete objective data.\n\nA&O x 3, Monitored in MAT/NSR, rate 90-110's. On procainimide/dilt po. No episodes of Afib. becomes dyspneic very easily. c/o SOB c every exertion from getting OOB to brushing his teeth. On neb treatments. Good appetite, OOB to commode x 3, guaiac neg. Voids yellow clr urine. 3 PIV's, called out to floor. Emtoionally support pt and family. Keep updated on plan.\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-06 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 938813,
"text": " 4:13 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o interval change or pneumonia\n Admitting Diagnosis: RAPID A-FIB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with past medical history significant for COPD and severe AS\n s/p AVR presents with increasing WBC.\n\n REASON FOR THIS EXAMINATION:\n r/o interval change or pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest x-ray, PA and lateral views.\n\n INDICATION: Status post AVR. Assess interval change.\n\n COMPARISON: Comparison is made to prior film dated .\n\n The heart is normal in size. There are several median sternotomy wires seen\n overlying the upper aspect of the midline of the thorax. The mediastinal and\n hilar contours are unremarkable. The pulmonary vasculature is normal. The\n lungs are clear. There is no evidence of pleural effusions. There is no\n evidence of pneumothorax. The soft tissues and osseous structures are\n unremarkable. The diaphragms are noted to be flattened, consistent with a\n history of COPD.\n\n IMPRESSION: No evidence of pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 938439,
"text": " 7:10 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: pls evaluate for chf\n Admitting Diagnosis: RAPID A-FIB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with AF and SOB now with acute SOB\n\n REASON FOR THIS EXAMINATION:\n pls evaluate for chf\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Short of breath. Evaluate for CHF.\n\n One view. Comparison with the previous study done earlier the same day. The\n lungs remain clear. The heart and mediastinal structures are unremarkable in\n appearance as before. The patient is status post median sternotomy. The bony\n thorax is grossly intact. There is no significant interval change.\n\n IMPRESSION: No active disease.\n\n\n"
}
] |
23,697 | 115,610 | 68 man with past medical history significant for CAD, CHF, DM, ESRD not yet on HD, presented with 1 day of fatigue, melena X 1 found to have anemia to 21. Transferred from MICU with stable hct in low 30's. . # Gastroenterology- Patient presented with 1 episode of melena in the setting of profound fatigue. In the ED, he was found to have hct 21 (down from basline of ~30)nasogastric lavage showed coffee grounds, blood. On Endoscopy he was found to have no active bleed, gastritis, esophagitis, esophagial nonbledding ulcer, esophagus,hiatal hernia, and repeat Endoscopy confirmed same thing. He was admitted to the Medical ICU and transfused approximately 6 units of packed RBC, IV PPI, and sucralfate was started. Because patient has history of CAD, he was maintained at a hematocrit to 30. Patient's hematocrit stabilized in the low 30's and he was transferred to the floor in stable condition. While on the floor, patient had one episode of melena, however, he was hemodynamically stable and hematocrit continued to be in low 30's, Patient did not require any more transfusions. Patient was scheduled for gastroenterology followup, along with followup with his primary care physician. . # Cardiovascular- Patient has history of CAD, CHF. While in the MICU, patient complained substernal chest pain, EKG was done which was consistent with old EKG. Troponins were 0.21-->0.l8-->0.17, however CK and MB negative X 3. Cardiology was made aware and the EKG seemed to implicate an area near his prior infarct in . Give the patient's chronic renal failure, the troponin clearing is was believed to be impaired accounting for the sustained high troponins, however given that the CK is not elevated, it does not appear that patient indeed sustained MI. Troponin levels along with CK would need to be elevated over time in order to support NSTEMI. Given the patient's GI bleed, anti-coagulation, plavix, and ASA 325mg was held. . However, while in MICU once GI bleed and hematocrit stabilized, ASA was restarted at 81mg. Plavix continued to be held. Blood pressure was controlled with metoprolol 100mg and hydralizine 25mg. Patient was discharged on ASA 81mg and plavix was held secondary to further outpatient assessment with gastroenterologist and cardiologist. . # Anemia: Likely due to both blood loss and chronic kidney disease. Stable, Hct=30. Procrit 4000U was continued. . # Renal- Patient has history of chronic kidney disease likely secondary to diabetes. Upon admission, creatinine was around baseline with an elevated BUN, likely due to upper GI source of bleeding. Electrolytes, in particular potassium was monitored and reamined within normal limits. Recommended patient continue to be closely followed as an outpatient in regard to chronic renal disease. . . #DM- Patient has history of diabetes type II, with secondary retinopathy, nephropathy. Blood sugars were maintained in the 150's-200's with regular insulin sliding scale while inpatient. Patient was discharged on home medications. | Compared to theprevious tracing of no change.TRACING #1 Denies chest pain. See carevue for objective data.Awake/alert/following commands/cooperative.HR/BP WNL and non-labile. Possible left ventricularhypertrophy. npnPt is a+o and denies gi upset/pain. endoscopy in AM.Continue currrent POC. Probable old anteriormyocardial infarction. Probable old anteriormyocardial infarction. Probbale old anterior myocardial infarction. Intraventricular conduction delay. Intraventricular conduction delay. Intraventricular conduction delay. NO N/V noted, denies. No nausae/vomiting or abd pain reported.Received (1) U PRBC's with post HCT 29.6. Sinus rhythm. Sinus rhythm. Sinus rhythm. Remains on Lopressor, VSS. Sinus rhythmMarked left axis deviationIntraventricular conduction defectAnteroseptal infarct - age undeterminedProbable lateral infarct - age undeterminedSince previous tracing of , anterior ST-T wave abnormalities areresolving Compared to the previous tracing of no change.TRACING #2 Sinus rhythmLeft axis deviationIV conduction defectAnteroseptal infarct - age undeterminedLateral ST-T changes may be due to myocardial ischemiaSince previous tracing of , anterior T wave inversion is resolving c/o "left collar bone pain" x1 2 pm- micu aware- ekg done and unchanged- enzymes/troponin sent. IMPRESSION: 1. Compared to the previous tracing of no change.TRACING #3 med size dark bm this pm- guiac +- no bright red blood noted. ace-inhibitors in am once BP less labile. Troponin elevated at .21/probable NSTEMI.Adeqaute urine output/voiding in urinal. Denies chest pain, pressure or tenderness. ?rule-in; serial CK/troponin, reinstitute beta-blockers, and ? Taking po fluids early in shift, NPO after MN for scope in am. There is loss of the soft tissue contour adjacent to the superior aspect of the left clavicle. The heart size and mediastinal contours are normal. HCT remains >30. Troponon .18 nad .17. BP drop but rebounded quickly without intervention. ? 2. No obvious signs of bleeding. PA AND LATERAL CHEST RADIOGRAPHS: The lungs are clear. Degenerative changes are seen within the thoracic spine. The osseous structures are stable. Taking clear liquids without difficulty. Awake, alert and oriwented, skin warm and dry, follows commands, cooperative. Remaining npo- except ice chips. condition updatedS/P UGI BLEEDFOR DETAIL INFO PLEASE REFER TO CAREVUE FLOWSHEETPt A+O x3 with c/o chest pain ; 3sl NTG given, EKG with changes, IV fluid bolus for drop in BP after ntg, and O2 combination WITH RELIEF OF CP IN <15MINUTES. There is loss of the soft tissue contour adjacent to the left clavicle, which may be suggestive of supraclavicular lymphadenopathy or soft tissue swelling in this location - correlate to physical exam findings. No pleural effusions or pneumothorax are seen. repeat EKG done with no change since previous @ 1900. No evidence of pneumonia. COMPARISON: Study from . Lopressor increased and tolerated well. noon hct 23.6 from 8 am hct of 26.6- micu notified and 1 unit prbc given with 20 mg iv lasix- plan hct 5 pm. 2100 PT TO SICU FROM ER 24 TO 48 HOUR HISTORY OF DARK BROWN STOOLS LIGHT HEADED N/V VAGUE IN NATURE WIFE NOTED COLOR IN ER HGB 7.0 PLAN REPLACE BLOOD UPPER GI THIS PM NEURO WNL MAE WEAKNESS REMAINS LEFT SIDE POST CVA OOB STANDS NO DRIFT MILD POSTUAL IN GOOD SPIRITS RESP CLEAR SA02 100 ON ROOM AIR NO SOB WIFE STATED SL SOB CLIMBING STAIRS HEART S1S2 M PULSES POS 3 THRUOUT NSR VSS NEG NVD NEG HJR GI POS B/S FOLY INSERTED FOR PT COMFORT DURING UP COMING PROCEDURE NEG N/V N/G REMOVED MD ORDER NOTE GASTRO DONE 1730 TO 1900 TOL WEL BP AVERAGE 110/67 HR 78 RESP 20 4LNP 100 SA02 VOMIT OLD BLOOD DURING EVENT TOL WELL CLEAR AIR WAY TOTAL FENT 125 VERSED 4 MG IV AROSABLE MONITOR SAO2 BP Q 5 MINUTES PLAN SUPPORTIVE KEEP UP ON EVENTS Evaluate for pneumonia. Nursing Progress Note Please see carevue for details of care. PLAN: Monitor labs, f/u scope in am, monitor glucose and RISS, advance DAT. HCT to be checked at 1800.Goal HCT>30 due to CAD. all po meds given and tolerated.awoke @ 22:50 with 2nd episode of CP NTGx2 with relief. Slept in naps t/o noc w/no c/o discomfort. 12:41 PM CHEST (PA & LAT) Clip # Reason: r/o pna MEDICAL CONDITION: 68 year old man with fatigue, low grade fever and abnormal ekg REASON FOR THIS EXAMINATION: r/o pna FINAL REPORT (REVISED) INDICATION: 68-year-old man with fatigue and low-grade fever and abnormal EKG. | 11 | [
{
"category": "Nursing/other",
"chartdate": "2173-08-08 00:00:00.000",
"description": "Report",
"row_id": 1572019,
"text": "npn\nPt is a+o and denies gi upset/pain. noon hct 23.6 from 8 am hct of 26.6- micu notified and 1 unit prbc given with 20 mg iv lasix- plan hct 5 pm. Remaining npo- except ice chips. med size dark bm this pm- guiac +- no bright red blood noted. c/o \"left collar bone pain\" x1 2 pm- micu aware- ekg done and unchanged- enzymes/troponin sent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-08-09 00:00:00.000",
"description": "Report",
"row_id": 1572020,
"text": "condition updated\nS/P UGI BLEED\nFOR DETAIL INFO PLEASE REFER TO CAREVUE FLOWSHEET\nPt A+O x3 with c/o chest pain ; 3sl NTG given, EKG with changes, IV fluid bolus for drop in BP after ntg, and O2 combination WITH RELIEF OF CP IN <15MINUTES. all po meds given and tolerated.\nawoke @ 22:50 with 2nd episode of CP NTGx2 with relief. repeat EKG done with no change since previous @ 1900. BP drop but rebounded quickly without intervention.\n?rule-in; serial CK/troponin, reinstitute beta-blockers, and ? ace-inhibitors in am once BP less labile.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-08-09 00:00:00.000",
"description": "Report",
"row_id": 1572021,
"text": "See carevue for objective data.\n\nAwake/alert/following commands/cooperative.\nHR/BP WNL and non-labile. Denies chest pain. Lopressor increased and tolerated well. Troponin elevated at .21/probable NSTEMI.\nAdeqaute urine output/voiding in urinal. Taking clear liquids without difficulty. No nausae/vomiting or abd pain reported.\nReceived (1) U PRBC's with post HCT 29.6. HCT to be checked at 1800.\nGoal HCT>30 due to CAD. No obvious signs of bleeding. ? endoscopy in AM.\n\nContinue currrent POC.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-08-10 00:00:00.000",
"description": "Report",
"row_id": 1572022,
"text": "Nursing Progress Note\n Please see carevue for details of care. Awake, alert and oriwented, skin warm and dry, follows commands, cooperative. Denies chest pain, pressure or tenderness. Remains on Lopressor, VSS. Troponon .18 nad .17. HCT remains >30.\n Taking po fluids early in shift, NPO after MN for scope in am. NO N/V noted, denies.\n Slept in naps t/o noc w/no c/o discomfort.\n PLAN: Monitor labs, f/u scope in am, monitor glucose and RISS, advance DAT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-08-07 00:00:00.000",
"description": "Report",
"row_id": 1572018,
"text": " 2100\n PT TO SICU FROM ER 24 TO 48 HOUR HISTORY OF DARK BROWN STOOLS LIGHT HEADED N/V VAGUE IN NATURE WIFE NOTED COLOR IN ER HGB 7.0 PLAN REPLACE BLOOD UPPER GI THIS PM\n NEURO WNL MAE WEAKNESS REMAINS LEFT SIDE POST CVA OOB STANDS NO DRIFT MILD POSTUAL IN GOOD SPIRITS\n RESP CLEAR SA02 100 ON ROOM AIR NO SOB WIFE STATED SL SOB CLIMBING STAIRS\n HEART S1S2 M PULSES POS 3 THRUOUT NSR VSS NEG NVD NEG HJR\n GI POS B/S FOLY INSERTED FOR PT COMFORT DURING UP COMING PROCEDURE NEG N/V N/G REMOVED MD ORDER\n NOTE GASTRO DONE 1730 TO 1900 TOL WEL BP AVERAGE 110/67 HR 78 RESP 20 4LNP 100 SA02 VOMIT OLD BLOOD DURING EVENT TOL WELL CLEAR AIR WAY TOTAL FENT 125 VERSED 4 MG IV AROSABLE MONITOR SAO2 BP Q 5 MINUTES\n PLAN SUPPORTIVE KEEP UP ON EVENTS\n"
},
{
"category": "ECG",
"chartdate": "2173-08-09 00:00:00.000",
"description": "Report",
"row_id": 139343,
"text": "Sinus rhythm. Intraventricular conduction delay. Probable old anterior\nmyocardial infarction. Compared to the previous tracing of no change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2173-08-08 00:00:00.000",
"description": "Report",
"row_id": 139344,
"text": "Sinus rhythm. Intraventricular conduction delay. Probable old anterior\nmyocardial infarction. Compared to the previous tracing of no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2173-08-08 00:00:00.000",
"description": "Report",
"row_id": 139345,
"text": "Sinus rhythm. Intraventricular conduction delay. Possible left ventricular\nhypertrophy. Probbale old anterior myocardial infarction. Compared to the\nprevious tracing of no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2173-08-08 00:00:00.000",
"description": "Report",
"row_id": 139346,
"text": "Sinus rhythm\nMarked left axis deviation\nIntraventricular conduction defect\nAnteroseptal infarct - age undetermined\nProbable lateral infarct - age undetermined\nSince previous tracing of , anterior ST-T wave abnormalities are\nresolving\n\n"
},
{
"category": "ECG",
"chartdate": "2173-08-07 00:00:00.000",
"description": "Report",
"row_id": 139347,
"text": "Sinus rhythm\nLeft axis deviation\nIV conduction defect\nAnteroseptal infarct - age undetermined\nLateral ST-T changes may be due to myocardial ischemia\nSince previous tracing of , anterior T wave inversion is resolving\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-08-07 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 924622,
"text": " 12:41 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with fatigue, low grade fever and abnormal ekg\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 68-year-old man with fatigue and low-grade fever and abnormal\n EKG. Evaluate for pneumonia.\n\n COMPARISON: Study from .\n\n PA AND LATERAL CHEST RADIOGRAPHS: The lungs are clear. The heart size and\n mediastinal contours are normal. No pleural effusions or pneumothorax are\n seen. There is loss of the soft tissue contour adjacent to the superior\n aspect of the left clavicle. The osseous structures are stable. Degenerative\n changes are seen within the thoracic spine.\n\n IMPRESSION:\n 1. No evidence of pneumonia.\n 2. There is loss of the soft tissue contour adjacent to the left clavicle,\n which may be suggestive of supraclavicular lymphadenopathy or soft tissue\n swelling in this location - correlate to physical exam findings.\n\n This was discussed with Dr. at 6:15 pm on /6.\n\n"
}
] |
32,619 | 150,073 | Pt is a 63 y/o F w/ h/o severe COPD on home O2, history of MAC, bronchiectasis, cavitary lesions, thought secondary to pseudomonas, on combination of oral antibiotics and prednisone with worsening SOB. It appeared that her symptoms were chronic with an acute exaccerbation. She was continued on supplemental oxygen and her prednisone dose was increased to 60mg po daily. She was continued on her prior regimen including inhaled tobramycin for her bronchiectasis. The patient was on azithromycin po on admission but was switched to Bactrim DS TIW during the admission. She was transferred to the ICU for titration of BIPAP to help with her severe obstruction. The patient tolerated BIPAP well and was transitioned back to the floor. She was subjectively improved and back on her baseline 2L oxygen with no accessory muscle use and good air movement at her bases. She will follow up with Dr. office regarding an outpatient sleep study. She was discharged on a prednisone taper. | Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: Plan: Respiratory assessment (LS, breathing pattern, Sat, RR), O2 therapy via NC, continue nebs, CPAP PRN, control any pain with oxycodone PRN, if continue to be stable, can be called out to a regular floor. Of note: pt treated with xopenex for insp and exp wheezing T/O. However, compared to the relatively remote CT of , there appears to be overall progression of the chronic interstitial lung disease. Respiratory failure, acute (not ARDS/) Assessment: c/o SOB on and off, LS insp/exp wheezes, anxious, sating above 95%, no tachypnea Action: Placed on CPAP, became anxious though reported improvement in breathing pattern, back on NC 2 LPM for most of the night alternated with CPAP as tolerated, given nebulizers by RT with moderate effect. Sinus rhythmPossible right atrial abnormalitySince previous tracing of , heart rate faster, T wave abnormalities areless - Initate non-invasive ventilation, settings per RT - Cont w/ 2 L NC during the day - Cont w/ pred 10 mg, nebs - pulmonary toilet with cough suppressant, anti-histamine - levalbuterol nebulizer tx QID as well as prn -mucinex 1200mg - chest PT (acapella device) consider change to solu medrol if worsening wheeze/cough 2)H/o Pseudomonas/MAC - Cont tobramycin inhalers, bactrim . - Initate non-invasive ventilation, settings per RT - Cont w/ 2 L NC during the day - Cont w/ pred 10 mg, nebs - pulmonary toilet with cough suppressant, anti-histamine - levalbuterol nebulizer tx QID as well as prn -mucinex 1200mg - chest PT (acapella device) consider change to solu medrol if worsening wheeze/cough 2)H/o Pseudomonas/MAC - Cont tobramycin inhalers, bactrim . Stable changes of severe interstitial lung disease. FINAL REPORT INDICATION: Bronchiolitis. Pseudomonal infection - pansensitive recently 4. related to RUL surgery), and with rheumatological w/u and PFT data. 3) Arthralgias/Arthritis: - cont oxycontin, oxycodone, amitryptiline, and prn celebrex ICU Care Nutrition: regular diet Glycemic Control: Lines: 20 Gauge - 09:18 PM Prophylaxis: DVT: heparin sq Stress ulcer: protonix Communication: Comments: Code status: Full Disposition: ICU overnight, likely tranfer back to floor in am Chief Complaint: Respiratory arrest 24 Hour Events: -started on BIPAP overnight, tolerated it for periods, did feel that air hunger was improved while wearing BIPAP History obtained from Medical records Patient unable to provide history: tracheostomy Allergies: Penicillins Hives; Iodine Hives; Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 05:56 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 36.7C (98 Tcurrent: 36.3C (97.3 HR: 83 (83 - 87) bpm BP: 125/65(80){118/59(78) - 126/80(81)} mmHg RR: 17 (17 - 22) insp/min SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Height: 64 Inch Total In: 100 mL 250 mL PO: 100 mL 250 mL TF: IVF: Blood products: Total out: 0 mL 500 mL Urine: 500 mL NG: Stool: Drains: Balance: 100 mL -250 mL Respiratory support O2 Delivery Device: Nasal cannula Ventilator mode: CPAP PS : 5 cmH2O SpO2: 99% ABG: ///31/ Physical Examination Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 439 K/uL 11.3 g/dL 110 mg/dL 0.7 mg/dL 31 mEq/L 4.6 mEq/L 19 mg/dL 100 mEq/L 140 mEq/L 34.6 % 15.5 K/uL [image002.jpg] 04:27 AM WBC 15.5 Hct 34.6 Plt 439 Cr 0.7 Glucose 110 Other labs: Ca++:9.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.9 mg/dL Assessment and Plan 63 year-old woman with panbrochiolistis on home O2, history of MAC, cavitary lesions who presented on with shortness of breath and cough, transferred to for initiation of non-invasive ventilation. Plan: Respiratory assessment (LS, breathing pattern, Sat, RR), O2 therapy via NC, continue nebs, CPAP PRN, control any pain with oxycodone PRN, if continue to be stable, can be called out to a regular floor. Action: Pt reports pain well controlled on baseline regimen of standing oxycontin and celebrex w/ amytriptaline at noc. Chief Complaint: initiation of non-invasive ventillation 24 Hour Events: -started on BIPAP overnight, tolerated it for periods, did feel that air hunger was improved while wearing BIPAP Allergies: Penicillins Hives; Iodine Hives; Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: Bactrim, inhaled tobramycin, prednisone 60, atrovent, , oxycontin, amitryptyline, SQheparin, mucinex, xopenex Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 05:56 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 36.7C (98 Tcurrent: 36.3C (97.3 HR: 83 (83 - 87) bpm BP: 125/65(80){118/59(78) - 126/80(81)} mmHg RR: 17 (17 - 22) insp/min SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Height: 64 Inch Total In: 100 mL 250 mL PO: 100 mL 250 mL TF: IVF: Blood products: Total out: 0 mL 500 mL Urine: 500 mL NG: Stool: Drains: Balance: 100 mL -250 mL Respiratory support O2 Delivery Device: Nasal cannula Ventilator mode: CPAP PS : 5 cmH2O SpO2: 99% ABG: ///31/ Physical Examination Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 439 K/uL 11.3 g/dL 110 mg/dL 0.7 mg/dL 31 mEq/L 4.6 mEq/L 19 mg/dL 100 mEq/L 140 mEq/L 34.6 % 15.5 K/uL [image002.jpg] 04:27 AM WBC 15.5 Hct 34.6 Plt 439 Cr 0.7 Glucose 110 Other labs: Ca++:9.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.9 mg/dL Assessment and Plan 63 year-old woman with panbrochiolistis on home O2, history of MAC, cavitary lesions who presented on with shortness of breath and cough, transferred to for initiation of non-invasive ventilation. | 27 | [
{
"category": "Radiology",
"chartdate": "2143-02-07 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 996681,
"text": " 12:54 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pnm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with COPD, dyspnea\n REASON FOR THIS EXAMINATION:\n ? pnm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old female with COPD and dyspnea. Evaluate for pneumonia.\n\n COMPARISON: Multiple series of prior studies from to , and CT of the chest and .\n\n CHEST PA AND LATERAL: There are extensive coarse reticular opacities\n diffusely throughout both lungs, with an apical predominance. This is\n consistent with known chronic interstitial lung disease. Surgical staples\n project within the right upper lobe. Compared to , which was\n obtained with similar technique, there is no short interval change. However,\n compared to the relatively remote CT of , there appears to be\n overall progression of the chronic interstitial lung disease. No acute focal\n consolidation concerning for pneumonia is identified. The cardiomediastinal\n contour is unchanged, with no pleural effusion. Osseous structures are\n unremarkable.\n\n IMPRESSION: No definite acute air space process. Severe interstitial lung\n disease, with no significant short-interval change, but overall progression\n since . Though this process may reflect a contribution of post-\n inflammatory scarring, given history of multiple pneumonia and bronchiolitis\n attributed to mycobacterial disease, the primary abnormality may represent the\n progressive interstitial fibrosis that has been reported as a significant\n accompaniment of polymyalgia rheumatica.\n\n COMMENT: These findings should be closely correlated with any\n relevant histopathology (eg. related to RUL surgery), and with rheumatological\n w/u and PFT data.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-02-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 996968,
"text": " 5:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval changes.\n Admitting Diagnosis: ASTHMA/COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with severe bronchiolitis admitted for CPAP trial.\n REASON FOR THIS EXAMINATION:\n eval for interval changes.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bronchiolitis.\n\n COMPARISONS: .\n\n AP PORTABLE UPRIGHT CHEST: New cardiac leads overlie the chest. Metallic\n staples are seen in the right upper lung. There has been no interval change\n in severe interstitial lung disease. There is no focal airspace opacity,\n effusion or pneumothorax. The cardiac size is stable.\n\n IMPRESSION:\n 1. Stable changes of severe interstitial lung disease.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2143-02-07 00:00:00.000",
"description": "Report",
"row_id": 275552,
"text": "Sinus rhythm. RSR' pattern in leads V1-V2 with ST-T wave abnormalities which\nare diffuse. Compared to the previous tracing of RSR' pattern and\nST-T wave abnormalities are more prominent. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2143-02-11 00:00:00.000",
"description": "Report",
"row_id": 275549,
"text": "Sinus rhythm\nPossible right atrial abnormality\nSince previous tracing of , heart rate faster, T wave abnormalities are\nless\n\n"
},
{
"category": "ECG",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Report",
"row_id": 275550,
"text": "Sinus rhythm\nConsider right atrial abnormality\nInferior + anterior T wave change\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2143-02-07 00:00:00.000",
"description": "Report",
"row_id": 275551,
"text": "Sinus rhythm. Compared to the previous tracing no significant change.\nTRACING #2\n\n"
},
{
"category": "Respiratory ",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Respiratory Care",
"row_id": 407682,
"text": "TITLE:\n Respiratory Care:\n CPAP requested for treatment of respiratory distress due to severe pan\n bronchiolitis and bronchiectasis.\n Pt started on CPAP via nasal mask @ 5 cm with O2 bled in @ 2lpm. Mask\n and settings adjusted to pt satisfaction. After one hour pt requested\n break from mask because of discomfort and wishes to try again\nlater\n Please note pt appears very particular about her\nlikes and dislikes\n as well as anxious that her needs are met to her exact specifications.\n It may be difficult to obtain the exact fit and comfort that she\n expects to attain from CPAP therapy.\n Pt in NAD with SpO2 98-100% on O2 at 2 lpm.\n ------ Protected Section ------\n Pt requested second trial of CPAP and tol better lasting 2.5 hours,\n felt pretty comfortable.\n ------ Protected Section Addendum Entered By: , \n on: 04:27 ------\n Actually wore CPAP for 3 hours not 2.5 as originally reported.\n Of note: pt treated with xopenex for insp and exp wheezing T/O.\n Remarkable improvement with treatment with complete clearing of wheeze\n and improved aeration T/O.\n Resp to continue and follow as ordered.\n ------ Protected Section Addendum Entered By: , \n on: 04:30 ------\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 407693,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2143-02-08 00:00:00.000",
"description": "Respiratory Care",
"row_id": 407679,
"text": "TITLE:\n Respiratory Care:\n CPAP requested for treatment of respiratory distress due to severe pan\n bronchiolitis and bronchiectasis.\n Pt started on CPAP via nasal mask @ 5 cm with O2 bled in @ 2lpm. Mask\n and settings adjusted to pt satisfaction. After one hour pt requested\n break from mask because of discomfort and wishes to try again\nlater\n Please note pt appears very particular about her\nlikes and dislikes\n as well as anxious that her needs are met to her exact specifications.\n It may be difficult to obtain the exact fit and comfort that she\n expects to attain from CPAP therapy.\n Pt in NAD with SpO2 98-100% on O2 at 2 lpm.\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 407680,
"text": "Chief Complaint: initiation of non-invasive ventilation\n HPI:\n This is a 63 year-old woman with panbrochiolistis on home O2, history\n of MAC, cavitary lesions (thought secondary to pseudomonas started on\n tobramycin/DNAase two weeks ago) who presented on with shortness\n of breath and cough, transferred to for initiation of non-invasive\n ventilation. She had seen her pulmonologist, Dr. , on \n with worsening SOB. She was undergoing outpatient pulmonary rehab,\n though her symptoms of cough and shortness of breath had worsened over\n the past year. She completed a three-week course of oral ciprofloxacin\n in mid- without relief. Later in the month her prednisone dose\n was increased to 30 mg, which she has tapered down to 10 mg. She was\n recently started on Tobramycin inhalers.\n .\n In the ER her vitals were T 97.9, HR 100, BP 112/71, O2 99 % RA. She\n was given methylprednisolone 100mg, cipro 500 mg , 325 mg,\n albuterol 0.083% nebs, and oxycodone po. On the floor she was\n transitioned to PO prednisone.\n .\n Currently the pt feels better, but cont to complain of mild SOB.\n History obtained from Patient\n Allergies:\n Penicillins\n Hives;\n Iodine\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Medications at :\n Atrovent HFA 17 mcg/Actuation - 2 puffs TID\n CELEBREX 200 mg PO Q12H prn pain\n CLARITIN 10 mg--1 tablet by mouth daily\n COLACE 100 mg--once a day\n Conjugated Estrogens 0.3 mg--1 (one) tablet(s) QDay\n GlycoLax 17 gram (100 %)--once a day\n MUCINEX 600 mg PO BID\n OXYCONTIN 20 mg PO BID\n Oxycodone 10 mg PO BID\n PROTONIX 20 mg PO QDay\n AMITRIPTYLINE 20 mg PO QDay\n IPRATROPIUM BROMIDE TID prn SOB\n IPRATROPIUM BROMIDE 42 mcg --1 puff inhaled each nostril \n PREDNISONE 10 mg--1 tablets by mouth daily\n Tobramycin 300 mg/5 mL Solution for Nebulization\n Past medical history:\n Family history:\n Social History:\n 1. panbronchiolitis, cystic lung dz (MAC, pseudomonas): dx in ,\n inflammatory disease of small airways, severe obstruction.\n 2. History of MAC - \n 3. Pseudomonal infection - pansensitive recently\n 4. Bronchiectasis\n 5. Arthralgias/Arthritis\n NC\n Occupation: not working medical illness\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: nasal congeestion\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema\n Respiratory: Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 03:39 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 83 (83 - 87) bpm\n BP: 125/65(80){118/59(78) - 126/80(81)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 100 mL\n 100 mL\n PO:\n 100 mL\n 100 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 100 mL\n -400 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP\n PS : 5 cmH2O\n SpO2: 100%\n Physical Examination\n VS: Tmax:98 BP: 120/80 HR:91 RR:19 O2sat: 98% on 2 L NC\n General: pleasant, moon facies, NAD, non toxic\n Eyes: : PERLLA, EOMI, no conjuctival injection, anicteric\n ENT: MMM, op without exudate or lesions\n Respiratory: fine scattered crackles and faint end- expiratory wheezes\n throughout.\n Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops\n appreciated\n Gastrointestinal: nd, +b/s, soft, nt, no masses or hepatosplenomegaly\n Musculoskeletal/extremities: no cyanosis, clubbing or edema\n Skin/nails: warm, no rashes/no jaundice/no splinters\n Labs / Radiology\n 559\n 137\n 0.8\n 16\n 36\n 98\n 3.6\n 142\n 37.4\n 13.5\n [image002.jpg] CK 30 MB3 Trop <0.01\n Ca 9.2 mg2.4 phos4.5 INR 1\n CXR: No definite acute air space process. Severe interstitial\n lung disease, with no significant short-interval change, but overall\n progression since . Though this process may reflect a contribution\n of post- inflammatory scarring, given history of multiple pneumonia and\n bronchiolitis attributed to mycobacterial disease, the primary\n abnormality may represent the progressive interstitial fibrosis that\n has been reported as a significant\n accompaniment of polymyalgia rheumatica.\n Assessment and Plan\n 63 year-old woman with panbrochiolistis on home O2, history of MAC,\n cavitary lesions who presented on with shortness of breath and\n cough, transferred to for initiation of non-invasive ventilation.\n .\n 1) Panbrochiolitis: Her pulmonologist feels that she would benefit from\n non-invasive ventilation at night as well as for acute dyspnea.\n - Initate non-invasive ventilation, settings per RT\n - Cont w/ 2 L NC during the day\n - Cont w/ pred 10 mg, nebs\n - pulmonary toilet with cough suppressant, anti-histamine\n - levalbuterol nebulizer tx QID as well as prn\n -mucinex 1200mg \n - chest PT (acapella device)\n consider change to solu medrol if worsening wheeze/cough\n 2)H/o Pseudomonas/MAC\n - Cont tobramycin inhalers, bactrim\n .\n 3) Arthralgias/Arthritis:\n - cont oxycontin, oxycodone, amitryptiline, and prn celebrex.\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 09:18 PM\n Prophylaxis:\n DVT: heparin sq\n Stress ulcer: protonix\n Communication: Comments:\n Code status: Full\n Disposition: ICU overnight, likely tranfer back to floor in am\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 407683,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n c/o SOB on and off, LS insp/exp wheezes, anxious, sating above 95%, no\n tachypnea\n Action:\n Placed on CPAP, became anxious though reported improvement in breathing\n pattern, back on NC 2 LPM for most of the night alternated with CPAP as\n tolerated, given nebulizers by RT with moderate effect.\n Response:\n Breathing pattern improved, less wheezy, breathing more comfortably,\n though still feeling anxious about the CPAP.\n Plan:\n Respiratory assessment (LS, breathing pattern, Sat, RR), O2 therapy via\n NC, continue nebs, CPAP PRN, control any pain with oxycodone PRN, if\n continue to be stable, can be called out to a regular floor.\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 407684,
"text": "Chief Complaint: Respiratory arrest\n 24 Hour Events:\n -Got 1/2 dose of glargine last night, Blood glucose of 46 this morning,\n given AMP d50\n -anxious/calling out throughout the night, restrained for pulling on\n trach, requested 1:1 sitter\n History obtained from Medical records\n Patient unable to provide history: tracheostomy\n Allergies:\n Penicillins\n Hives;\n Iodine\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 83 (83 - 87) bpm\n BP: 125/65(80){118/59(78) - 126/80(81)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 100 mL\n 250 mL\n PO:\n 100 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 100 mL\n -250 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP\n PS : 5 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 439 K/uL\n 11.3 g/dL\n 110 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 100 mEq/L\n 140 mEq/L\n 34.6 %\n 15.5 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 15.5\n Hct\n 34.6\n Plt\n 439\n Cr\n 0.7\n Glucose\n 110\n Other labs: Ca++:9.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ARTHRITIS, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:18 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 407685,
"text": "Chief Complaint: Respiratory arrest\n 24 Hour Events:\n -Got 1/2 dose of glargine last night, Blood glucose of 46 this morning,\n given AMP d50\n -anxious/calling out throughout the night, restrained for pulling on\n trach, requested 1:1 sitter\n History obtained from Medical records\n Patient unable to provide history: tracheostomy\n Allergies:\n Penicillins\n Hives;\n Iodine\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 83 (83 - 87) bpm\n BP: 125/65(80){118/59(78) - 126/80(81)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 100 mL\n 250 mL\n PO:\n 100 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 100 mL\n -250 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP\n PS : 5 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 439 K/uL\n 11.3 g/dL\n 110 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 100 mEq/L\n 140 mEq/L\n 34.6 %\n 15.5 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 15.5\n Hct\n 34.6\n Plt\n 439\n Cr\n 0.7\n Glucose\n 110\n Other labs: Ca++:9.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 09:18 PM\n Prophylaxis:\n DVT: heparin sq\n Stress ulcer: protonix\n Communication: Comments:\n Code status: Full\n Disposition: ICU overnight, likely tranfer back to floor in am\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 407686,
"text": "Chief Complaint: Respiratory arrest\n 24 Hour Events:\n -started on BIPAP overnight, tolerated it for periods, did feel that\n air hunger was improved while wearing BIPAP\n History obtained from Medical records\n Patient unable to provide history: tracheostomy\n Allergies:\n Penicillins\n Hives;\n Iodine\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 83 (83 - 87) bpm\n BP: 125/65(80){118/59(78) - 126/80(81)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 100 mL\n 250 mL\n PO:\n 100 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 100 mL\n -250 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP\n PS : 5 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 439 K/uL\n 11.3 g/dL\n 110 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 100 mEq/L\n 140 mEq/L\n 34.6 %\n 15.5 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 15.5\n Hct\n 34.6\n Plt\n 439\n Cr\n 0.7\n Glucose\n 110\n Other labs: Ca++:9.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 63 year-old woman with panbrochiolistis on home O2, history of MAC,\n cavitary lesions who presented on with shortness of breath and\n cough, transferred to for initiation of non-invasive ventilation.\n .\n 1) Panbrochiolitis: Her pulmonologist feels that she would benefit from\n non-invasive ventilation at night as well as for acute dyspnea.\n - Initate non-invasive ventilation, settings per RT\n - Cont w/ 2 L NC during the day\n - Cont w/ pred 10 mg, nebs\n - pulmonary toilet with cough suppressant, anti-histamine\n - levalbuterol nebulizer tx QID as well as prn\n -mucinex 1200mg \n - chest PT (acapella device)\n consider change to solu medrol if worsening wheeze/cough\n 2)H/o Pseudomonas/MAC\n - Cont tobramycin inhalers, bactrim\n .\n 3) Arthralgias/Arthritis:\n - cont oxycontin, oxycodone, amitryptiline, and prn celebrex\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 09:18 PM\n Prophylaxis:\n DVT: heparin sq\n Stress ulcer: protonix\n Communication: Comments:\n Code status: Full\n Disposition: ICU overnight, likely tranfer back to floor in am\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 407687,
"text": "Chief Complaint: initiation of non-invasive ventillation\n 24 Hour Events:\n -started on BIPAP overnight, tolerated it for periods, did feel that\n air hunger was improved while wearing BIPAP\n History obtained from Medical records\n Patient unable to provide history: tracheostomy\n Allergies:\n Penicillins\n Hives;\n Iodine\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 83 (83 - 87) bpm\n BP: 125/65(80){118/59(78) - 126/80(81)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 100 mL\n 250 mL\n PO:\n 100 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 100 mL\n -250 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP\n PS : 5 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 439 K/uL\n 11.3 g/dL\n 110 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 100 mEq/L\n 140 mEq/L\n 34.6 %\n 15.5 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 15.5\n Hct\n 34.6\n Plt\n 439\n Cr\n 0.7\n Glucose\n 110\n Other labs: Ca++:9.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 63 year-old woman with panbrochiolistis on home O2, history of MAC,\n cavitary lesions who presented on with shortness of breath and\n cough, transferred to for initiation of non-invasive ventilation.\n .\n 1) Panbrochiolitis: Her pulmonologist feels that she would benefit from\n non-invasive ventilation at night as well as for acute dyspnea.\n - Initate non-invasive ventilation, settings per RT\n - Cont w/ 2 L NC during the day\n - Cont w/ pred 10 mg, nebs\n - pulmonary toilet with cough suppressant, anti-histamine\n - levalbuterol nebulizer tx QID as well as prn\n -mucinex 1200mg \n - chest PT (acapella device)\n consider change to solu medrol if worsening wheeze/cough\n 2)H/o Pseudomonas/MAC\n - Cont tobramycin inhalers, bactrim\n .\n 3) Arthralgias/Arthritis:\n - cont oxycontin, oxycodone, amitryptiline, and prn celebrex\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 09:18 PM\n Prophylaxis:\n DVT: heparin sq\n Stress ulcer: protonix\n Communication: Comments:\n Code status: Full\n Disposition: ICU overnight, likely tranfer back to floor in am\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 407688,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n c/o SOB on and off, LS insp/exp wheezes, anxious, sating above 95%, no\n tachypnea\n Action:\n Placed on CPAP, became anxious though reported improvement in breathing\n pattern, back on NC 2 LPM for most of the night alternated with CPAP as\n tolerated, given nebulizers by RT with moderate effect.\n Response:\n Breathing pattern improved, less wheezy, breathing more comfortably,\n though still feeling anxious about the CPAP.\n Plan:\n Respiratory assessment (LS, breathing pattern, Sat, RR), O2 therapy via\n NC, continue nebs, CPAP PRN, control any pain with oxycodone PRN, if\n continue to be stable, can be called out to a regular floor.\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 407689,
"text": "Chief Complaint: initiation of non-invasive ventillation\n 24 Hour Events:\n -started on BIPAP overnight, tolerated it for periods, did feel that\n air hunger was improved while wearing BIPAP\n Allergies:\n Penicillins\n Hives;\n Iodine\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 83 (83 - 87) bpm\n BP: 125/65(80){118/59(78) - 126/80(81)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 100 mL\n 250 mL\n PO:\n 100 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 100 mL\n -250 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP\n PS : 5 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 439 K/uL\n 11.3 g/dL\n 110 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 100 mEq/L\n 140 mEq/L\n 34.6 %\n 15.5 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 15.5\n Hct\n 34.6\n Plt\n 439\n Cr\n 0.7\n Glucose\n 110\n Other labs: Ca++:9.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 63 year-old woman with panbrochiolistis on home O2, history of MAC,\n cavitary lesions who presented on with shortness of breath and\n cough, transferred to for initiation of non-invasive ventilation.\n .\n 1) Panbrochiolitis: Her pulmonologist feels that she would benefit from\n non-invasive ventilation at night as well as for acute dyspnea.\n - Initate non-invasive ventilation, settings per RT\n - Cont w/ 2 L NC during the day\n - Cont w/ pred 10 mg, nebs\n - pulmonary toilet with cough suppressant, anti-histamine\n - levalbuterol nebulizer tx QID as well as prn\n -mucinex 1200mg \n - chest PT (acapella device)\n consider change to solu medrol if worsening wheeze/cough\n 2)H/o Pseudomonas/MAC\n - Cont tobramycin inhalers, bactrim\n .\n 3) Arthralgias/Arthritis:\n - cont oxycontin, oxycodone, amitryptiline, and prn celebrex\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 09:18 PM\n Prophylaxis:\n DVT: heparin sq\n Stress ulcer: protonix\n Communication: Comments:\n Code status: Full\n Disposition: ICU overnight, likely tranfer back to floor in am\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 407690,
"text": "Chief Complaint: Bright red blood per rectum\n 24 Hour Events:\n none\n Allergies:\n Penicillins\n Hives;\n Iodine\n Hives;\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 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 83 (83 - 87) bpm\n BP: 125/65(80){118/59(78) - 126/80(81)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 100 mL\n 250 mL\n PO:\n 100 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 100 mL\n -250 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP\n PS : 5 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 439 K/uL\n 11.3 g/dL\n 110 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 100 mEq/L\n 140 mEq/L\n 34.6 %\n 15.5 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 15.5\n Hct\n 34.6\n Plt\n 439\n Cr\n 0.7\n Glucose\n 110\n Other labs: Ca++:9.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ARTHRITIS, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:18 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 407691,
"text": "Chief Complaint:\n 24 Hour Events:\n none\n Allergies:\n Penicillins\n Hives;\n Iodine\n Hives;\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 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 83 (83 - 87) bpm\n BP: 125/65(80){118/59(78) - 126/80(81)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 100 mL\n 250 mL\n PO:\n 100 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 100 mL\n -250 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP\n PS : 5 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 439 K/uL\n 11.3 g/dL\n 110 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 100 mEq/L\n 140 mEq/L\n 34.6 %\n 15.5 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 15.5\n Hct\n 34.6\n Plt\n 439\n Cr\n 0.7\n Glucose\n 110\n Other labs: Ca++:9.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ARTHRITIS, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:18 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 407692,
"text": "Chief Complaint:\n 24 Hour Events:\n none\n Allergies:\n Penicillins\n Hives;\n Iodine\n Hives;\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 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 83 (83 - 87) bpm\n BP: 125/65(80){118/59(78) - 126/80(81)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 100 mL\n 250 mL\n PO:\n 100 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 100 mL\n -250 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP\n PS : 5 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 439 K/uL\n 11.3 g/dL\n 110 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 100 mEq/L\n 140 mEq/L\n 34.6 %\n 15.5 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 15.5\n Hct\n 34.6\n Plt\n 439\n Cr\n 0.7\n Glucose\n 110\n Other labs: Ca++:9.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ARTHRITIS, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:18 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 06:25 ------\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 407694,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt to MICU for BiPapP initation.\n Action:\n Pt tolerating Bipap intermittently over noc. Continues on abx, inhaled\n tobra, and xopenex nebs and oral prednisone. C+DB encouraged q1hr WA.\n Response:\n Pt transitioned to baseline 02 2L via NC. BBS w/ exp wheezes though\n good airflow t/o. Pt afebrile, speaking in full sentences w/ no use of\n accessory muscles w/ quiet respirations. Pt practicing C+DB exercises\n during each TV commercial.\n Plan:\n Continue working to adjust Bipap fittings for comfort. Encourage\n progressive use of bipap over noc. Continue abx and nebs as ordered.\n Encourage C+DB exercises.\n Anxiety\n Assessment:\n Pt somewhat anxious this am per her report. Verbalizing concern that\n she will\nhave another coughing fit like yesterday.\n Action:\n Guiaifenesin-Codiene obtained from pharmacy and given as ordered.\n Relaxation techniques taught and encouraged. Calm and gentle approach\n used.\n Response:\n Pt appears calm and relaxed. Reports feeling more less anxious. Reports\n using relaxation techniques.\n Plan:\n Continue to use calm approach. Medicate as ordered and indicated.\n Encourage relaxation techniques.\n Chest pain\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": "2143-02-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 407695,
"text": "Chief Complaint:\n HPI:\n 63 year old with history of bronchiolitis, recurrent MAC/psuedomonal\n infections with multiple admissions for pneumonia/infection.\n Transfered to the ICU for semi-elective non-invasive\n 24 Hour Events:\n - Started on bipap overnight () and was able tolerate intermittently\n - otherwise, no new events\n History obtained from Medical records\n Allergies:\n Penicillins\n Hives;\n Iodine\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Bactrim\n Tobra (inhaled)\n Oxycotin\n Amytrip\n Atrovent\n Zopidex\n \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 11:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36\nC (96.8\n HR: 86 (67 - 98) bpm\n BP: 124/71(82){89/41(52) - 138/80(93)} mmHg\n RR: 20 (13 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 100 mL\n 680 mL\n PO:\n 100 mL\n 670 mL\n TF:\n IVF:\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 1,200 mL\n Urine:\n 1,200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 100 mL\n -520 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP\n PS : 5 cmH2O\n SpO2: 96%\n ABG: ///31/\n Physical Examination\n General Appearance: Well nourished\n Cardiovascular: (S1: Normal), (S2: Normal), S3\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: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 11.3 g/dL\n 439 K/uL\n 110 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 100 mEq/L\n 140 mEq/L\n 34.6 %\n 15.5 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 15.5\n Hct\n 34.6\n Plt\n 439\n Cr\n 0.7\n Glucose\n 110\n Other labs: Ca++:9.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 1- Bronchiolitis exacerbation\n Plan: continue prednisonse, nebs, pulmonary toilet, inhaled tobra,\n bactrim\n 2- Chest pressure\n Plan: EKG, serial troponins,\n 3-\n ARTHRITIS, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:18 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 407696,
"text": "Chief Complaint: initiation of non-invasive ventillation\n 24 Hour Events:\n -started on BIPAP overnight, tolerated it for periods, did feel that\n air hunger was improved while wearing BIPAP\n Allergies:\n Penicillins\n Hives;\n Iodine\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Bactrim, inhaled tobramycin, prednisone 60, atrovent, , oxycontin,\n amitryptyline, SQheparin, mucinex, xopenex\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 83 (83 - 87) bpm\n BP: 125/65(80){118/59(78) - 126/80(81)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 100 mL\n 250 mL\n PO:\n 100 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 100 mL\n -250 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP\n PS : 5 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 439 K/uL\n 11.3 g/dL\n 110 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 100 mEq/L\n 140 mEq/L\n 34.6 %\n 15.5 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 15.5\n Hct\n 34.6\n Plt\n 439\n Cr\n 0.7\n Glucose\n 110\n Other labs: Ca++:9.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 63 year-old woman with panbrochiolistis on home O2, history of MAC,\n cavitary lesions who presented on with shortness of breath and\n cough, transferred to for initiation of non-invasive ventilation.\n .\n 1) Panbrochiolitis: Her pulmonologist feels that she would benefit from\n non-invasive ventilation at night as well as for acute dyspnea.\n - Initate non-invasive ventilation, settings per RT\n - Cont w/ 2 L NC during the day\n - Cont w/ pred 10 mg, nebs\n - pulmonary toilet with cough suppressant, anti-histamine\n - levalbuterol nebulizer tx QID as well as prn\n -mucinex 1200mg \n - chest PT (acapella device)\n consider change to solu medrol if worsening wheeze/cough\n 2)H/o Pseudomonas/MAC\n - Cont tobramycin inhalers, bactrim\n .\n 3) Arthralgias/Arthritis:\n - cont oxycontin, oxycodone, amitryptiline, and prn celebrex\n ICU Care\n Nutrition: regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 09:18 PM\n Prophylaxis:\n DVT: heparin sq\n Stress ulcer: protonix\n Communication: Comments:\n Code status: Full\n Disposition: ICU overnight, likely tranfer back to floor in am\n"
},
{
"category": "Physician ",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 407697,
"text": "Chief Complaint: initiation of non-invasive ventillation\n 24 Hour Events:\n -started on BIPAP overnight, tolerated it for periods, did feel that\n air hunger was improved while wearing BIPAP\n -settings overnight were CPAP of 5\n Allergies:\n Penicillins\n Hives;\n Iodine\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Bactrim, inhaled tobramycin, prednisone 60, atrovent, , oxycontin,\n amitryptyline, SQheparin, mucinex, xopenex\n Changes to medical and family history:none\n Review of systems is unchanged from admission except as noted below\n Review of systems:none\n Flowsheet Data as of 05:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 83 (83 - 87) bpm\n BP: 125/65(80){118/59(78) - 126/80(81)} mmHg\n RR: 17 (17 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 64 Inch\n Total In:\n 100 mL\n 250 mL\n PO:\n 100 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 100 mL\n -250 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP\n PS : 5 cmH2O\n SpO2: 99%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 439 K/uL\n 11.3 g/dL\n 110 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 100 mEq/L\n 140 mEq/L\n 34.6 %\n 15.5 K/uL\n [image002.jpg]\n 04:27 AM\n WBC\n 15.5\n Hct\n 34.6\n Plt\n 439\n Cr\n 0.7\n Glucose\n 110\n Other labs: Ca++:9.2 mg/dL, Mg++:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 63 year-old woman with panbrochiolistis on home O2, history of MAC,\n cavitary lesions who presented on with shortness of breath and\n cough, transferred to for initiation of non-invasive ventilation.\n Did well overnight, tolerated CPAP with improvement in symptoms and no\n hypoxia/desaturation or respiratory depression.\n .\n 1) Panbrochiolitis: Her pulmonologist feels that she would benefit from\n non-invasive ventilation at night as well as for acute dyspnea. She\n tolerated CPAP of 5 overnight, did report improvement in sensation of\n dyspnea. Likely would benefit from outpatient sleep study and\n determination of ideal settings.\n - Cont w/ 2 L NC during the day\n - Cont w/ pred 60mg, likely ready for taper\n - pulmonary toilet with cough suppressant, anti-histamine\n - levalbuterol nebulizer tx QID as well as prn\n -mucinex 1200mg \n - chest PT (acapella device)\n 2)H/o Pseudomonas/MAC\n - Cont tobramycin inhaled, bactrim\n .\n 3) Arthralgias/Arthritis:\n - cont oxycontin, oxycodone, amitryptiline, and prn celebrex\n ICU Care\n Nutrition: regular diet\n Glycemic Control: none, monitor blood glucose\n Lines:\n 20 Gauge - 09:18 PM\n Prophylaxis:\n DVT: heparin sq\n Stress ulcer: protonix\n Communication: Comments:\n Code status: Full\n Disposition : c/o to floor\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 407698,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt to MICU for BiPapP initation.\n Action:\n Pt tolerating Bipap intermittently over noc. Continues on abx, inhaled\n tobra, and xopenex nebs and oral prednisone. C+DB encouraged q1hr WA.\n Response:\n Pt transitioned to baseline 02 2L via NC. BBS w/ exp wheezes though\n good airflow t/o. Pt afebrile, speaking in full sentences w/ no use of\n accessory muscles w/ quiet respirations. Pt practicing C+DB exercises\n during each TV commercial.\n Plan:\n Continue working to adjust Bipap fittings for comfort. Encourage\n progressive use of bipap over noc. Continue abx and nebs as ordered.\n Encourage C+DB exercises.\n Anxiety\n Assessment:\n Pt somewhat anxious this am per her report. Verbalizing concern that\n she will\nhave another coughing fit like yesterday.\n Action:\n Guiaifenesin-Codiene obtained from pharmacy and given as ordered.\n Relaxation techniques taught and encouraged. Calm and gentle approach\n used.\n Response:\n Pt appears calm and relaxed. Reports feeling more less anxious. Reports\n using relaxation techniques.\n Plan:\n Continue to use calm approach. Medicate as ordered and indicated.\n Encourage relaxation techniques.\n Chest pain\n Assessment:\n Pt w/ hx jaw pain and chest pressure X 5 episodes previously. Has had\n multiple w/u including cycling enzymes, EKG\ns and negative stress per\n pt\ns report. Pt reported substernal chest pressure w/ minimal jaw\n pain this am. No change in VS, pt remained free of diaphoresis or\n distress.\n Action:\n EKG obtained, reviewed by Dr. who reports ST-T changes in\n inferior leads and V4. Pt reported s/s resolved by completion of EKG.\n Pt started on 325mg as ordered. New orders to re-cycle cardiac\n enzymes\n labs sent at 1130am as ordered.\n Response:\n Pt remains free of further s/s CP. Labs pnd.\n Plan:\n Repeat set of cardiac enzymes due at as ordered. Repeat EKG and\n w/u for further s/s CP.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reports chronic BLE pain in addition to arthritis pain.\n Action:\n Pt reports pain well controlled on baseline regimen of standing\n oxycontin and celebrex w/ amytriptaline at noc.\n Response:\n Pt reports on this regimen pain remains 0/10 and she denies lethargy.\n Plan:\n Continue current regimen\n"
},
{
"category": "Nursing",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 407699,
"text": "Demographics\n Attending MD:\n Dr. \n Admit diagnosis:\n ASTHMA/COPD EXACERBATION\n Code status:\n Full code\n Height:\n 64 Inch\n Admission weight:\n 58.2 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Hives;\n Iodine\n Hives;\n Precautions:\n PMH: COPD\n CV-PMH:\n Additional history: Asthma, Pan-bronchiectasis, bronchiolitis since\n , Arthritis, TAH/BSO in 91, Pseudomonas infection\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:113\n D:60\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 82 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 24h total in:\n 800 mL\n 24h total out:\n 1,200 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 04:27 AM\n Potassium:\n 4.6 mEq/L\n 04:27 AM\n Chloride:\n 100 mEq/L\n 04:27 AM\n CO2:\n 31 mEq/L\n 04:27 AM\n BUN:\n 19 mg/dL\n 04:27 AM\n Creatinine:\n 0.7 mg/dL\n 04:27 AM\n Glucose:\n 110 mg/dL\n 04:27 AM\n Hematocrit:\n 34.6 %\n 04:27 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: CD player, palm pilot, 5 metallic bracelets, one\n yellow bracelet, one metallic watch.\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: Boyfriend\n Jewelry:\n Transferred from: 402\n Transferred to: 11R\n Date & time of Transfer: \n"
},
{
"category": "Respiratory ",
"chartdate": "2143-02-09 00:00:00.000",
"description": "Respiratory Care",
"row_id": 407681,
"text": "TITLE:\n Respiratory Care:\n CPAP requested for treatment of respiratory distress due to severe pan\n bronchiolitis and bronchiectasis.\n Pt started on CPAP via nasal mask @ 5 cm with O2 bled in @ 2lpm. Mask\n and settings adjusted to pt satisfaction. After one hour pt requested\n break from mask because of discomfort and wishes to try again\nlater\n Please note pt appears very particular about her\nlikes and dislikes\n as well as anxious that her needs are met to her exact specifications.\n It may be difficult to obtain the exact fit and comfort that she\n expects to attain from CPAP therapy.\n Pt in NAD with SpO2 98-100% on O2 at 2 lpm.\n ------ Protected Section ------\n Pt requested second trial of CPAP and tol better lasting 2.5 hours,\n felt pretty comfortable.\n ------ Protected Section Addendum Entered By: , \n on: 04:27 ------\n"
}
] |
14,898 | 108,698 | So at this time the patient was admitted with end-stage liver disease for a liver transplant. He was placed nil per os. Consent was signed. CellCept, Solu- Medrol, Unasyn, fluconazole were started. Labs were drawn. Urinalysis was performed. A chest x-ray was performed and an electrocardiogram was performed. Anesthesia consent was also obtained as he was seen by their staff. On , liver transplant was performed under general anesthesia. The patient was brought to the Surgical Intensive Care Unit after the operation. The patient was progressing well at this time and on postoperative day one the plan was to use morphine sulfate for pain as needed. A transesophageal echocardiogram had shown residual clot and adequate biventricular function. A chest x-ray was sent and the patient was weaned off of FiO2. The patient was also nil per os at this time and on an nasogastric tube. The patient was also on a Foley catheter to follow urine output closely. Infectious Disease: The patient was placed on Unasyn times three days. The patient was also transfused platelets, fresh frozen plasma and cryoprecipitate at this time and the patient began the immunosuppressive regimen with Solu-Medrol at 140 twice a day, CellCept 1 gram twice a day, ________ times one intraoperatively and, in terms of endocrine, patient was placed on a regular insulin sliding scale at this time with a plan to move to an insulin drip if glucose levels trended upwards. The patient continued to progress well during his stay and continued to oxygenate well and was able to be weaned off of oxygen, FiO2 as he was weaned off of propofol at this time. Prophylactic medications, Bactrim and fluconazole, were continued at this time. The patient continued to progress well at this time and on the propofol was discontinued. An electrocardiogram was taken showing no ischemic changes. The patient did not need a beta blocker at this time. Patient was receiving Nipride which was being held for systolic blood pressure less than 160. The patient was given Lasix to diurese and established an adequate urine output. The patient was started on total parenteral nutrition and Unasyn was discontinued at this time. On , the patient continued to progress taking Dilaudid p.r.n. for pain at this time. Stable vital signs. Patient receiving CPAP and his total bilirubin and other liver function tests including ALT and AST continued to trend downward. Good bile output out of the drain. His liver function tests on this day were 155 for AST, 614 for ALT and 64 for alk phos. The previous day on were AST of 252, ALT of 309 and alk phos of 65. The patient was continued on Lasix diuresis and continued on prophylactic Bactrim, fluconazole and ganciclovir. The patient at this time was on an insulin drip. The patient continued to progress on the and was being followed at this time by the inpatient clinical Nutrition team. They recommended titrating insulin drip as needed and set up a TPN to regiment with a goal of 2,150 kilocalories per day. On , the patient continued to progress well. His wound was noted to be without pus or erythema at this time. He was continued on Dilaudid as needed for pain. He was still being followed by the SICU team in the Surgical Intensive Care Unit. At this time patient was able to change to largely oral medications. He had stable respiratory status and was now off of ventilation. On postoperative day nine, , the patient continued to be stable but appeared somewhat confused upon examination. It was recommended at this time the patient be transferred to the floor and later in the day he was transferred to 10. Date of extubation for this patient was . The patient began to be evaluated by Physical Therapy on . On , it was noted they found the patient to be alert and oriented but mildly inappropriate with tangential speech. They noting that he was practicing even coordinated breathing. Their general impression was that this man's mobility would improve. He was tolerating being out-of-bed well but that he would require short term rehabilitation upon discharge to maximize functional status. They also stated that his potential to return to baseline was good. They recommended one to three more weeks of physical therapy or until discharge to rehabilitation. The patient began to be followed by the consult team on the . The attending noted that the patient was now transitioning to eating meals and suggested starting Lentes and Humalog regimen. As per their request after they reviewed the chart they noted that his prior regimen was likely suboptimal and that his insulin needs would be significantly different after this liver transplantation due to the effects of steroids and his new liver and they began to discuss outpatient regimens for the patient. The patient was also receiving Occupational Therapy evaluations and it was noted on , by Occupational Therapy that patient was minimally confused and that he would likely need rehabilitation prior to returning home. On the the patient continued to progress well, complained of some mild abdominal pain but noted significant improvement since the immediate postoperative time. There were noted to be multiple ecchymotic areas over his right upper extremity at this time and four to five skin ulcerations on his left upper extremity. Ancef 1 gram every eight hours was started at this time and a full HUS workup was commenced and Hematology was consulted. A blood smear was sent that was viewed by Hematology not to contain any schistocytes and that most likely a hemolytic-uremic syndrome workup was not necessarily warranted but that they would follow the results. On postoperative day 12, , the patient continued to progress well and began to be screened for rehabilitation. He continued to be followed by for glucose levels and was continued on Ancef at this time. His vital signs were stable and the patient was without pain at this time. He was passing gas and having bowel movements and was noted an increased appetite. The patient continued to be followed by Nutrition, Respiratory Care and his liver function tests continued to trend downwards. Cyclosporin levels were found to be therapeutic and it was determined again by Transplant staff that the patient would likely need rehabilitation. continued to follow the patient at this time and recommended that the patient continue with current Lentes and Humalog sliding scale regimen. On the the patient was doing well with only mild abdominal pain with lunging or reaching movements. He was still passing gas and having bowel movements and taking solid foods at this time. The patient still appeared somewhat distant in conversation and a Psychiatry consult was ordered. Per Psychiatry's request, the lithium level was sent and found to be 1.9. At this time Psychiatry recommended that lithium be held and Haldol be used as needed for agitation. At this time it was noted that the patient was not taking enough food orally and a feeding tube was placed by Interventional Radiology. Then on the morning of , the patient went on to pull the feeding tube from its position and it was determined that total parenteral nutrition would be delivered through a PICC line placed on the . The patient continued to improve at this time and was followed again by Psychiatry who suggested 1 mg dose of Haldol for standing order at night and their formal consultation was noted in the chart. The patient's mental status was significant for confusion and inattention and tangential thought at this time. His lithium level and renal function were noted to be improving at this time. His lithium level was now down to 1.6. On the patient continued to feel better and continued to note improving appetite. He was noted by the staff to be taking all of his meals. Calorie counts were occurring at this time. The patient continued to be screened for rehabilitation. The patient was continued on total parenteral nutrition. was notified of the total parenteral nutrition and they advised adding 10 units of insulin to his TPN order which was done. On , the day of discharge, the patient was doing very well, not complaining of any pain, with increasing appetite. Had been out-of-bed three times the previous day. On physical examination vital signs were temperature maximum over the last 24 hours of 98.4 degrees. Current temperature 97.6 degrees. 59 beats per minute. Blood pressure 132/71. Respiratory rate of 20. Oxygen saturation 94 percent on room air. His weight was 123.3 kilograms. His fingersticks were in the low 100's. The patient was in no apparent distress. His cardiac examination revealed regular rate and rhythm with no murmurs, rubs or gallops. His respiratory examination revealed clear to auscultation bilaterally. No wheezes, rales or rhonchi. On abdominal examination the patient was noted to be non-distended, normoactive bowel sounds, soft and non-tender throughout with a well-healing wound. It was clean, dry and intact. Screening for rehabilitation at this time continued and it was determined that patient would be discharged on this day. His laboratory values at this time were the following: PT time 12.5, PTT 22.4, INR 1.0, fibrinogen 431. On , his cyclosporin level was 944. His liver function tests revealed an ALT of 14, an AST of 15, alk phos of 127, a total bilirubin of 1.8 and albumin of 2.8. White count at this time was 12.9, hematocrit 27.6 and platelet count 137,000. | DILAUDID PRN.CV-AFEB. EKG DONE. MSO4 PRN.CV-AFEB. INR/HCT STABLE. TO GET 2 U FFP AND VIT K. HCT STABLE. BILIOUS, DR IN TO EVAL. + EDEMA. HYPO BS. NGT to LWS drng bilious. copious drng around JP MD sutured. INCISION WNL. nsg noteSEE FLOWSHEET FOR SPECIFIFCS.NEURO-PT SEDATED ON PROPOFOL GTT. SKIN W+D. SKIN W+D. SBP STABLE OFF NEO. PROPOFOL GTT WEANING PER DISCUSSION WITH MD . PERRL. PERRL. PERRL. The SVC position was confirmed by injecting contrast. PBOOTS ON. PBOOTS ON. Drsg x2. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.NEURO: SEDATED ON PROPOFOL GTT. Prop off, now on precedex and weaned down with agitation lessening. afebrile. PA NUMBERS STABLE OFF NTG. NGT TO LWS WITH CLEAR TO LIGHT BILIOUS DRG. CONT PER CURRENT MGMT. TO START HCL GTT.RESP-PT REMAINS ON CMV. TPN started. HCL GTT. Will follow, wean as sedation weans. ABG PENDING.CV: AFEBRILE. HRR. MONITOR ABGS. +PP. +PP. HRR, NSR. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.NEURO: PT VERY LIGHTLY SEDATED ON PROPOFOL GTT. TO REMAIN ON PROPOFOL GTT OVER NOC. brought pt's glasses. NGT TO LWS WITH BILIOUS DRG. HCL GTT RUNNING UNCHANGED MD .CV: AFEBRILE. NEO WEANED WITH STABLE BP. NITRO GTT WEANED WITH STABLE PA PRESSURES. COMPARISON: . Fluoroscopic guidance was used. SEE FLOWSHEET. Normal sinus rhythmEarly R wave progression - ? nipride initiated to keep SBP < 160. SUPPLEMENTAL HYDROMORPHONE GIVEN AS ORDERED.RESP: LS CLEAR. WEAN VENT AS TOLERATED. LAST ABG 7.45/44/155/32/6. follows commands. JP x2, bili tube. MEDIAL JP O/P TEA COLORED. INSULIN GTT STARTED. KCL REPLETED. Resp CarePt remians on unchanged vent settings. TO RECEIVE 2U PRBC FOR LOW HCT.GI: NGT WITH SCANT BILIOUS O/P. Lasix x3. WILL FOLLOW.PLAN-CON'T WITH CURRENT PLAN. DSG CHANGED. REASON FOR THIS EXAMINATION: ..... JP INSERT SITES WITH LARGE AMT SEROUS DRG. TO GET LASIX THIS PM. MEDIAL JP WITH TEA COLORED DRG. LAT JP WITH DARK SANG DRG. 1 BAG PLT, 1 U PRBC GIVEN, AND 1U FFP COMPLETED FROM ORDER OF PREVIOUS SHIFT. ABG IMPROVED. OPENS EYES TO VOICE. Admitting Diagnosis: HEPATO CELLULAR CAECINOMA ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. CONT PER TRANSPLANT PROTOCOLS. Plam: Continue close ICU monitoring. ARROUSABLE TO STIMULATION. The sheath was removed. 11:18 AM PICC LINE PLACMENT SCH Clip # Reason: ..... See Careview. He arrived and place ventilator . HYPERTENSIVE WITH STIMULATION. MED JP NOW WITH AMBER DRG. LS CLEAR, DECREASED AT BASES,. LS clear, thick white scant secretions.GI:NPO. HYDROMORPHONE FOR PAIN,RESP: LS CTA. DSG CHANGED X FEW. afebrile.CV:SR to SB, no ectopy. ? The right basilic vein was patent and compressible. nsg noteSEE FLOWSHEET FOR SPECIFICSNEURO-PROP DECREASED SLIGHTLY. NGT to LWS drng clear to bilious drng. EKG DONE. Resp CarePt. Suture abd - serosangious moderate amount - DSD. CXR done. SKIN W+D. SKIN W+D. LOW-DOSE PRECEDEX CONTINUES.RESP: LS CLEAR TO COARSE. PERRL. USING I.GI-ABD OBESE, SOFTLY DISTENDED. NARD NOTED. REPEAT ABG PENDING.CV: AFEBRILE. PA #'s trending down with CVP. CONT CURRENT MGMT. JP'S BOTH WITH SEROSANG O/P. Afebrile. Afebrile. FOLLOWS COMMANDS.CV-AEB. abd suture - drainage ss - DSD X2 done. PBOOTS ON.RESP-PT REMAINS VENTED. HRR. HRR. PBOOTS ON. INC LEAKING LRG AMT SEROUS FLUID, DRSG . SEE CAREVUE FOR SPECIFICSRESP: BS COARSE. +PP. +PP. NGT TO LWS WITH CLEAR DRG. NGT TO LWS WITH CLEAR DRG. CONTINUE PER CURRENT MGMT. FOLLOWS COMMANDS.CV-LOW GRADE TEMP. Ambu/syringe @ hob. clear to slurr speech. ABG borderline. +BS. +BS. +BS. +flatus. + FLATUS. RR WNL. Possible extubation in AM. INCISION WITH STAPLES C/D/I. T-TUBE WITH BILIOUS DRAINAGE.CONTINUES ON SCHEDULED LASIX AND DIAMOX. CO . BS auscultated reveal bilateral coarse sounds. PT USING FREQ FOR ORAL SECRETIONS.GI-ABD OBESE, SOFTLY DISTENDED. WEANED AND EXTUBATED. NPO ON TPN. PERLA. ACETAZOLAMIDE CONTINUES. INCISION NOTED TO BE DRAINING LARGE AMT SEROUSSANG. T-bile bag - bilious. PT WITH MOD AMT DRG AROUND JP INSERT SITE. ABG IMPROVED. C+DB ENC. FOLLOWS COMMANDS. 7p-7a; Full assessment in flow sheet.neuro; A+O1-3. JP - ss, site drain ss. AM LABS PENDING.GI: ABD OBESE, SOFT. NGT TO LCWS WITH BILIOUS O/P.GU: CLEAR AMBER U/O VIA FOLEY. 7p-7a; Full assessment in flow sheet.a+OX1-3. LOPRESSOR AND HYDRALAZINE STARTED. PT WILL GET DIURESED TODAY. DR. HCL GTT STOPPED AS ORDERED. Lasix x1. JP DRAINING SEROSANG FLUID. ABG PENDING. NG +placement, clear drainage. Bile - bilious. nusring noteNeuro:Alert, mouthing words over ET tube. ? ? ET SUCTIONED THIS AM FOR LG AMT THICK BLOODY SPUTUM X1. Pt 's conversation disjointed. SBP PARAMETERS<160, STARTED ON PO HYDRALAZINE AND LOPRESSOR W/ GOOD RESULTS. T-TUBE WITH BILIOUS DRG.GU-VOIDING VIA FOLEY. T-TUBE WITH BILIOUS DRG.GU-VOIDING VIA FOLEY. +BSX4. answer appropriately - sometime vague. Placed on a rate, repeat abg revealed resp acidosis, rate increased again.Bs: coarse bilat. AM lab done. sintubated on PS 15/5. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS:NEURO: PT ALERT. LS CLEAR, DECREASED AT BASES. MAE. MAE. MAE. MAE. MAE. follow commands. Follow commands. PERLA - 3 mm brisk.cv; NSR (70-80). LYTES STABLE.PLAN:CONTINUE CURRENT PLAN OF CARE. DSG CHANGED X FEW. Affect - flat. Nipride off - inc lopressor, resting - not anxious - able to maintain SBO <160. nsg noteSEE FLOWSHEET FOR SPECIFICS.NEURO-A+OX3. AWAITING PT CONSULT. Afebrile.CV:SR to SB, no ectopy. JP - site ss, tea color drainage. LASIX GIVEN WITH + EFFECT.ENDO-REMAIN ON INSULIN GTT.PLAN-CON'T WITH CURRENT PLAN. TEAM IN TO EVAL. LOPRESSOR, HYDRALAZINE WITH GOOD RESULTS.LUNG SOUNDS DIMINISHED BILAT BASES. PT HAD TRIAL THIS AM. PLAN IS TO CONT ON SAME SETTINGS. MOUTHING WORDS APPROPRIATELY. LS COARSE, DECREAED AT BASES. Nipride drip <160 - able to wean with pain med given. HR 90'S NSR. Resting on CPAP. Respiratory toileting. FOCUS: STATUS UPDATEDATA:PT ALERT AND ORIENTED X3, ALTHOUGH AT TIMES APPEARS TO BE SLIGHTLY CONFUSED.HYPERTENSIVE TO 180'S ESPECIALLY WITH ACTIVITY AND COMPANY. | 30 | [
{
"category": "Radiology",
"chartdate": "2158-06-06 00:00:00.000",
"description": "FLUOR GUID PLCT/REPLCT/REMOVE",
"row_id": 830407,
"text": " 11:18 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: .....\n Admitting Diagnosis: HEPATO CELLULAR CAECINOMA\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 62 year old man with OLT, trouble obtaining access, needs double lumen PICC by\n interventional radiology. Has to be double lumen.\n REASON FOR THIS EXAMINATION:\n .....\n ______________________________________________________________________________\n FINAL REPORT\n The patient needs a long term antibiotics and TPN. Please place a double lumen\n PICC line. IV therapy was not able to place the line at the bedside.\n\n PROCEDURE: The procedure was performed by Dr. , Dr. and Dr. ,\n the Attending Radiologist, who was present and supervising. The right upper\n arm was prepped and draped in the standard sterile fashion. Since no suitable\n superficial veins were visible, ultrasound was used for localization of a\n suitable vein. The right basilic vein was patent and compressible. After\n local anesthesia with 3 cc of 1% lidocaine, the basilic was entered under\n ultrasonographic guidance with a 21 gauge needle. Hard copies of ultrasound\n images were obtained documenting patent vein before and after establishing an\n access. Initially a 0.18 guidewire was advanced under fluoroscopy, however,\n this could only be advanced to the level of the axilla. This was then\n exchanged for a short Nintonal wire which also could not be advanced beyond\n the axilla. A 5 French introducer sheath was introduced into the vein and a\n hand injection venogram was performed. This demonstrated occlusion of the\n axillary vein as it enters the subclavian with a large colateral coursing\n around into the SVC. A 0.18 glidewire was then used to course the catheter\n through the colateral into the SVC. Fluoroscopic guidance was used. The PICC\n line was trimmed to a length of 45 cm and advanced over the 5 French\n introducer sheath through the colateral under fluoroscopic guidance into the\n SVC. The sheath was removed. The catheter was flushed, a final chest x-ray was\n obtained and demonstrates the tip to be in the SVC just above the atrium. The\n SVC position was confirmed by injecting contrast. The line is ready for use.\n\n A stat lock was applied and the line was hep locked.\n\n IMPRESSION: Successful placement of a 45 cm double lumen total length PICC\n line with the tip in the SVC. The line is ready for use.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-05-30 00:00:00.000",
"description": "TUBE CHOLANGIOGRAM",
"row_id": 829806,
"text": " 2:43 PM\n CATH CHEK/REMV Clip # \n Reason: S/P TRANSPLANT\n Admitting Diagnosis: HEPATO CELLULAR CAECINOMA\n Contrast: CONRAY Amt: 20\n ********************************* CPT Codes ********************************\n * CHALNAGIOGRAPHY VIA EXISTING C TUBE CHOLANGIOGRAM *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 62 y/o gentleman status post liver transplant 8 days ago.\n\n PROCEDURE/FINDINGS: The procedure is performed by Dr. and who was\n present and supervising throughout.\n\n The patient's T-tube was attached to a syringe with Conray contrast and\n gravity cholangiogram was performed. The intrahepatic bile ducts were\n decompressed. There is brisk passage of contrast through the common bile duct\n into the small bowel. There is no extravasation of contrast observed. The T\n tube was then re-attached to bag drainage. The patient tolerated the\n procedure well and there were no immediate post procedure complications.\n\n IMPRESSION: Gravity to the T-tube cholangiogram demonstrating decompressed\n biliary tree with free drainage into the small bowel. No extravasation of\n contrast observed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-05-23 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 829141,
"text": " 9:31 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: please duplex liver transplant\n Admitting Diagnosis: HEPATO CELLULAR CAECINOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with s/p liver transplant . donor liver had replaced right\n HA which was anastomosed to donor splenic artery, donor celiac trunk/aortic\n cuff then anastomosed to recipient proper hepatic artery\n REASON FOR THIS EXAMINATION:\n please duplex liver transplant\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver transplant.\n\n COMPARISON: .\n\n LIMITED ULTRASOUND OF THE LIVER: The hepatic veins, portal vein, hepatic\n arteries and IVC are patent and have the appropriate direct of flow. This was\n elevated via the -scale, color and Doppler ultrasound.\n\n IMPRESSION: Patent liver transplant vessels.\n\n"
},
{
"category": "ECG",
"chartdate": "2158-05-25 00:00:00.000",
"description": "Report",
"row_id": 181252,
"text": "Normal sinus rhythm\nEarly R wave progression - ? lead position or posterior myocardial infarct\nSince previous tracing of , not suggestive of right bundle branch block\n\n"
},
{
"category": "ECG",
"chartdate": "2158-05-22 00:00:00.000",
"description": "Report",
"row_id": 181253,
"text": "Sinus rhythm\nRight bundle branch block\nQT prolonged for rate\nSince previous tracing, the heart rate has increased and right bundle branch\nblock new\nClinical correlation is suggested\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-24 00:00:00.000",
"description": "Report",
"row_id": 1456151,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS\n\nNEURO-PROP DECREASED SLIGHTLY. PT OPENS EYES TO VOICE, NODS HEAD, MAE, OCC FOLLOWS COMMANDS. PERRL. PT AGITATED WHEN OFF SEDATION AND PA NUMBERS VERY ELEVATED. TO REMAIN ON PROPOFOL GTT OVER NOC. DILAUDID PRN.\n\nCV-AFEB. HRR, NSR. SBP STABLE OFF NEO. PA NUMBERS STABLE OFF NTG. SKIN W+D. +PP. PBOOTS ON. INR/HCT STABLE. PLTS LOW, TX WITH 1 U PLTS AND RESULTS NOW IMPROVED. TO START HCL GTT.\n\nRESP-PT REMAINS ON CMV. RATE INCREASED TO 16 FOR HIGH CO2. TV REMAINS 800, PEEP 5, FIO2 50%. O2 SAT 100%. LS CLEAR, DECREASED AT BASES,. SXN FOR SCANT SPUTUM.\n\nGI-ABD OBESE, SOFT. HYPO BS. NGT TO LWS WITH CLEAR TO LIGHT BILIOUS DRG. INCISION WNL. JP INSERT SITES WITH LARGE AMT SEROUS DRG. DSG CHANGED X FEW. JP MEDIAL WITH DARKER TEA COLORED DRG, ? BILIOUS, DR IN TO EVAL. JP LAT WITH DARK SEROUSSANG DRG. T-TUBE WITH BILIOUS DRG.\n\nGU-VOIDING VIA FOLEY CL AMBER URINE. TO GET LASIX THIS PM. WILL MONITOR.\n\nENDO-CON'T ON INSULIN GTT AND D10.\n\nPLAN-CON'T WITH CURRENT PLAN. FOLLOW LABS CLOSELY. HCL GTT. MONITOR FOR CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-25 00:00:00.000",
"description": "Report",
"row_id": 1456152,
"text": "Respiratory Care Note:\n\nPt remain orally intubated on Day 3 Post-op Liver Tx. No vent changes done o/n. RSBI not done this AM, Pt apneic. He requires bolus of sedation for increase of BP issue. Plam: Continue close ICU monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-25 00:00:00.000",
"description": "Report",
"row_id": 1456153,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT VERY LIGHTLY SEDATED ON PROPOFOL GTT. OPENS EYES TO VOICE. FOLLOWS MOST COMMANDS. MAE. PERRL. HYDROMORPHONE FOR PAIN,\nRESP: LS CTA. NO VENT CHANGES. ABG'S REFLECT WORSENING METABOLIC ACIDOSIS. HCL GTT RUNNING UNCHANGED MD .\nCV: AFEBRILE. HYPERTENSIVE WITH STIMULATION. CCO NUMBERS STABLE. SINUS BRADY TO 40S, MD INFORMED. EKG DONE. ENZYMES SENT TO LAB. RECEIVED 1 BAG PLT FOR CT 90. AM PLT 89, TO RECEIVE ANOTHER BAG PLT. TO RECEIVE 2U PRBC FOR LOW HCT.\nGI: NGT WITH SCANT BILIOUS O/P. FAINT BOWEL SOUNDS. NO BM.\nGU: CLEAR AMBER U/O, OCCASIONALLY DOEN TO ~25 CC/. MD INFORMED.\nENDO: INSULIN GTT TITRATED TO FSBG.\nSKIN: COPIOUS AMTS SEROUS DRG FROM JP DRAIN SITES. MEDIAL JP WITH TEA COLORED DRG. LATERAL JP WITH MAROON O/P. T-TUBE WITH AMBER O/P.\nPLAN: TRANSFUSE BLOOD PRODUCTS AS ORDERED. ? DECREASE SEDATION AND ATTEMPT TO WEAN VENT. CONT PER CURRENT MGMT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-25 00:00:00.000",
"description": "Report",
"row_id": 1456154,
"text": "nursing note\nplease see carevue for details.\n\nNeuro:increasing alertness throughout day. Prop off, now on precedex and weaned down with agitation lessening. denies pain. afebrile. follows commands. agitated at times re:restraints. afebrile.\nCV:SR to SB, no ectopy. nipride initiated to keep SBP < 160. P-boots on. Lasix x3. 1u PRBC, 1 pack plts. labs q12.\nRESP:tol CPAP 15/5. ABg acidotic, PS increased to 15 from 10. LS clear, thick white scant secretions.\nGI:NPO. NGT to LWS drng bilious. JP x2, bili tube. copious drng around JP MD sutured. Drsg x2. TPN started. no bm.\nGU:foley patent dark yellow to amber urine.\nSocial: in to visit. brought pt's glasses.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-23 00:00:00.000",
"description": "Report",
"row_id": 1456146,
"text": "RESPIRATORY CARE\nPT REMAINS ORALLY INTUBATED CMV 800/18/50%/+5 PEEP. LAST ABG 7.45/44/155/32/6. NO WEANING AT THIS POINT, POST OP DAY 1. WILL CONTINUE TO FOLLOW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-23 00:00:00.000",
"description": "Report",
"row_id": 1456147,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFIFCS.\n\nNEURO-PT SEDATED ON PROPOFOL GTT. PERRL. PT AROUSES TO PAIN/STIMULI. APPEARS COMFORTABLE. MSO4 PRN.\n\nCV-AFEB. HRR. PT ON NEO GTT TO KEEP MAP >70. PA PRESSURES 70-80'S THIS AM. NTG GTT STARTED AND PAP NOW 40'S WITH MEAN 30'S. SKIN W+D. +PP. + EDEMA. PBOOTS ON. INR UP TO 1.6. TO GET 2 U FFP AND VIT K. HCT STABLE. CON'T TO CYCLE CPK'S.\n\nRESP-PT REMAINS VENTED ON CMV, RATE INCREASED TO 18, TV 800, PEEP 5, FI02 50%. ABG IMPROVED. SEE FLOWSHEET. O2 SAT 100%. LS COARSE. SXN FOR THICK YELLOW SPUTUM.\n\nGI-ABD OBESE, SOFTLY DISTENDED. NO BS. NGT TO LWS WITH BILIOUS DRG. ABD INCISION WITH SEROUSSANG AND SOME BILIOUS DRG AROUND T-TUBE. DSG CHANGED. MED JP NOW WITH AMBER DRG. LAT JP WITH DARK SANG DRG. T-TUBE WITH BILIOUS DRG.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nENDO-FS REMAIN VERY HIGH. INSULIN GTT STARTED. WILL FOLLOW.\n\nPLAN-CON'T WITH CURRENT PLAN. MONITOR CLOSELY. FOLLOW LABS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-24 00:00:00.000",
"description": "Report",
"row_id": 1456148,
"text": "Respiratory Care Note:\n\nPt remain orally intubated on total vent support, following liver transplant Post-op day 2. No vent changes o/n so far, following ABG. Plan: monitor ICU closely, will attempt RSBI measurements only.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-23 00:00:00.000",
"description": "Report",
"row_id": 1456144,
"text": "Respiratory Care Note:\n\nPt admitted post liver tranplantation. He arrived and place ventilator . See Careview. His VS were unstable when he arrived esp his PAP which a stat TEE was done and some vent changes to correct his hypercapnea. Now more stable. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-24 00:00:00.000",
"description": "Report",
"row_id": 1456149,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: SEDATED ON PROPOFOL GTT. ARROUSABLE TO STIMULATION. MOVES ALL EXTREMTITIES ON BED. DOES NOT FOLLOW COMMANDS. PROPOFOL GTT WEANING PER DISCUSSION WITH MD . SUPPLEMENTAL HYDROMORPHONE GIVEN AS ORDERED.\nRESP: LS CLEAR. SCANT SECRETIONS. ABG REFLECTS METABOLIC ACIDOSIS. RR DECREASED TO 16 MD . ABG PENDING.\nCV: AFEBRILE. NSR, NO ECTOPY. SEE FLOWSHEET FOR PA NUMBERS. NITRO GTT WEANED WITH STABLE PA PRESSURES. NEO WEANED WITH STABLE BP. 1 BAG PLT, 1 U PRBC GIVEN, AND 1U FFP COMPLETED FROM ORDER OF PREVIOUS SHIFT. KCL REPLETED. SEE FLOWSHEET FOR LAB VALUES.\nGI: ABD LARGE. NO BOWEL SOUNDS. NGT TO LCWS WITH MOD AMT THICK CLEAR DRG.\nGU: CLEAR AMBER U/O, IN AMT THIS AM.\nENDO: INSULIN GTT TITRATED DOWN AND UP PER FSBG. IVF CHANGED TO .45% NS AT 100CC/HOUR WITH D10% AT 10CC/HOUR.\nSKIN: ABD INC WITH STAPLES INTACT. DSD CHANGED X2 FOR LG AMTS SEROUS DRG FROM R SIDE AND DRAIN SITES, SM AMT SEROSANG FROM L CORNER OF WOUND. MEDIAL JP O/P TEA COLORED. LATERAL JP O/P MAROON. T-TUBE O/P AMBER.\nPLAN: WEAN SEDATION WHILE ASSESSING FOR AGGITATION. MEDICATE FOR PAIN. WEAN VENT AS TOLERATED. MONITOR ABGS. MONITOR PA NUMBERS CLOSELY. Q4 HOUR LABS AS ORDERED. TITRATE INSULIN GTT TO FSBG. SKIN CARE. CONT PER TRANSPLANT PROTOCOLS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-24 00:00:00.000",
"description": "Report",
"row_id": 1456150,
"text": "Resp Care\nPt remians on unchanged vent settings. ABG's acceptable, well oxygenated, slight acidosis. Sx scant-no secretions. Will follow, wean as sedation weans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-23 00:00:00.000",
"description": "Report",
"row_id": 1456145,
"text": "admission note\nD: PT ADMITTED DIRECTLY FROM OR- S/P LIVER TRANSPLANT. PT 22 UNITS FFP, 28 UNITS PC, 6 PLTS, 6 CRYO, 2 LITERS CELL AND 9 LITERS PLASMOLYTE. PT HAD EPISODE OF HYPOTENSION AND ELEVATED PA NUMBERS TO 90'S. TEE DONE WHICH SHOWED MASSIVE CLOTS, PT GIVEN 5000 UNITS HEPARIN. REPEAT TEE DONE ON ADMISSION TO SICU= IMPROVED BUT PA NUMBERS REMAIN ELEVATED. TRANSFUSED WITH 2 UNITS FFP.\nNEURO: NON-REVERSED FROM OR, STARTED ON PROPOFOL PER DR . PUPILS PINPOINT WITH BRISK REACTION.\nCV: STARTED ON IV NEO TO IMPROVE MAP >70, IV NTG TO START AFTER MAP IMPROVED WITH GOAL OF DECREASING PAS. CO . HR 90'S NSR. EKG DONE. SEE CAREVUE FOR SPECIFICS\nRESP: BS COARSE. PRESENTLY ON 50%/800/X 16/5 PEEP, CMV MODE.\nGI: ABD OBESE, NO BS PRESENT, NGT REPLACED AFTER TEE- DRAINING BLOODY- HO AWARE\nGU: CLEAR YELLOW IN GOOD AMTS\nENDO: BS 203- TX'D WITH 6 UNITS REGULAR\nWOUND- ABD INCISION CLEAN WITH MOD AMT BLOODY DRAINAGE PRESENT. 2 JP'S TO BULB SX DRAINING BLOODY, T-TUBE TO GRAVITY WITH SM AMT BILIOUS.\nA: MONITOR HEMODYNAMICS AND RESP PARAMETERS, START NTG AS TOL, SERIAL CPK'S\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-29 00:00:00.000",
"description": "Report",
"row_id": 1456164,
"text": "7p-7a; Full assessment in flow sheet.\n\na+OX1-3. Period of confusion when overtired - oriented easily. MAE. follow commands. clear to slurr speech. answer appropriately - sometime vague. Affect - flat. PERLA. Good gag and cough reflex. NSR without ectopy. Nipride off - inc lopressor, resting - not anxious - able to maintain SBO <160. Please see flow sheet for CO, SVO2, PA - MD are aware of the wide range. Afebrile. warm, dry, general edema. coarse lung sound - productive cough - self suction - white/thick sputum. Encourage deep breathing and coughing. Face mask tolerated when awake - RR 12-20, SaO2 >90%. When asleep - sleep apnea, obstruction, RR 8-10 - needed to be on CPAP for SaO2 >86%. Obese abd, +BSX4, no bm (Last on day ). foley patent - clear yellow urine. NG +placement, clear drainage. Suture abd - serosangious moderate amount - DSD. JP - ss, site drain ss. Bile - bilious. AM lab done. Insulin drip titrate 80-120.\n\nPlan; Continue to monitor. Respiratory toileting.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-29 00:00:00.000",
"description": "Report",
"row_id": 1456165,
"text": "NEURO: A&O X3, APPROPRIATE CONVERSATION, FOLLOWING COMMANDS, MAE SPONT/PURP.\n\nCV: HR 60-80'S, NSR, NO ECTOPY. SBP PARAMETERS<160, STARTED ON PO HYDRALAZINE AND LOPRESSOR W/ GOOD RESULTS. CVP 2-13.\n\nRESP: LUNG SOUNDS DIMINISHED, EXPECTORATING THICK YELLOW SECRETIONS. O2 SAT >92% ON 60% VIA FACE TENT, ENC TO C+DB.\n\nGI: ABD OBESE, SOFTLY DISTENDED, +BOWEL SOUNDS, NGT PULLED OUT AND PT STARTED ON CLEARS, WELL TOLERATED WITHOUT N/V. INC LEAKING LRG AMT SEROUS FLUID, DRSG . JP DRAINING SEROSANG FLUID. T-TUBS DRAINING GREENISH/GOLDEN FLUID.\n\nGU: FOLEY DRAINING ADEQ U/O, CLEAR AMBER/ORANGY URINE.\n\nID: TMAX 98.9\n\nPLAN: MONITOR VS, LABS, RESP STATUS. AWAITING PT CONSULT. CONT CURRENT MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-30 00:00:00.000",
"description": "Report",
"row_id": 1456166,
"text": "FOCUS: STATUS UPDATE\nDATA:\nPT ALERT AND ORIENTED X3, ALTHOUGH AT TIMES APPEARS TO BE SLIGHTLY CONFUSED.\n\nHYPERTENSIVE TO 180'S ESPECIALLY WITH ACTIVITY AND COMPANY. LOPRESSOR, HYDRALAZINE WITH GOOD RESULTS.\n\nLUNG SOUNDS DIMINISHED BILAT BASES. DESATS WITHOUT O2 WHICH HE TAKES OFF AT TIMES. PACO2 TO 51 THIS AM, DR. AWARE.\n\nABDOMINAL INCISION WITH STAPLES INTACT AND COPIOUS AMOUNTS OF SEROUS DRAINAGE REQUIRING MULTIPLE DRESSING CHANGES. DR. ASKED TO ASSESS DURING A DRESSING CHANGE. JP DRAIN STRIPPED EVERY 1-2 HOURS/NO CLOTS NOTED. T-TUBE WITH BILIOUS DRAINAGE.\n\nCONTINUES ON SCHEDULED LASIX AND DIAMOX. GOOD URINE OUTPUT. URINE AMBER IN COLOR. LYTES STABLE.\n\nPLAN:\nCONTINUE CURRENT PLAN OF CARE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-28 00:00:00.000",
"description": "Report",
"row_id": 1456160,
"text": "7p-7a; Full assessment in flow sheet.\n\nneuro; A+O1-3. MAE. Follow commands. c/o pain general, ET tube, incision - hydromorphone ivp given - good effect (able to rest and easily awake calm). PERLA - 3 mm brisk.\n\ncv; NSR (70-80). Nipride drip <160 - able to wean with pain med given. Afebrile. warm, dry, general edema.\n\nresp; Coarse lung sound. Strong cough and gag. Resting on CPAP. Productive cough white/thick sputum.\n\ngu/gi; obese abd. +BSX4. +flatus. no bm. foley patent - clear yellow urine. JP - site ss, tea color drainage. T-bile bag - bilious. abd suture - drainage ss - DSD X2 done. NG - +placement, bilious.\n\nskin; intact - small skin tears - cover with DSD.\n\nInsulin drip - titrate to 80-120. AM Lab done.\n\nPlan; Continue to monitor. Possible extubation in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-28 00:00:00.000",
"description": "Report",
"row_id": 1456161,
"text": "Resp: pt on psv 15/5/49%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral coarse sounds. Suctioned small amounts of thick whitish secretions, pt suctions oral cavity. RSBI=18, plan to continue to wean, possible extubation today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-28 00:00:00.000",
"description": "Report",
"row_id": 1456162,
"text": "\nPT MAINTAINED ON 50% FACE TENT AFTER BEING EXTUBATED TO THE PT'S DELIGHT THIS A.M. PT STATES HIS BREATHING HAS SO IMPROVED SINCE GETTING THE TUBE OUT. ABG PENDING. PT THIS A.M. AS WELL FOR NEGATIVE RESULTS, POOR INDICATIONS FOR PROCEDURE TO BEGIN WITH. SATURATIONS IN THE 94 RANGE BUT SAT MONITOR NOT CORELATING WITH ABG. VENTILATOR LEFT IN ROOM FOR NON-INVASIVE PURPOSES. PLAN IS TO USE BIPAP AT NIGHT AND AEROSOL OR NASAL O2 DURING THE DAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-28 00:00:00.000",
"description": "Report",
"row_id": 1456163,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-A+OX3. MAE. FOLLOWS COMMANDS.\n\nCV-AEB. HRR. CON'T ON NIPRIDE GTT TO KEEP SBP <160. LOPRESSOR AND HYDRALAZINE STARTED. SKIN W+D. +PP. PBOOTS ON. DENIES CARDIAC COMPLAINTS. LABS STABLE\n\nRESP- THIS AM FOR THICK YELLOW SPUTUM. WEANED AND EXTUBATED. ABG STABLE ON 50% FACE TENT. RR WNL. NARD NOTED. LS CLEAR, DECREASED AT BASES. C+DB ENC. USING I.\n\nGI-ABD OBESE, SOFTLY DISTENDED. +BS. NGT TO LWS WITH CLEAR DRG. CON'T ON TPN. + FLATUS. DUCOLAX GIVEN WITH LITTLE EFFECT. INCISION NOTED TO BE DRAINING LARGE AMT SEROUSSANG. TEAM IN TO EVAL. DSG CHANGED X FEW. JP LAT WITH TEA COLORED DRG. T-TUBE WITH BILIOUS DRG.\n\nGU-VOIDING VIA FOLEY. LASIX GIVEN WITH + EFFECT.\n\nENDO-CON'T ON INSULIN GTT.\n\nCOMFORT-DENIES NEED FOR PAIN MED.\n\nPLAN-CON'T WITH CURRENT PLAN. MONITOR CLOSELY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-26 00:00:00.000",
"description": "Report",
"row_id": 1456155,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS:\nNEURO: PT ALERT. MOUTHING WORDS APPROPRIATELY. FOLLOWS COMMANDS. PERRL. MAE. DENIES PAIN. LOW-DOSE PRECEDEX CONTINUES.\nRESP: LS CLEAR TO COARSE. ET SUCTIONED THIS AM FOR LG AMT THICK BLOODY SPUTUM X1. ABG REFLECTS METABOLIC ALKALOSIS WITH WORSENING RESPIRATORY ACIDOSIS. HCL GTT STOPPED AS ORDERED. ACETAZOLAMIDE CONTINUES. VENT SETTINGS CHANGED TO IMV 12 X 800. RATE LATER INCREASED TO 14 DUE TO RISING PCO2. REPEAT ABG PENDING.\nCV: AFEBRILE. HEMODYNAMICALLY STABLE. SBP REMAINS <160 WITH NIPRIDE GTT UNCHANGED. AM LABS PENDING.\nGI: ABD OBESE, SOFT. FAINT BOWEL SOUNDS. NGT TO LCWS WITH BILIOUS O/P.\nGU: CLEAR AMBER U/O VIA FOLEY. FLUID BAL NEG >250CC.\nENDO: INSULIN GTT TITRATED TO FSBG.\nSKIN: DECEASED AMTS SEROSANG DRG AROUND JP DRAIN SITES. JP'S BOTH WITH SEROSANG O/P. T-TUBE WITH AMBER O/P. NO S/S BREAKDOWN.\nPLAN: CONT TO MONITOR ABG'S CLOSELY. INCREASE ACTIVITY AS TOLERATED. CONTINUE PER CURRENT MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-26 00:00:00.000",
"description": "Report",
"row_id": 1456156,
"text": "Resp Care\nPt. remains intubated/sedated on vent. Initially on PSV however pt, became progressivly more hypercapneic. Placed on a rate, repeat abg revealed resp acidosis, rate increased again.\nBs: coarse bilat. sxn'd x2 for thick bloody , oral secreations copious blood tinged thick.\nAbg: respiratory acidosis with metabolic alkalosis and hyperoxia.\nPlan: maintain current support, wean as abg's improve.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-26 00:00:00.000",
"description": "Report",
"row_id": 1456157,
"text": "nusring note\nNeuro:Alert, mouthing words over ET tube. Appropriate with care and following commands. Afebrile.\nCV:SR to SB, no ectopy. Cont to be HTN-nipride increased up throughout day. p-boots on and hep SQ.\nRESP:LS coarse, copious secretions as day went on, frothy. CXR done. Lasix x1. PA #'s trending down with CVP. sintubated on PS 15/5. TV 600-800. ABG borderline. CPAP on windowsill.\nGI:Abd soft, large,nt. NGT to LWS drng clear to bilious drng. No BM. +BS. Abd incision clean, drsg and x2 thus far.\nGU:foley patent dark yellow urine adeq amounts. JP x2 and T-tube WNL.\nSKIN:intact.\nSocial: friend in to visit.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-27 00:00:00.000",
"description": "Report",
"row_id": 1456158,
"text": "\nPT MAINTAINED ON PSV VENTILATION AT 50% WITH GOOD OXYGENATION. PT WEANED TO T-PIECE VENTILATION IN HOPES OF EXTUBATION, HOWEVER THE ABG REVEALED AN ACIDOSIS OF 7.25, PT RETURNED TO PSV OF 15. PT WILL GET DIURESED TODAY. FRIEND BROUGHT IN CPAP MASK IN THE EVENT PT GETS EXTUBATED. PLAN IS TO CONT ON SAME SETTINGS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-27 00:00:00.000",
"description": "Report",
"row_id": 1456159,
"text": "NSG NOTE\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT AWAKE, WRITES/USES ABC BOARD APPOP. MAE. FOLLOWS COMMANDS.\n\nCV-LOW GRADE TEMP. HRR. CON' T ON NIPRIDE GTT TO KEEP SBP < 160. SKIN W+D. +PP. PBOOTS ON.\n\nRESP-PT REMAINS VENTED. PT HAD TRIAL THIS AM. O2 SAT LOW, AND PT ACIDOTIC TO 7.29. TEAM AWARE. PT BACK ON CPAP, PEEP 5, IPS 15. ABG IMPROVED. ? ATTEMPT WEAN/EXTUBATE TOMORROW. LS COARSE, DECREAED AT BASES. SXN PRN FOR THICK WHITE SPUTUM. PT USING FREQ FOR ORAL SECRETIONS.\n\nGI-ABD OBESE, SOFTLY DISTENDED. +BS. NGT TO LWS WITH CLEAR DRG. NPO ON TPN. INCISION WITH STAPLES C/D/I. PT WITH MOD AMT DRG AROUND JP INSERT SITE. JP LAT WITH TEA COLORED DRG. T-TUBE WITH BILIOUS DRG.\n\nGU-VOIDING VIA FOLEY. LASIX GIVEN WITH + EFFECT.\n\nENDO-REMAIN ON INSULIN GTT.\n\nPLAN-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. FOLLOW LABS CLOSELY. ? WEAN/EXTUBAT TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-30 00:00:00.000",
"description": "Report",
"row_id": 1456167,
"text": "NEURO; A&O X3, BUT OCCAS INAPPROPRIATE AND CONFUSED REGARDING OBJECTS IN ROOM ETC ,AND TRAILS OFF INTO UNRELATED CONVERSATIONS, EASILY RE-ORIENTED FOR BRIEF PERIODS, TRANSPLANT TEAM IN AND AWARE\n\nCARDIOVASCULAR; HR 80'S, SR, SYS BP 130'S-140'S, CVP 5-12,\n\nWOUND; ABD DSG CHANGED X 2 FOR COPOIUS SEROUS DGE, T TUBE DGING THICK BILE MATERIAL, J P BULB DGING MODER SERO-SANGE DGE, STAPLES INTACT, STRIPPED Q 2-3 HRS FOR PATENTCY,\n\nENDOCRINE; SERUM GLUCOSE LABILE THIS SHIFT, GTT UP AS HIGH AS 12 UNITS/HR BUT DR. DOES NOT WANT GTT > 10 UNITS/HR, LAST BS 188-PRESENTY AT 10 UNITS/HR, TUBE FEEDINGS WITH INSULIN IN BAG, NEED NPH INSULIN,\n\nPLAN; PT TAKEN TO ANGIO FOR CHOLANGIOGRAM TODAY, WILL DISCHARGE IF BED NEEDED BUT OTHERWISE TRANSPLANT TEAM WOULD KEEP TONOC, ALSO ISSUE WITH INSULIN GTT AND NECESSITY TO COVER GLUCOSE ALTERNATIVE METHO9D\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-05-31 00:00:00.000",
"description": "Report",
"row_id": 1456168,
"text": "Condition Update 0400-0700 B:\nD: Pt very agitated and anxious this morning, insisting he go home to \"improve his helth, mind body, and spiritually\". Able to calm for short periods of time with conversation. Pt 's conversation disjointed. Now having delusions as evidenced by the following statement: \" He was in here interviewing me for 4 hours for the journal\". When asked which journal pt responded \"the American journal\". Dr. and Dr. notified of the morning events.\n\nPLAN: Discuss psych meds with Transplant team. Cont with ICU care and monitoring.\n"
}
] |
5,867 | 152,239 | The patient was admitted to the Cardiothoracic Surgery Service. The patient was taken to the Operating Room where she underwent coronary artery bypass graft times three. The grafts were left internal mammary artery to left anterior descending, saphenous vein graft to OM and saphenous vein graft to posterior descending artery. She tolerated this procedure well. She underwent an EPH performed on the right thigh. Patient was transferred to the Cardiothoracic Intensive Care Unit hemodynamically stable. Patient was extubated without incident. Patient was weaned off all drips without incident. Patient's chest tube output decreased appropriately. Patient was alert and oriented times three. Patient's diet was advanced as tolerated. On postoperative day number one, the patient was seen by for better glucose control. Patient was transferred to the floor for the remainder of her recovery. On postoperative day number two, patient's hematocrit was found to be 20, down from 25. She was transfused two units of packed red blood cells. Her hematocrit remained stable at 29. She otherwise remained hemodynamically stable. Onperative day number three and four, patient developed some nausea with emesis. The patient's nausea became refractory to antiemetic therapy. Due to her presentation initially with nausea and vomiting, it was thought this might be an anginal equivalent. The patient was taken for an emergency catheterization which was significant for left internal mammary artery to left anterior descending being patent. Saphenous vein graft to OM patent and vein to posterior descending artery patent. Patient tolerated this procedure well. Her nausea and emesis resolved over the next ensuing days. Patient has remained stable and has been ambulating to a level five. Patient is now ready for discharge home with follow-up with Dr. in four weeks and patient will follow-up with Dr. , her primary care physician in two weeks. | Mild (1+) mitralregurgitation is seen. There is moderate globalright ventricular free wall hypokinesis. The aortic valve leaflets are mildlythickened. GENERALIZED EDEMA NOTED.RESP: ON 4L N/C. Basal inferior wall function isrelatively preserved.septum is sevrely hypokinetic -akinetic.Overall leftventricular systolic function is severely depressed. Sinus rhythm One premature ventricular contractionPossible inferior infarct - age undetermined Anterolateral T wave changes are nonspecificNo previous tracing There is moderateglobal right ventricular free wall hypokinesis.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened.MITRAL VALVE: The mitral valve leaflets are mildly thickened. WEANED & EXTUBATED W/O INCIDENT. JUNCTIONAL)BP DECREASING W/ RATE CHANGE. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are normal. Right jugular CV line is in proximal SVC. GOOD NON-PRODUCTIVE COUGH NOTED. NEURO INTACT.CV: REMAINS ON LOW DOSE NEO THROUGHOUT SHIFT. FEW BSP. Mild tricuspid [1+]regurgitation is seen.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is no pericardial effusion.Conclusions:Technically difficult study.The left atrium is mildly dilated. Sinus rhythmOld inferior infarctLateral T wave changes are nonspecificSince previous tracing, lateral T wave changes CSRU UPDATENEURO: PT SLEEPY MUCH OF SHIFT. REMAINS ON INSULIN DRIP 2U/HR.GU: UOP MARGINAL VIA FOLEY.ASSESS: STABLE PM THOUGH DOES REMAIN ON LOW DOSE NEO.PLAN: D/C SWAN. FFP & PROTAMINE GIVEN FOR OOZY MED. There is no pericardial effusion.Compared to the Echo report dated , ( tape not available), LV functionhas declined. There is severeglobal left ventricular hypokinesis. CT'S W RESOLUTION. PORTABLE ABDOMEN: The bowel gas pattern is nonspecific and non-obstructed. H/O cardiac surgery.Height: (in) 63Weight (lb): 205BSA (m2): 1.96 m2BP (mm Hg): 154/86Status: InpatientDate/Time: at 10:00Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.LEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.There is severe global left ventricular hypokinesis. LUNGS CLEAR BILAT. NO LEAK OR CREPITUS.GI: ABD SOFT. There are small bilateral pleural effusions and bibasilar subsegmental atelectases. S/P CABG. CO/ CI STABLE. HEMODYNAMICALLY STABLE W A PACING(UNDER SB 50'S)& VOLUME. HISTORY: Chest tube removal. WEAN NEO. Sinus rhythmConsider prior inferior myocardial infarctionLead(s) unsuitable for analysis: V3 Lateral T wave changes are nonspecificSince previous tracing, no significant change CT X3 MOD AMT SEROSANG DNG THROUGH THE SHIFT. INTERMIT NAUSEA. REFER TO FLOWSHEET FOR VS/ HEMOS. INCISIONAL SPLINTING W COUGH PILLOW DEMONSTRATED.MSO4 & TORADOL(CREAT. Evaluate for ptx. Leftventricular wall thicknesses and cavity size are normal. OOB, ADVANCE DIET AS TOL. Residual contrast material is seen in the renal collecting systems with no obvious hydronephrosis. IS INSTRUCTION THIS AM -> 750CC. TO RECEIVE REGLAN QID ATC TODAY. Contrast material in the urinary tract. Radiopaque density in the pelvis is probably the bladder filled with some contrast material. The mitral valve leaflets are mildly thickened. The upper diaphragmatic borders are not seen obscured from view. Overall left ventricularsystolic function is severely depressed.RIGHT VENTRICLE: The right ventricle is not well seen. IMPRESSION: No radiographic evidence of obstruction. was on insulin gtt now sc insulin,seen by .plan:transfer to floor. ? REMAINS A-PACED AT 88. PERFORMS DEEP BREATHING WELL ON DEMAND. No pneumothorax. 1.O)GIVEN FOR PAIN CONTROL W EFFECT/ SLEEPING IN NAPS. No evidence of free or pneumatosis. DOES AWAKEN EASILY. UNDERLYING RHYTHM IN 40'S EARLY IN SHIFT (? 6 LATER IN AFTERNOON.ASSESS: TOOK ONLY FEW ICE CHIPS EARLY IN SHIFT. PATIENT/TEST INFORMATION:Indication: Coronary artery disease. MOM & SISTERS IN,SPOKE W DR. & .EXTENT OF PT'S VASCULAR DISEASE REINFORCED,QUESTIONS ANSWERED. nursing progress note and transfer note.see carview for detailsa 44 year old female with admitted to cardinal hospital in with complaints of nausea vomiting and feeling of fluttering in her chest .she ruled out for mi.she was readmitted again about 10 days later,for nausea,vomiting and symptoms of pulmonary edema.a ett thallium revealed mild lv dilitation and ef of 38%.since she reports no other symptoms but sob.she was referred to for cath.pmh:htn,elevated chol,iddm,borderline anemia,gastropesis.past surgical hx:amputation of little toe on right foot.allergies:nka.on had cabgx3,lima to lad,vg om1,pda.post op pt required neo for bp support and apacing.was extubated post op night.required morphine and toradol for pain control.neuro:awake,alert and orientedx3.speech clear,follows commands and moves all extremites with appears equal strenght.able to stand and walk to chair.resp:breath sounds clear but diminished bibasilar.sp02 97% on 4l np.resp rate 16 to 20.instructed in spirocare.gi:abd obese and soft.complaint of nausea has tolerated small amount of clears.medicated with zofran and reglan with good effect.gu:urine output has been low.started this afternoon on lasix 20mg iv.cv:was apaced,now in nsr rate 60s.when returing to bed became orthostatic lasting only briefly and was apaced briefly.access:has new right ij triple line.endocrine. I do not see evidence for contrast enhanced study having been performed at this institution so one presumes this was previously performed outside. 4:32 PM CHEST (PORTABLE AP) Clip # Reason: s/p removal of chest tubes MEDICAL CONDITION: 44 year old woman with REASON FOR THIS EXAMINATION: s/p removal of chest tubes FINAL REPORT CHEST, SINGLE AP FILM. | 9 | [
{
"category": "Radiology",
"chartdate": "2133-03-06 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 757373,
"text": " 5:39 PM\n PORTABLE ABDOMEN Clip # \n Reason: emesis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with\n REASON FOR THIS EXAMINATION:\n emesis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Emesis.\n\n PORTABLE ABDOMEN: The bowel gas pattern is nonspecific and non-obstructed.\n Radiopaque density in the pelvis is probably the bladder filled with some\n contrast material. I do not see evidence for contrast enhanced study having\n been performed at this institution so one presumes this was previously\n performed outside. Residual contrast material is seen in the renal collecting\n systems with no obvious hydronephrosis. The upper diaphragmatic borders are\n not seen obscured from view. No evidence of free or pneumatosis.\n\n IMPRESSION: No radiographic evidence of obstruction. Contrast material in\n the urinary tract.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-03-02 00:00:00.000",
"description": "Report",
"row_id": 1339053,
"text": "HEMODYNAMICALLY STABLE W A PACING(UNDER SB 50'S)& VOLUME. FFP & PROTAMINE GIVEN FOR OOZY MED. CT'S W RESOLUTION. WEANED & EXTUBATED W/O INCIDENT. PERFORMS DEEP BREATHING WELL ON DEMAND. INCISIONAL SPLINTING W COUGH PILLOW DEMONSTRATED.MSO4 & TORADOL(CREAT. 1.O)GIVEN FOR PAIN CONTROL W EFFECT/ SLEEPING IN NAPS. MOM & SISTERS IN,SPOKE W DR. & .EXTENT OF PT'S VASCULAR DISEASE REINFORCED,QUESTIONS ANSWERED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-03-03 00:00:00.000",
"description": "Report",
"row_id": 1339054,
"text": "CSRU UPDATE\nNEURO: PT SLEEPY MUCH OF SHIFT. DOES AWAKEN EASILY. NEURO INTACT.\n\nCV: REMAINS ON LOW DOSE NEO THROUGHOUT SHIFT. CO/ CI STABLE. REFER TO FLOWSHEET FOR VS/ HEMOS. REMAINS A-PACED AT 88. UNDERLYING RHYTHM IN 40'S EARLY IN SHIFT (? JUNCTIONAL)BP DECREASING W/ RATE CHANGE. GENERALIZED EDEMA NOTED.\n\nRESP: ON 4L N/C. LUNGS CLEAR BILAT. GOOD NON-PRODUCTIVE COUGH NOTED. IS INSTRUCTION THIS AM -> 750CC. CT X3 MOD AMT SEROSANG DNG THROUGH THE SHIFT. NO LEAK OR CREPITUS.\n\nGI: ABD SOFT. FEW BSP. INTERMIT NAUSEA. TOOK ONLY FEW ICE CHIPS EARLY IN SHIFT. TO RECEIVE REGLAN QID ATC TODAY. REMAINS ON INSULIN DRIP 2U/HR.\n\nGU: UOP MARGINAL VIA FOLEY.\n\nASSESS: STABLE PM THOUGH DOES REMAIN ON LOW DOSE NEO.\n\nPLAN: D/C SWAN. WEAN NEO. OOB, ADVANCE DIET AS TOL. ? 6 LATER IN AFTERNOON.\n\nASSESS:\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-03-03 00:00:00.000",
"description": "Report",
"row_id": 1339055,
"text": "nursing progress note and transfer note.\nsee carview for details\n\na 44 year old female with admitted to cardinal hospital in with complaints of nausea vomiting and feeling of fluttering in her chest .she ruled out for mi.she was readmitted again about 10 days later,for nausea,vomiting and symptoms of pulmonary edema.a ett thallium revealed mild lv dilitation and ef of 38%.since she reports no other symptoms but sob.she was referred to for cath.\n\npmh:htn,elevated chol,iddm,borderline anemia,gastropesis.past surgical hx:amputation of little toe on right foot.\n\nallergies:nka.\n\non had cabgx3,lima to lad,vg om1,pda.post op pt required neo for bp support and apacing.was extubated post op night.required morphine and toradol for pain control.\n\nneuro:awake,alert and orientedx3.speech clear,follows commands and moves all extremites with appears equal strenght.able to stand and walk to chair.\n\nresp:breath sounds clear but diminished bibasilar.sp02 97% on 4l np.resp rate 16 to 20.instructed in spirocare.\n\ngi:abd obese and soft.complaint of nausea has tolerated small amount of clears.medicated with zofran and reglan with good effect.\n\ngu:urine output has been low.started this afternoon on lasix 20mg iv.\n\ncv:was apaced,now in nsr rate 60s.when returing to bed became orthostatic lasting only briefly and was apaced briefly.\n\naccess:has new right ij triple line.\n\nendocrine. was on insulin gtt now sc insulin,seen by .\n\nplan:transfer to floor.\n"
},
{
"category": "Echo",
"chartdate": "2133-03-05 00:00:00.000",
"description": "Report",
"row_id": 64845,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. H/O cardiac surgery.\nHeight: (in) 63\nWeight (lb): 205\nBSA (m2): 1.96 m2\nBP (mm Hg): 154/86\nStatus: Inpatient\nDate/Time: at 10:00\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\nThere is severe global left ventricular hypokinesis. Overall left ventricular\nsystolic function is severely depressed.\n\nRIGHT VENTRICLE: The right ventricle is not well seen. There is moderate\nglobal right ventricular free wall hypokinesis.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nTechnically difficult study.The left atrium is mildly dilated. Left\nventricular wall thicknesses and cavity size are normal. There is severe\nglobal left ventricular hypokinesis. Basal inferior wall function is\nrelatively preserved.septum is sevrely hypokinetic -akinetic.Overall left\nventricular systolic function is severely depressed. There is moderate global\nright ventricular free wall hypokinesis. The aortic valve leaflets are mildly\nthickened. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. There is no pericardial effusion.\nCompared to the Echo report dated , ( tape not available), LV function\nhas declined.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2133-03-05 00:00:00.000",
"description": "Report",
"row_id": 128550,
"text": "Sinus rhythm\nOld inferior infarct\nLateral T wave changes are nonspecific\nSince previous tracing, lateral T wave changes\n\n"
},
{
"category": "ECG",
"chartdate": "2133-03-06 00:00:00.000",
"description": "Report",
"row_id": 128551,
"text": "Sinus rhythm\nConsider prior inferior myocardial infarction\nLead(s) unsuitable for analysis: V3\n Lateral T wave changes are nonspecific\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2133-03-02 00:00:00.000",
"description": "Report",
"row_id": 128552,
"text": "Sinus rhythm\n One premature ventricular contraction\nPossible inferior infarct - age undetermined\n Anterolateral T wave changes are nonspecific\nNo previous tracing\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-03-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 757300,
"text": " 4:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p removal of chest tubes\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p removal of chest tubes\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, SINGLE AP FILM.\n\n HISTORY: Chest tube removal. Evaluate for ptx.\n\n S/P CABG. Right jugular CV line is in proximal SVC. There are small\n bilateral pleural effusions and bibasilar subsegmental atelectases. No\n pneumothorax.\n\n\n"
}
] |
4,509 | 182,469 | The patient was seen by Dr. who concurred with the exam and recommended discontinuing his IV Integrilin and his sheath at midnight the night prior to surgery, and planned for surgery the following morning. His sheath was pulled at 7 pm on the 3. In addition, his carotid ultrasound preliminary report showed bilateral internal carotid stenoses of less than 40 percent a piece, and on , the patient underwent coronary artery bypass grafting x 4 with a LIMA to the LAD, a vein graft to the diagonal, a vein great to the OM1, and a vein graft to the PDA. He was transferred to the Cardiothoracic ICU in stable condition on a phenylephrine drip at 0.4 mcg/kg/min and a titrated propofol drip. On postoperative day 1, the patient had been extubated overnight, had a blood pressure of 109/49, had a cardiac index of 2.3 with PA pressures of 34/14, and a T-max of 101, with heart rate in sinus rhythm at 92, and satting 97 percent on 3 liters nasal cannula. His heart was regular in rate and rhythm. He had decreased breath sounds bilaterally. His abdomen was soft. He had 1 plus peripheral edema. His beta blockade was started with Lopressor 25 mg po bid. Lasix diuresis was started. Chest tubes were kept in for some elevated output. Swan-Ganz was discontinued, and the patient was transferred to the floor. On the floor, he was evaluated by physical therapy to start his ambulation with the nurses. On postoperative day 1, cardiology was asked to reevaluate the patient regarding his risk stabilization in light of his VF arrest at initial presentation. The patient did continue with his perioperative antibiotics, as well as his beta blockade, aspirin and IV diuresis with Lasix. In addition, he was continued on Plavix and started on his anticholesterol . The patient also had some episodes of atrial fibrillation. On postoperative day 2, the patient was seen by ophthalmology for some bilateral subconjunctival blood in both eyes. He had no other complaints otherwise. He was on anticoagulation at the time. Ophthalmology had no other specific recommendations. The patient continued to work with physical therapy on ambulation. He went back into sinus rhythm after that episode of atrial fibrillation. The patient was encouraged to continue his pulmonary exercise and ambulate as much as he possibly could with physical therapy. His chest tubes were pulled on postoperative day 2. He also had an echocardiogram which revealed an ejection fraction of 50-55 percent, 1 plus AI, 1 plus MR, 2 plus TR, without any effusion. He was followed again by electrophysiology from cardiology who stated that he had no further need for EP risk stratification given his improved echocardiogram, and said they would follow if needed for reconsultation. Dr. also examined the patient again on the 7 and noted that he was afebrile, but had a sternal click without any drainage or redness. His pacing wires were removed also on that day. On postoperative day 4, he had no events overnight. He was hemodynamically stable, satting 93 percent on room air, in sinus rhythm at 79. He was alert and oriented. He still had decreased breath sounds bilaterally. His heart was regular in rate and rhythm with 1-2 plus peripheral edema. His beta blockade was increased, as his blood pressure was 165/52. On overnight, the patient remained in sinus rhythm with no complaints. His sternal incision was clean, dry and intact. Overnight, he had a 10-beat run of VT. His exam was unremarkable. He was satting 96 percent on room air on the day of discharge, with a blood pressure of 127/71, sinus rhythm at 71, with a temperature of 99.2. His exam was otherwise unremarkable. EP recommended increasing his Lopressor. A repeat EKG was done, as well as repeat lab work. He continued with his diuresis, and the patient was given instructions to follow-up with Dr. approximately 2 weeks postoperatively, and to follow-up with electrophysiology in approximately 3-4 weeks. The patient was discharged to home in stable condition on . | There is nopericardial effusion. Moderate[2+] tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Mild (1+)aortic regurgitation is seen. BS DIMINISHED BIBASILAR. GIVEN 1 L LR FOR HYPOTENSION. STERNAL DSG WITH SANGUINOUS DRAINAGE. There is mild symmetric left ventricularhypertrophy. Pt experienced sign amt of N/V at OSH. The ETT terminates in satisfactory position, just below the thoracic inlet. USING INS WELL. ?CHF. MAINTAINING BG LEVEL PER CSRU PROTOCOL.A/P~LABILE BP RESOLVED. ON NEO BRIEFLY. L groin sheath removed with site slightly eccymotic otherwise d/i, distal pulses palpable. Hct down to 27.1, team aware, to be transfused with total of 2u prbc's.Resp: Lungs with crackles at r base otherwise clear. FINDINGS: AP supine view. LABILE BP. TEMP 101.1. LUNGS CLEAR UPPER, VERY DIM IN RIGHT BASE. EFFECTIVE.CARDIAC~SR NO ECTOPY NOTED. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. The mitral valve leaflets are mildly thickened.Mild (1+) mitral regurgitation is seen. OGT placed. C+R SMALL AMOUNT OF BLOODY. Mild (1+) aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. PALP PP. Overall left ventricular systolic functionis mildly depressed.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal inferior - hypokinetic; mid inferior -hypokinetic; basal inferolateral - hypokinetic; mid inferolateral -hypokinetic;RIGHT VENTRICLE: The right ventricular cavity is dilated. Sinus rhythm. There is noaortic valve stenosis. Neo weaned off at OSH. Lungs diminshed at bases clear otherwise. ADEQUATE U/O. Clinical correlation issuggested. Atrial fibrillation. OREIENTED X 3 PRESENTLY. Right ventricular systolic functionis borderline normal. Status post CABG. Palpable distal pulses. RESOLVED. DELINE. The ascending aorta is mildly dilated. CARAFATE X1. Pt denies chest pain. Serial ck's. Referred for CABG to LM,LAd and LCX. There are bibasilar linear and discoid atelectases. S/P CABG.Height: (in) 71Weight (lb): 220BSA (m2): 2.20 m2BP (mm Hg): 144/80HR (bpm): 79Status: InpatientDate/Time: at 10:26Test: TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. K + CALCIUM REPLACED. CPK's cont to decrease. Q waves in leads III and aVF consistent with priorinferior myocardial infarction. The tricuspid regurgitation jet iseccentric and may be underestimated.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is mildly dilated. ALTERED CARDIAC STATUS, CABG X4S: "IT'S COMING UP"O: ARRIVED SEDATED ON PROPOFOL AND .4 MCQ NEO. RESP: EXTUBATED ON PRECEDEX WITHOUT INCIDENT. SBP 90-120 OFF NEO. NEURO~INTACT. Nasal packing removed with extubation. "O: See vs/objective data per carevue.ID: Low grade temp.CV: Hr 80 to low 90's with occ/rare pvc, had one short run AIVR see chart for strip. Probable inferior (and question posterior) myocardialinfarction with ST-T wave configuration suggesting acute/recent/in evolutionprocess. The ascending aorta is mildlydilated.AORTIC VALVE: The aortic valve leaflets are mildly thickened. R groin also slightly eccymotic but d/i. The ICA to CCA ratio is 0.9. ABD SOFT. MINIMAL CT DRAINAGE. MINIMAL CT DRAINAGE. HO TO BE NOTIFIED OF TEMP. A PACED MINIMAL CT DRAINAGE. COMPARISON: . CARDIAC: A PACED TO SR WITHOUT VEA, SR 90'S. A~WIRES SENSING & PACING APPROPRIATELY.V~WIRES SENSING, NOT PACING APPROPRIATELY. There are calcifications in the aorta. Resting regional wallmotion abnormalities include inferior and inferolateral akinesis/hypokinesis.The right ventricular cavity is dilated. Recieved dose of lopressor 12.5mg po. CONT TO ENCOURAGE REHAB. There are low lung volumes. The NG tube terminates below the left hemidiaphragm, in the expected location of the stomach. GU: GIVEN LASIX IN OR WITH A TREMENDOUS RESPONSE, ADEQUATE UO PRESENTLY. GI: HAS REMAINED NPO. Overall leftventricular systolic function is mildly depressed. There is bilateral antegrade vertebral artery flow. The left ventricular cavity size is normal. The leftventricular cavity size is normal. The aortic valveleaflets are mildly thickened. AS PER ORDERS. CI>2. Right ventricularsystolic function is borderline normal.AORTA: The aortic root is normal in diameter. SBP > 100. Sats remained in the upper 90's with 4lnp. The heart and mediastinal contours are within normal limits given preceeding surgery. Started on Integrilin at 2mcg/kg/min with no bolus and restarted heparin at 1300u/hr with therapeutic ptt. OTHER DSGS D+I. Venous sheath via R fem vein. HCT >30. MAE. MAE. He denies cp/sob. ABSENT BOWEL SOUNDS. Bp 100-110's. Able to MAE. RESULTS: Duplex evaluation demonstrates mild echogenic plaque in bilateral carotid bulb. IV Heparin at 1300u/hr. Cont to monitor hemodynamics. POS PAL PEDAL PULSES BILAT.RESP~WEANED TO 3L NP. O2 requirement weaned down to room air with sats 94-96%.Neuro: Pt is alert and oriented. The ICA to CCA ratio is 0.8. Start Integrilin after sheath pull. MAINTAINING SATS OF 97-98%. Abd is soft with bowel sounds present. #9fr sheath via L fem after IABP was pulled at OSH. A DEMAND. Nursing Progress NoteS: I feel pretty good. IMPRESSION: 1) ETT balloon hyperinflation. Compared to the previous tracing of atrial fibrillation is new and the Q waves are more prominent in the inferiorleads suggestive of an interim myocardial infarction. No c/o n/v since admit here. On the right, peak systolic velocities are 92, 122, and 104, in the ICA, CCA, and ECA respectively, with an ICA and diastolic velocity of 36. Clinical correlation is suggested. There are 2 left sided chest tubes and one right sided chest tube. However, the ETT balloon is hyperinflated. On the left, peak systolic veolcities are 90, 102, and 82, in the ICA, CCA, and ECA respectively. Aware of plan for CABG . PATIENT/TEST INFORMATION:Indication: Left ventricular function. No deficits noted.A: Painfree awaiting CABG decreased hct rec'ing 2u Prbc'sP: follow hct cont to follow groin sites prepare for 3rd case CABG Tele sinus rhythm rate 90's. The right internal jugular central venous catheter terminates in the right main pulmonary artery. ELECTROLYTES REPLETED. 2) Satisfactory position of lines and tubes. TRANSFER TO 2 THIS AM. FC. NEURO: AGITATED UPON AWAKENING PROPOFOL @40MCQ AFTER REVERSED, CHANGED TO PRECEDEX AND WITH TIME CALMER AND FOLLOWING COMMANDS. | 12 | [
{
"category": "Echo",
"chartdate": "2144-09-02 00:00:00.000",
"description": "Report",
"row_id": 76877,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/P CABG.\nHeight: (in) 71\nWeight (lb): 220\nBSA (m2): 2.20 m2\nBP (mm Hg): 144/80\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 10:26\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\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.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis mildly depressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferior - hypokinetic; mid inferior -\nhypokinetic; basal inferolateral - hypokinetic; mid inferolateral -\nhypokinetic;\n\nRIGHT VENTRICLE: The right ventricular cavity is dilated. Right ventricular\nsystolic function is borderline normal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\ndilated.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\naortic valve stenosis. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Moderate\n[2+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is\neccentric and may be underestimated.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is mildly depressed. Resting regional wall\nmotion abnormalities include inferior and inferolateral akinesis/hypokinesis.\nThe right ventricular cavity is dilated. Right ventricular systolic function\nis borderline normal. The ascending aorta is mildly dilated. The aortic valve\nleaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+)\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. The tricuspid\nregurgitation jet is eccentric and may be underestimated. There is no\npericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-08-31 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 840622,
"text": " 8:17 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: PREOP CABG\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with 3VD , CABG, pre-op\n REASON FOR THIS EXAMINATION:\n Eval for carotid dz\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID SERIES COMPLETE\n\n REASON: Pre-op CABG.\n\n RESULTS: Duplex evaluation demonstrates mild echogenic plaque in bilateral\n carotid bulb.\n\n On the right, peak systolic velocities are 92, 122, and 104, in the ICA, CCA,\n and ECA respectively, with an ICA and diastolic velocity of 36. The ICA to\n CCA ratio is 0.8.\n\n On the left, peak systolic veolcities are 90, 102, and 82, in the ICA, CCA,\n and ECA respectively. The ICA to CCA ratio is 0.9.\n\n There is bilateral antegrade vertebral artery flow.\n\n IMPRESSION: Less than 40% stenosis of bilateral carotid arteries.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-09-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 841102,
"text": " 2:56 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p cabg, r/o chf\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n s/p cabg, r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST:\n\n HISTORY: CABG.\n\n Status post CABG. All tubes and lines have been removed. No pneumothorax.\n There are bibasilar linear and discoid atelectases. There are low lung\n volumes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-08-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 840690,
"text": " 2:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop film\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man s/p cabg x4\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative evaluation, s/p CABG.\n\n COMPARISON: .\n\n Please note that this report is dictated on because the\n radiographs were previously not placed on the appropriate list in the\n PACS archiving system.\n\n FINDINGS: AP supine view. The ETT terminates in satisfactory position, just\n below the thoracic inlet. However, the ETT balloon is hyperinflated. The NG\n tube terminates below the left hemidiaphragm, in the expected location of the\n stomach. The right internal jugular central venous catheter terminates in the\n right main pulmonary artery. There are 2 left sided chest tubes and one right\n sided chest tube. There is no pneumothorax. There is no pleural effusion. The\n heart and mediastinal contours are within normal limits given preceeding\n surgery. New sternal wires, surgical clips, and skin staples noted. There is\n no parenchymal consolidation. There is no pulmonary edema.\n\n The findings were discussed with at 11:50 a.m. on .\n\n IMPRESSION:\n\n 1) ETT balloon hyperinflation.\n\n 2) Satisfactory position of lines and tubes. No pneumothorax.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-08-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 840572,
"text": " 5:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?CHF\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with s/p cath, extubation\n REASON FOR THIS EXAMINATION:\n ?CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent cardiac catheterization with respiratory failure. ?CHF.\n\n COMPARISON: None.\n\n FINDINGS: A single portable AP view of the chest shows no areas of\n atelectasis/collapse or effusion, although the extreme left portion of the\n thorax is not included on this exam. No CHF. There are calcifications in the\n aorta. Osseous structures are unremarkable.\n\n IMPRESSION: No evidence of active lung disease.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-08-31 00:00:00.000",
"description": "Report",
"row_id": 1320549,
"text": "CCU Progress Note:\n\nSurgery time advanced- stable- anesthesia & surgical consent forms signed- pre-op check list transferred to OR @ 10am in bed- glasses sent to CSRU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-08-31 00:00:00.000",
"description": "Report",
"row_id": 1320550,
"text": "ALTERED CARDIAC STATUS, CABG X4\nS: \"IT'S COMING UP\"\nO: ARRIVED SEDATED ON PROPOFOL AND .4 MCQ NEO. A PACED MINIMAL CT DRAINAGE.\n CARDIAC: A PACED TO SR WITHOUT VEA, SR 90'S. SBP 90-120 OFF NEO. MINIMAL CT DRAINAGE. STERNAL DSG WITH SANGUINOUS DRAINAGE. OTHER DSGS D+I. MINIMAL CT DRAINAGE. FEET COOL TO TOUCH. PALP PP. A DEMAND. BOTH WIRES SENSE AND CAPTURE. HCT >30. K + CALCIUM REPLACED. TEMP 101.1.\n RESP: EXTUBATED ON PRECEDEX WITHOUT INCIDENT. O2 VIA OPEN FACE TENT 67 THEREFORE O2 INCREASED TO 70%. RR LO TWENTIES, O2 SAT >95%. BS DIMINISHED BIBASILAR. NO CT LEAK. IS 500. C+R SMALL AMOUNT OF BLOODY.\n NEURO: AGITATED UPON AWAKENING PROPOFOL @40MCQ AFTER REVERSED, CHANGED TO PRECEDEX AND WITH TIME CALMER AND FOLLOWING COMMANDS. MAE. PERL, NOTED BLOODY SCLERA. OREIENTED X 3 PRESENTLY.\n GI: HAS REMAINED NPO. ABD SOFT. ABSENT BOWEL SOUNDS. CARAFATE X1.\n GU: GIVEN LASIX IN OR WITH A TREMENDOUS RESPONSE, ADEQUATE UO PRESENTLY.\n ENDO: INSULIN GTT @ 5 UNITS/HR.\n ID: TO RECIEVE VANCO @ 2400\n PAIN: MSO4 2 MG X4 WITH GOOD EFFECT\n SOCIAL: WIFE AND CHILDREN INTO VISIT AND UPDATED\nA: STABLE POST OP. TEMP 101.1\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, DSGS, CT DRAINAGE, PP, RESP STATUS-PULM TOILET, I+O, LABS PENDING. HO TO BE NOTIFIED OF TEMP. AS PER ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-09-01 00:00:00.000",
"description": "Report",
"row_id": 1320551,
"text": "NEURO~INTACT. FC. MAE. MED W/ MORPHINE 3 MG X 2 FOR C/O CHEST DISCOMFORT. EFFECTIVE.\n\nCARDIAC~SR NO ECTOPY NOTED. A~WIRES SENSING & PACING APPROPRIATELY.\nV~WIRES SENSING, NOT PACING APPROPRIATELY. LABILE BP. ON NEO BRIEFLY. GIVEN 1 L LR FOR HYPOTENSION. RESOLVED. CI>2. ELECTROLYTES REPLETED. POS PAL PEDAL PULSES BILAT.\n\nRESP~WEANED TO 3L NP. MAINTAINING SATS OF 97-98%. LUNGS CLEAR UPPER, VERY DIM IN RIGHT BASE. USING INS WELL. NON PRODUCTIVE COUGH.\n\n\nGI/GU~TOL ICE CHIPS WELL. ADEQUATE U/O. HYPOACTIVE BS.\n\nENDO~CONT ON INSULIN DRIP. MAINTAINING BG LEVEL PER CSRU PROTOCOL.\n\nA/P~LABILE BP RESOLVED. MAINTAINING MAP~60-90. CONT TO ENCOURAGE REHAB. DELINE. TRANSFER TO 2 THIS AM.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-08-30 00:00:00.000",
"description": "Report",
"row_id": 1320547,
"text": "Nursing Progress Note\n\nS: I feel pretty good.\"\n\nO: 65 yo man admitted to OSH with ST elevation inferiorly and PCI to RCA. Referred for CABG to LM,LAd and LCX. Please see FHP for additional info. Tele sinus rhythm rate 90's. Recieved dose of lopressor 12.5mg po. Neo weaned off at OSH. SBP > 100. IV Heparin at 1300u/hr. Stopped at 16oo for sheath pull. #9fr sheath via L fem after IABP was pulled at OSH. Venous sheath via R fem vein. Pt denies chest pain. Palpable distal pulses. Pt has not received Plavix since stent. House staff and Dr aware to start on Integrilin after sheath pull.\n\nResp: Pt extubated at OSH at 1145. Lungs diminshed at bases clear otherwise. O2 requirement weaned down to room air with sats 94-96%.\n\nNeuro: Pt is alert and oriented. Able to MAE. Pt seems overwhelmed with events of last 24hrs. Aware of plan for CABG . Pt admits to 2 beers/day.\n\nGU/GI: Pt taking sips of clear liquids. Pt experienced sign amt of N/V at OSH. NGT not able to be placed with sign nose bleed requiring packing. OGT placed. No c/o n/v since admit here. Abd is soft with bowel sounds present. Nasal packing removed with extubation. NPO after mn for OR .\n\nSocial: Wife and children in to visit. All have spoken to cardiology staff and CT surgeons for OR .\n\nA&P: 65 yo man s/p IMI with PCI to RCA who needs revascularization to LM LAD and LCX. Start Integrilin after sheath pull. Cont to monitor hemodynamics. Serial ck's. Emotional support for pt and family. OR later in the day tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-08-31 00:00:00.000",
"description": "Report",
"row_id": 1320548,
"text": "CCU NPN\nS: \"What time do I go (to surgery)?\"\nO: See vs/objective data per carevue.\nID: Low grade temp.\nCV: Hr 80 to low 90's with occ/rare pvc, had one short run AIVR see chart for strip. Bp 100-110's. Started on Integrilin at 2mcg/kg/min with no bolus and restarted heparin at 1300u/hr with therapeutic ptt. Integrilin dc'd at 12am for CABG today. L groin sheath removed with site slightly eccymotic otherwise d/i, distal pulses palpable. R groin also slightly eccymotic but d/i. He denies cp/sob. CPK's cont to decrease. Hct down to 27.1, team aware, to be transfused with total of 2u prbc's.\nResp: Lungs with crackles at r base otherwise clear. On room air with sats mid 90's but o2 started when asleep due to sats decreasing to 90's. Sats remained in the upper 90's with 4lnp. Has cough productive of brownish sputum per pt. States he has been having this drng in the back of his throat for a while now.\nGI/GU: Has remained npo after 12am for upcoming CABG. No BM, foley drng clear yellow urine, spec sent for cx.\nMS: He is alert and oriented x 3. No deficits noted.\nA: Painfree awaiting CABG\n decreased hct rec'ing 2u Prbc's\nP: follow hct\n cont to follow groin sites\n prepare for 3rd case CABG\n"
},
{
"category": "ECG",
"chartdate": "2144-09-02 00:00:00.000",
"description": "Report",
"row_id": 183013,
"text": "Atrial fibrillation. Q waves in leads III and aVF consistent with prior\ninferior myocardial infarction. Compared to the previous tracing of \natrial fibrillation is new and the Q waves are more prominent in the inferior\nleads suggestive of an interim myocardial infarction. Clinical correlation is\nsuggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2144-08-31 00:00:00.000",
"description": "Report",
"row_id": 183014,
"text": "Sinus rhythm. Probable inferior (and question posterior) myocardial\ninfarction with ST-T wave configuration suggesting acute/recent/in evolution\nprocess. Clinical correlation is suggested. No previous tracing available for\ncomparison.\n\n"
}
] |
7,580 | 174,558 | The patient was admitted on , the same day as his surgery. He was taken to the Operating Room and a coronary artery bypass times three vessels was performed. The LMA was brought to the LAD, SVG was brought to the OM, SVG was brought to the distal RCA. Cardiac bypass time was 79 minutes. Cross clamp time was 41 minutes. The patient was brought to the Cardiothoracic Surgery Intensive Care Unit postoperatively. Patient on postoperative day #1 remained intubated with a normal arterial blood gas. PH was 7.32, pCO2 of 40, pO2 of 152, bicarbonate 22. On postoperative day #2, the patient was extubated without complication and maintained his oxygen saturation. Patient's urine output was maintained and he was diuresed with IV Lasix. Chest tubes were discontinued and the patient was subsequently discharged to the Surgery floor. Patient's postoperative course was complicated by occasional rapid atrial fibrillation for which the patient was on Inderal previously and was subsequently switched to Toprol 25 mg p.o. b.i.d. He maintained his ventricular rate well from the 70s to the 90s. | post extubation ABG WNL.CT draining minimal serousanginous draingage.gi/gu: pt with + hypoactive BS. ph now normal, gd abgs.Ct to sxn, ACT 140 protamine given. Compared to the previous tracing of the axis is leftward, right bundle-branch block has appeared, and there is anatrial paced rhythm with prolonged A-V conduction. started nitro, normalized, swan placed, CI low started milrinone, received 1 uprbc's, and 4 units FFp, CI >2 after milrinone and colloids,Resp: vented now on imv 8, fio2 40%, init. There has been interval removal of chest tube, mediastinal drains, Swan-Ganz catheter and endotracheal tube. Comparison to the preop study shows that a component of the right pleural opacity is due to pre-existing pleural thickening or fluid. OGT dc'd when extubated. CI 3.13-2.34. mixed venous per CCO swan 68-77. Resp Care: Pt continues intubated and on ventilatory support with simv 800x8/fio2 .4/+5 peep/5 psv with good abg; BS distant throughout, sxn blood tinged secretions, see carevue for details. The patient is status post median sternotomy and CABG. IMPRESSION: SG catheter may terminate in the interlobar artery, but appears somewhat more distal than expected. Right bundle-branch block.Inferior myocardial infarction. A right SG catheter is present, which may terminate in the interlobar artery, but appears somewhat distal. CHEST, SINGLE VIEW: Comparison is made to prior study of . Clinical correlation issuggested. Interval removal of the lines and tubes. There is mediastinal widening and left bailar atelectasis, all presumably representing postsurgical changes. addendum: am hct 22, will transfuse w 2uprbc's. A mediastinal drain is in place. acidotic given 2 amps bicarb. SVO2 70'sPAD 22 and CVP 14. Chest tube removal. , see above for blood productsGI: absent bs, ogt to sxn, bil.drain.GU: foley patent u/o adeqEndo: BS >200 insulin gtt started.Assess/plan: hemodynamics improving, cont to replenish electr., wean vent, monitor ct output., 7am-7pm updateneuro: propofol gtt weaned to off at 0815 am -> pt slow to wake. this afternonn the patient was able to follow commands, MAE, and pt remained slightly lethargic although able easily arousable.Cv: Pt contines to be A paced for slow sinus in the 40's. There is improving atelectasis at the lung bases, there are persistent small bilateral pleural effusions. Tolerating sips of H2OGU: Foley to gravity draining yel urineEndocrine: BS checked q6hrs and Insulin given per protocolPLAN: DC swan, pulm toilet and OOB Cardiac and mediastinal contours are stable in the postoperative period. HCT stable. UO 25-60 cc/hrendo: insulin gtt weaned to off at 1015 am. The ET tube is in place. Neuro: sedated on propofol at 20mcg/kg/, ,Cardio: Pacer A paced at 80, no ectopy, arrived from OR--on neo, propofol, hypotensive episode epi given , bp elev. Neo gtt weaned to off at 10 am. Small bilateral pleural effusions. PA AND LATERAL CHEST: Patient is status post median sternotomy and coronary bypass surgery. Milrinoe gtt decreased to 0.125 mcg/kg/ at 10 am and then weaned to off at 1600. Bibasilar atelectasis, improved since recent study. IMPRESSION: 1. Chest PTdone and pt encouraged to cough and deep breath, med for pain with fair effect.GI: Abd lg, soft and faint BS. pt started on SC reg insulin this afternoon per protocol.plan: monitor CI/mixed venous, pulm toliet, pain control, monitor lytes/bs/hct, MAP 60-80. rare PVC noted. MAP 60's to 70's. Lasix 10mg given with fair response. CI > 2. pt remained sedated (propfol off at 0815 am) -> requring verbal prompting to take deep breaths -> Pt remained intubated until 1500 for airway protection d/t pt being so lethargic. CCO recaled at 1600. Atrial paced rhythm with prolonged A-V conduction. Neuro: Pt awake, sleepy at begining of the night, answered questons , , follows commands, is weak and did get confusedduring the night, easily reoriented.CV: Heart rate 80 100% A paced, underlying slow junctional 50's to 60's, with BP drop. There also appears to be some degree of scarring at the right lung base, which is partially obscured by the acute changes on the current study. Chest tube output SS and minimal.RESP: OFM at 50% most of the night, changed to to NC 4l, O2 sats 97%RR 17 to 30, depending on activity, lungs with rales bilat bases,occ end exp wheeze. PP present by dopplerRESP: pt placed on CPAP 40%, 5 peep and 5 ips at 9am (ABG drawn at 10 WNL). RLE mottled in color (team aware). There is a small left pleural effusion as well. 2. pt with foley to gravity draining clear yellow urine. 3. 9:23 AM CHEST (PA & LAT) Clip # Reason: r/o infiltrate MEDICAL CONDITION: 88 year old man with s/p cabg REASON FOR THIS EXAMINATION: r/o infiltrate FINAL REPORT INDICATIONS: S/P coronary bypass surgery. 12:13 AM CHEST (PORTABLE AP) Clip # Reason: s/p swan placement MEDICAL CONDITION: 88 year old man with CAD s/p CABG REASON FOR THIS EXAMINATION: s/p swan placement FINAL REPORT INDICATION: Coronary artery disease, status post CABG and Swan placement. | 8 | [
{
"category": "Radiology",
"chartdate": "2159-11-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 774948,
"text": " 12:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p swan placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CAD s/p CABG\n REASON FOR THIS EXAMINATION:\n s/p swan placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease, status post CABG and Swan placement.\n\n CHEST, SINGLE VIEW: Comparison is made to prior study of . The\n patient is status post median sternotomy and CABG. The ET tube is in place.\n A mediastinal drain is in place. There is also a large chest tube. A right\n SG catheter is present, which may terminate in the interlobar artery, but\n appears somewhat distal. There is mediastinal widening and left bailar\n atelectasis, all presumably representing postsurgical changes. There is a\n small left pleural effusion as well.\n\n IMPRESSION: SG catheter may terminate in the interlobar artery, but appears\n somewhat more distal than expected.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-11-19 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 775387,
"text": " 9:23 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: S/P coronary bypass surgery. Chest tube removal.\n\n PA AND LATERAL CHEST: Patient is status post median sternotomy and coronary\n bypass surgery. Cardiac and mediastinal contours are stable in the\n postoperative period. There has been interval removal of chest tube,\n mediastinal drains, Swan-Ganz catheter and endotracheal tube.\n\n There is improving atelectasis at the lung bases, there are persistent small\n bilateral pleural effusions. Skeletal structures reveal findings of DISH in\n the spine.\n\n IMPRESSION:\n\n 1. Interval removal of the lines and tubes. There is no evidence\n pneumothorax.\n\n 2. Bibasilar atelectasis, improved since recent study.\n\n 3. Small bilateral pleural effusions. Comparison to the preop study shows\n that a component of the right pleural opacity is due to pre-existing pleural\n thickening or fluid. There also appears to be some degree of scarring at the\n right lung base, which is partially obscured by the acute changes on the\n current study.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-11-13 00:00:00.000",
"description": "Report",
"row_id": 1363887,
"text": "Neuro: sedated on propofol at 20mcg/kg/, ,\n\nCardio: Pacer A paced at 80, no ectopy, arrived from OR--on neo, propofol, hypotensive episode epi given , bp elev. started nitro, normalized, swan placed, CI low started milrinone, received 1 uprbc's, and 4 units FFp, CI >2 after milrinone and colloids,\n\nResp: vented now on imv 8, fio2 40%, init. acidotic given 2 amps bicarb. ph now normal, gd abgs.\nCt to sxn, ACT 140 protamine given. , see above for blood products\n\nGI: absent bs, ogt to sxn, bil.drain.\n\nGU: foley patent u/o adeq\n\nEndo: BS >200 insulin gtt started.\n\nAssess/plan: hemodynamics improving, cont to replenish electr., wean vent, monitor ct output.,\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-11-13 00:00:00.000",
"description": "Report",
"row_id": 1363888,
"text": "Resp Care: Pt continues intubated and on ventilatory support with simv 800x8/fio2 .4/+5 peep/5 psv with good abg; BS distant throughout, sxn blood tinged secretions, see carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-11-13 00:00:00.000",
"description": "Report",
"row_id": 1363889,
"text": "addendum: am hct 22, will transfuse w 2uprbc's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-11-13 00:00:00.000",
"description": "Report",
"row_id": 1363890,
"text": "7am-7pm update\nneuro: propofol gtt weaned to off at 0815 am -> pt slow to wake. this afternonn the patient was able to follow commands, MAE, and pt remained slightly lethargic although able easily arousable.\n\nCv: Pt contines to be A paced for slow sinus in the 40's. rare PVC noted. Neo gtt weaned to off at 10 am. MAP 60-80. Milrinoe gtt decreased to 0.125 mcg/kg/ at 10 am and then weaned to off at 1600. CI 3.13-2.34. mixed venous per CCO swan 68-77. CCO recaled at 1600. HCT stable. RLE mottled in color (team aware). PP present by doppler\n\nRESP: pt placed on CPAP 40%, 5 peep and 5 ips at 9am (ABG drawn at 10 WNL). pt remained sedated (propfol off at 0815 am) -> requring verbal prompting to take deep breaths -> Pt remained intubated until 1500 for airway protection d/t pt being so lethargic. post extubation ABG WNL.\nCT draining minimal serousanginous draingage.\n\ngi/gu: pt with + hypoactive BS. OGT dc'd when extubated. pt with foley to gravity draining clear yellow urine. UO 25-60 cc/hr\n\nendo: insulin gtt weaned to off at 1015 am. pt started on SC reg insulin this afternoon per protocol.\n\nplan: monitor CI/mixed venous, pulm toliet, pain control, monitor lytes/bs/hct,\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-11-14 00:00:00.000",
"description": "Report",
"row_id": 1363891,
"text": "Neuro: Pt awake, sleepy at begining of the night, answered questons , , follows commands, is weak and did get confused\nduring the night, easily reoriented.\n\nCV: Heart rate 80 100% A paced, underlying slow junctional 50's to 60's, with BP drop. No ectopy. MAP 60's to 70's. CI > 2. SVO2 70's\nPAD 22 and CVP 14. Chest tube output SS and minimal.\n\nRESP: OFM at 50% most of the night, changed to to NC 4l, O2 sats 97%\nRR 17 to 30, depending on activity, lungs with rales bilat bases,\nocc end exp wheeze. Lasix 10mg given with fair response. Chest PT\ndone and pt encouraged to cough and deep breath, med for pain with fair effect.\n\nGI: Abd lg, soft and faint BS. Tolerating sips of H2O\n\nGU: Foley to gravity draining yel urine\n\nEndocrine: BS checked q6hrs and Insulin given per protocol\n\nPLAN: DC swan, pulm toilet and OOB\n"
},
{
"category": "ECG",
"chartdate": "2159-11-12 00:00:00.000",
"description": "Report",
"row_id": 170354,
"text": "Atrial paced rhythm with prolonged A-V conduction. Right bundle-branch block.\nInferior myocardial infarction. Compared to the previous tracing of \nthe axis is leftward, right bundle-branch block has appeared, and there is an\natrial paced rhythm with prolonged A-V conduction. Clinical correlation is\nsuggested.\n\n"
}
] |
46,845 | 173,151 | Pt was admitted to the neurosurgery service and montiored closely neurologically. Her exam remained stable to improved. She had repeat head CT on HD#2 that was stable. She was traneferred to the floor. Her diet and activity were advanced. She was seen by PT and OT who recommended rehab. Her facial sutures were removed today this day of discharge / wounds well healed. It is noted that there is a lytic lesion at the skull base on CT - when she is seen in the office for follow up in 2 weeks she will have and MRI of the brain wiht and without contrast per dr for further eval. | PMH: dementia, HTN, afib (not on coumadin), CAD 5) GERD and hiatal hernia. Chief complaint: sdh PMHx: dementia, HTN, afib, CAD Current medications: 1. Chief complaint: sdh PMHx: dementia, HTN, afib, CAD Current medications: 1. Escitalopram Oxalate 7. Escitalopram Oxalate 7. Escitalopram Oxalate 7. Escitalopram Oxalate 7. Taken to where NCHCT preformed at 18:32 showed ~9mm L parietal SDH. Taken to where NCHCT preformed at 18:32 showed ~9mm L parietal SDH. Taken to where NCHCT preformed at 18:32 showed ~9mm L parietal SDH. Taken to where NCHCT preformed at 18:32 showed ~9mm L parietal SDH. Taken to where NCHCT preformed at 18:32 showed ~9mm L parietal SDH. Taken to where NCHCT preformed at 18:32 showed ~9mm L parietal SDH. Taken to where NCHCT preformed at 18:32 showed ~9mm L parietal SDH. Hydrochlorothiazide 9. Hydrochlorothiazide 9. Found to have left sided parietal SDH. Found to have left sided parietal SDH. Found to have left sided parietal SDH. Found to have left sided parietal SDH. Found to have left sided parietal SDH. Emesis today w/o signs of elevated ICP. Patient s/p fall at . Patient s/p fall at . Patient s/p fall at . Patient s/p fall at . Patient s/p fall at . Chief complaint: loss of consciousness PMHx: dementia, HTN, afib, CAD Current medications: Calcium Gluconate 4. Chief complaint: loss of consciousness PMHx: dementia, HTN, afib, CAD Current medications: Calcium Gluconate 4. Metoprolol Succinate XL 12. Metoprolol Succinate XL 12. Metoprolol Succinate XL 12. Metoprolol Succinate XL 12. Hydrochlorothiazide 8. Hydrochlorothiazide 8. Demographics Attending MD: J. Atrial fibrilltion at a rate of 117. Docusate Sodium 6. Docusate Sodium 6. Docusate Sodium 6. Docusate Sodium 6. Calcium Gluconate 4. Calcium Gluconate 4. C-spine negative. C-spine negative. C-spine negative. C-spine negative. C-spine negative. C-spine negative. C-spine negative. To obtain S/S eval. return to vs. need for skilled nursing facility. Pt xferred to for further eval. Pt xferred to for further eval. Pt xferred to for further eval. Pt xferred to for further eval. Pt xferred to for further eval. Pt xferred to for further eval. Subarachnoid hemorrhage (SAH) Assessment: Imaging finding as above. Needs PT/OT consults. Needs PT/OT consults. Needs PT/OT consults. Pt xferred to for further eval Repeat NCHCT at 23:30 shows progression of acute left subdural hematoma which now measures 1.5 cm maximal dimensions with leftward subfalcine herniation of 8 mm, downward transtentorial herniation with obliteration of the left suprasellar cistern, and uncal herniation. Exploratory laparotomy and reduction of internal hernia. Unresponsive for 1 min after found. Unresponsive for 1 min after found. Unresponsive for 1 min after found. Unresponsive for 1 min after found. Unresponsive for 1 min after found. Unresponsive for 1 min after found. Unresponsive for 1 min after found. Donepezil 5. Donepezil 5. Donepezil 5. Donepezil 5. Non-specific ST segment changesin leads I, II, III, aVF and V2-V6. Ramipril 17. Ramipril 17. Promethazine 16. Promethazine 16. Promethazine 16. Promethazine 16. SOCIAL Hx: Daughter serves as HCP; Pt currently DNR/DNI except for elective procedure (****SEE CLARIFICATIOIN BELOW****). Patient is DNR/DNI and not a surgical candidate PMH: dementia, HTN, afib (not on coumadin), CAD Subdural hemorrhage (SDH) Assessment: Patient with baseline dementia, oriented only to self. Patient is DNR/DNI and not a surgical candidate PMH: dementia, HTN, afib (not on coumadin), CAD Subdural hemorrhage (SDH) Assessment: Patient with baseline dementia, oriented only to self. Patient is DNR/DNI and not a surgical candidate PMH: dementia, HTN, afib (not on coumadin), CAD Subdural hemorrhage (SDH) Assessment: Patient with baseline dementia, oriented only to self. Patient is DNR/DNI and not a surgical candidate PMH: dementia, HTN, afib (not on coumadin), CAD Subdural hemorrhage (SDH) Assessment: Patient with baseline dementia, oriented only to self. Action: neuro checks as ordered. Nexium 13. Nexium 13. Compared to the previous tracingof the ST segment changes in the lateral precordial leads arenew and may be related to ischemia. Keep SBP <140-160 Cardiovascular: - baseline bradycardia/PAFib - continue rate control with lopressor. Keep SBP <140-160 Cardiovascular: - baseline bradycardia/PAFib - continue rate control with lopressor. Pulmonary: IS, - no active issues; OOB/upright position Gastrointestinal / Abdomen: - no active issues - GERD at baseline - cont PPI. Pulmonary: IS, - no active issues; OOB/upright position Gastrointestinal / Abdomen: - no active issues - GERD at baseline - cont PPI. Potassium Chloride 15. Potassium Chloride 15. Potassium Chloride 15. Potassium Chloride 15. Pantoprazole 14. Pantoprazole 14. Repeat head CT in the morning. Repeat head CT in the morning. Repeat head CT in the morning. Ondansetron 14. Ondansetron 14. Cardiovascular: afib rate controlled, on beta blockade Pulmonary: encourage IS Gastrointestinal / Abdomen: on pantoprazole; NPO until s/s eval Nutrition: NPO (emesis w/ liquid), await s/s eval Renal: sufficient UO hyponatremia-132--->134, to monitor Hematology: crit stable 28>26, will monitor Endocrine: RISS Infectious Disease: no active ID issues Lines / Tubes / Drains: Foley Wounds: Imaging: CT scan head today Fluids: Will KVO as diet advanced Consults: Neuro surgery Billing Diagnosis: (Hemorrhage, NOS: Subdural) ICU Care Nutrition: Glycemic Control: Regular insulin sliding scale Lines: 16 Gauge - 01:24 AM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP bundle: Comments: Communication: Patient discussed on interdisciplinary rounds Comments: Code status: DNR / DNI Disposition: Transfer to floor Total time spent: 35 minutes Patient is critically ill | 14 | [
{
"category": "Nursing",
"chartdate": "2174-10-21 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541717,
"text": "Patient s/p fall at . Found to have left sided parietal\n SDH. Patient is DNR/DNI and not a surgical candidate\n PMH: dementia, HTN, afib (not on coumadin), CAD\n Subdural hemorrhage (SDH)\n Assessment:\n Patient with baseline dementia, oriented only to self. Patient states:\nm feeling a little slow today\n Very lethargic throughout the day,\n arouses easily to voice. Moves all extremities with good strength\n Action:\n Q2H neuro checks as ordered.\n Response:\n No change in neuro status\n Plan:\n Monitor overnight in floor bed. Repeat head CT in the morning. ? Need\n for swallow evaluation. Needs PT/OT consults.\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-21 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541721,
"text": "Patient s/p fall at . Found to have left sided parietal\n SDH. Patient is DNR/DNI and not a surgical candidate\n PMH: dementia, HTN, afib (not on coumadin), CAD\n Subdural hemorrhage (SDH)\n Assessment:\n Patient with baseline dementia, oriented only to self. Patient states:\nm feeling a little slow today\n Very lethargic throughout the day,\n arouses easily to voice. Moves all extremities with good strength.\n Oriented to self only. Occasionally will know she is in the hospital.\n Action:\n neuro checks as ordered.\n Response:\n No change in neuro status, patient seems slightly brighter today\n Plan:\n Follow neuro exams as ordered. ? return to vs. need for\n skilled nursing facility.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n SUBDURAL HEMORRHAGE\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 50 kg\n Daily weight:\n 50 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: 1) HTN\n 2) Angina\n 3) Atrial fibrillation/atrial flutter\n -diagnosed from admission \n 4) Choledocholithiasis with obstruction and cholecystitis.\n - Diagnosed \n - Treated with ERCP-guided sphincterotomy and stone extraction.\n 5) GERD and hiatal hernia.\n 6) Dementia\n Surgery / Procedure and date: : Right lower extremity angiogram\n with stent placement\n Arthroscopy of left knee and partial medial meniscectomy.\n Exploratory laparotomy and reduction of internal hernia.\n excision of Duct ectasia, left breast.\n Wide excision of basilar carcinoma of left ear in canal plus\n reconstruction and excision\n of lesion of chin.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:103\n D:45\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 101 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,254 mL\n 24h total out:\n 875 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 02:51 AM\n Potassium:\n 4.3 mEq/L\n 02:51 AM\n Chloride:\n 102 mEq/L\n 02:51 AM\n CO2:\n 24 mEq/L\n 02:51 AM\n BUN:\n 15 mg/dL\n 02:51 AM\n Creatinine:\n 0.8 mg/dL\n 02:51 AM\n Glucose:\n 96 mg/dL\n 02:51 AM\n Hematocrit:\n 26.5 %\n 02:51 AM\n Finger Stick Glucose:\n 139\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 Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: t/sicu\n Transferred to: \n Date & time of Transfer: 1730\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 541708,
"text": "TSICU\n HPI:\n F found unresponsive on ground at nursing home. Pt was\n in dining room and found by staff. Unresponsive for 1 min after\n found. Pt cannot recollect events preceding fall but with some\n c/o HA and some neck/shoulder discomfort. Taken to \n where NCHCT preformed at 18:32 showed ~9mm L parietal SDH.\n C-spine negative. Pt xferred to for further eval.\n Chief complaint:\n sdh\n PMHx:\n dementia, HTN, afib, CAD\n Current medications:\n 1. 2. 1000 mL NS 3. Calcium Gluconate 4. Donepezil 5. Docusate Sodium\n 6. Escitalopram Oxalate\n 7. Hydrochlorothiazide 8. Influenza Virus Vaccine 9. Insulin 10.\n Magnesium Sulfate 11. Metoprolol Succinate XL\n 12. Ondansetron 13. Pantoprazole 14. Potassium Chloride 15.\n Promethazine 16. Ramipril 17. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n Pt made DNR/DNI by family. Awaiting tx to floor.\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 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 36.8\nC (98.2\n HR: 60 (49 - 96) bpm\n BP: 156/67(90) {119/34(55) - 156/67(90)} mmHg\n RR: 18 (9 - 35) insp/min\n SPO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 50 kg (admission): 50 kg\n Total In:\n 1,834 mL\n 478 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,834 mL\n 478 mL\n Blood products:\n Total out:\n 1,515 mL\n 300 mL\n Urine:\n 1,015 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 319 mL\n 178 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 366 K/uL\n 8.6 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 15 mg/dL\n 102 mEq/L\n 134 mEq/L\n 26.5 %\n 11.2 K/uL\n [image002.jpg]\n 03:39 AM\n 02:51 AM\n WBC\n 13.7\n 11.2\n Hct\n 28.2\n 26.5\n Plt\n 412\n 366\n Creatinine\n 0.9\n 0.8\n Glucose\n 120\n 96\n Other labs: PT / PTT / INR:13.6/33.0/1.2, CK / CK-MB / Troponin T:42//,\n Ca:8.5 mg/dL, Mg:1.8 mg/dL, PO4:3.0 mg/dL\n Imaging: No significant change in the acute left subdural hematoma,\n with\n associated rightward subfalcine herniation, as well as likely a\n downward\n transtentorial herniation and uncal herniation.\n Microbiology: no acute issues\n Assessment and Plan\n SUBDURAL HEMORRHAGE (SDH), TRAUMA, S/P\n Assessment and Plan:\n Neurologic: SDH w/ midline shift and herniation\n stable, neuro exam\n baseline. Pt mildly agitated in evenings, but redirectable. Neuro\n checks Q4hr, Pain well controlled. Emesis today w/o signs of elevated\n ICP. To obtain S/S eval.\n Cardiovascular: afib\n rate controlled, on beta blockade\n Pulmonary: encourage IS\n Gastrointestinal / Abdomen: on pantoprazole; NPO until s/s eval\n Nutrition: NPO (emesis w/ liquid), await s/s eval\n Renal: sufficient UO\n hyponatremia-132--->134, to monitor\n Hematology: crit stable 28>26, will monitor\n Endocrine: RISS\n Infectious Disease: no active ID issues\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging: CT scan head today\n Fluids: Will KVO as diet advanced\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 01:24 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 541678,
"text": "Subdural hemorrhage (SDH)\n Assessment:\n Pt remains confused, grossly intact, no changes in neuro status, pulled\n two\n of her IVs,\n Action:\n Trying to reorient , maintain safety,\n Response:\n Pt was able to sleep 1-2 hour at a time, denies pain, headache\n Plan:\n Transfer to floor when bed is available\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 541672,
"text": "TSICU\n HPI:\n F found unresponsive on ground at nursing home. Pt was\n in dining room and found by staff. Unresponsive for 1 min after\n found. Pt cannot recollect events preceding fall but with some\n c/o HA and some neck/shoulder discomfort. Taken to \n where NCHCT preformed at 18:32 showed ~9mm L parietal SDH.\n C-spine negative. Pt xferred to for further eval.\n Chief complaint:\n sdh\n PMHx:\n dementia, HTN, afib, CAD\n Current medications:\n 1. 2. 1000 mL NS 3. Calcium Gluconate 4. Donepezil 5. Docusate Sodium\n 6. Escitalopram Oxalate\n 7. Hydrochlorothiazide 8. Influenza Virus Vaccine 9. Insulin 10.\n Magnesium Sulfate 11. Metoprolol Succinate XL\n 12. Ondansetron 13. Pantoprazole 14. Potassium Chloride 15.\n Promethazine 16. Ramipril 17. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n Pt made DNR/DNI by family. Awaiting tx to floor.\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 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.7\n T current: 36.8\nC (98.2\n HR: 60 (49 - 96) bpm\n BP: 156/67(90) {119/34(55) - 156/67(90)} mmHg\n RR: 18 (9 - 35) insp/min\n SPO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 50 kg (admission): 50 kg\n Total In:\n 1,834 mL\n 478 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,834 mL\n 478 mL\n Blood products:\n Total out:\n 1,515 mL\n 300 mL\n Urine:\n 1,015 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 319 mL\n 178 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 366 K/uL\n 8.6 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 15 mg/dL\n 102 mEq/L\n 134 mEq/L\n 26.5 %\n 11.2 K/uL\n [image002.jpg]\n 03:39 AM\n 02:51 AM\n WBC\n 13.7\n 11.2\n Hct\n 28.2\n 26.5\n Plt\n 412\n 366\n Creatinine\n 0.9\n 0.8\n Glucose\n 120\n 96\n Other labs: PT / PTT / INR:13.6/33.0/1.2, CK / CK-MB / Troponin T:42//,\n Ca:8.5 mg/dL, Mg:1.8 mg/dL, PO4:3.0 mg/dL\n Imaging: No significant change in the acute left subdural hematoma,\n with\n associated rightward subfalcine herniation, as well as likely a\n downward\n transtentorial herniation and uncal herniation.\n Microbiology: no acute issues\n Assessment and Plan\n SUBDURAL HEMORRHAGE (SDH), TRAUMA, S/P\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain well controlled\n Pt mildly agitated in evenings, but redirectable.\n Stable SDH\n Cardiovascular: no acute issues\n Pulmonary: encourage IS\n Gastrointestinal / Abdomen: pantoprazole\n Nutrition: ADAT\n Renal: sufficient UO\n hyponatremia-132--->134\n Hematology: crit stable 28>26, will monitor\n Endocrine: RISS\n Infectious Disease: no active ID issues\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging: CT scan head today\n Fluids: Will KVO as diet advanced\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 01:24 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 541659,
"text": "Subdural hemorrhage (SDH)\n Assessment:\n Pt remains confused, grossly intact, no changes in neuro status, pulled\n one of her IVs,\n Action:\n Trying to reorient , maintain safety,\n Response:\n Pt was able to sleep 1-2 hour at a time, denies pain, headache\n Plan:\n Transfer to floor when bed is available\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 541545,
"text": "TITLE:\n F found unresponsive on ground at nursing home. Pt was\n in dining room and found by staff. Unresponsive for 1 min after\n found. Pt cannot recollect events preceding fall but with some\n c/o HA and some neck/shoulder discomfort. Taken to \n where NCHCT preformed at 18:32 showed ~9mm L parietal SDH.\n C-spine negative. Pt xferred to for further eval\n Repeat NCHCT at 23:30 shows progression of acute\n left subdural hematoma which now measures 1.5 cm maximal\n dimensions with leftward subfalcine herniation of 8 mm, downward\n transtentorial herniation with obliteration of the left\n suprasellar cistern, and uncal herniation. No fx,\n destructive infiltrative lesion involving the skull base.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Imaging finding as above. Confused, combative at times, trying to get\n OOB, says she needs to void-? If this is her baseline dementia, MAE,\n PERL\n Action:\n Neuro checks q1-2h, haldol given prn for aggitaion\n Response:\n No changes in neuro status, repeat CT head done at 6am\n Plan:\n Obtain CT head this am , develop plan of care according to ct results\n Trauma, s/p\n Assessment:\n Fell off the bed in nursing home\nunwitnessed, +LOC, got DT+ dilantin\n in OSH, bradycardic in 50s, normotensive/hypertensive, several facial\n lacs were stitched in ED, multiple bruising areas all over the body.\n pt denies pain but c/o nausea\n Action:\n Pt had bilateral hips film to r/o fractures, ct head, c/spine was\n cleared, dr. spoke with family about code statuse and pt\n daughter wanted an intervention if needed, then pt became eligible to\n intubate for OR if needed. Zofran was given for nausea\n Response:\n Plan:\n Follow up with film results, family meeting, address code status,\n consider transfer to s/d or floor\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 541625,
"text": "Patient s/p fall at . Found to have left sided parietal\n SDH. Patient is DNR/DNI and not a surgical candidate\n PMH: dementia, HTN, afib (not on coumadin), CAD\n Subdural hemorrhage (SDH)\n Assessment:\n Patient with baseline dementia, oriented only to self. Patient states:\nm feeling a little slow today\n Very lethargic throughout the day,\n arouses easily to voice. Moves all extremities with good strength\n Action:\n Q2H neuro checks as ordered.\n Response:\n No change in neuro status\n Plan:\n Monitor overnight in floor bed. Repeat head CT in the morning. ? Need\n for swallow evaluation. Needs PT/OT consults.\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-20 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 541520,
"text": "Chief Complaint: s/p fall with SDH\n HPI:\n HPI: F found unresponsive on ground at nursing home. Pt was\n in dining room and found by staff. Unresponsive for 1 min after\n found. Pt cannot recollect events preceding fall but with some\n c/o HA and some neck/shoulder discomfort. Taken to \n where NCHCT preformed at 18:32 showed ~9mm L parietal SDH.\n C-spine negative. Pt xferred to for further eval.\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n dementia, HTN, afib, CAD\n SURGICAL Hx: unknown\n .\n SOCIAL Hx: Daughter serves as HCP; Pt currently DNR/DNI except for\n elective procedure (****SEE CLARIFICATIOIN BELOW****).\n .\n ALLERGIES: NKDA\n Flowsheet Data as of 01:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.9\nC (96.7\n HR: 58 (58 - 68) bpm\n BP: 156/63(132) {156/63(132) - 156/63(132)} mmHg\n RR: 20 (20 - 20) insp/min\n SpO2: 99%\n Wgt (current): 50 kg (admission): 50 kg\n Total In:\n 28 mL\n PO:\n TF:\n IVF:\n 28 mL\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -472 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n bialterally)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): A+O x 2, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: 11:40p\n -----------------------------------------------------------------------\n ---------\n Color\n Straw Appear\n Clear SpecGr\n 1.011 pH\n 7.0 Urobil\n Neg Bili\n Neg\n Leuk\n Neg Bld\n Neg Nitr\n Neg Prot\n Neg Glu\n Neg Ket\n Neg\n \n 10:16p\n -----------------------------------------------------------------------\n ---------\n Green Top\n Na:133\n K:4.6\n Cl:96\n TCO2:24\n Glu:134 freeCa:1.00\n Lactate:2.7\n pH:7.41\n Hgb:10.8\n CalcHCT:32\n \n 10:10p\n -----------------------------------------------------------------------\n ---------\n 131 95 24 142 AGap=17\n 4.6 24 0.9\n estGFR: 58/70 (click for details)\n CK: 43 MB: Notdone Trop-T: <0.01\n Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n Ca: 8.8 Mg: 1.9 P: 3.0\n 95\n 20.2 D 9.9 427\n 29.9\n N:91.0 L:6.0 M:2.6 E:0.2 Bas:0.2\n PT: 13.6 PTT: 32.5 INR: 1.2\n Imaging: CT head w/o contrast Acute left subdural hematoma measuring\n 1.5 cm maximal dimensions with leftward subfalcine herniation of 8 mm,\n downward transtentorial herniation with obliteration of the left\n suprasellar cistern, and uncal herniation. No fx, destructive\n infiltrative lesion involving the skull base\n Microbiology: MICRO: no acute infectious issue thus far\n Assessment and Plan\n F found unresponsive on ground at nursing home. Pt was\n in dining room and found by staff. Unresponsive for 1 min after\n found. Pt cannot recollect events preceding fall but with some\n c/o HA and some neck/shoulder discomfort. Taken to \n where NCHCT preformed at 18:32 showed ~9mm L parietal SDH.\n C-spine negative. Pt xferred to for further eval.\n Assessment And Plan:\n Neurologic: SDH with midline shift:= q1h neuro checks, CT head in AM,\n if decompensates -> intubate and proceed to OR for evacuation\n Cardiovascular: SDH with midline shift:= SBP < 140-160, no diuresis at\n this time\n Pulmonary: no issues, will continue to monitor\n Gastrointestinal: NPO thus far for possible OR\n Renal: no issues thus far, will continue to monitor\n Hematology: will continue to monitor, stable anemia\n Infectious Disease: no acute infectious issues at this time\n Endocrine: RISS to maintain BS < 150\n Fluids: NS @ 80 for maintenance fluids while awaiting possible OR\n Electrolytes: will replete aggressively with scales\n Nutrition: NPO thus far as discussed above\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 01:24 AM\n 20 Gauge - 01:24 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-20 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541590,
"text": "Patient s/p fall at . Found to have left sided parietal\n SDH.\n PMH: dementia, HTN, afib (not on coumadin), CAD\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-20 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541592,
"text": "Patient s/p fall at . Found to have left sided parietal\n SDH. Patient is DNR/DNI and not a surgical candidate\n PMH: dementia, HTN, afib (not on coumadin), CAD\n Subdural hemorrhage (SDH)\n Assessment:\n Patient with baseline dementia, oriented only to self. Patient states:\nm feeling a little slow today\n Very lethargic throughout the day,\n arouses easily to voice. Moves all extremities with good strength\n Action:\n Q2H neuro checks as ordered.\n Response:\n No change in neuro status\n Plan:\n Monitor overnight in floor bed. Repeat head CT in the morning. ? Need\n for swallow evaluation. Needs PT/OT consults.\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 541552,
"text": "TSICU\n HPI:\n F found unresponsive on ground at nursing home. Pt was\n in dining room and found by staff. Unresponsive for 1 min after\n found. Pt cannot recollect events preceding fall but with some\n c/o HA and some neck/shoulder discomfort. Taken to \n where NCHCT preformed at 18:32 showed ~9mm L parietal SDH.\n C-spine negative. Pt xferred to for further eval.\n Chief complaint:\n loss of consciousness\n PMHx:\n dementia, HTN, afib, CAD\n Current medications:\n Calcium Gluconate 4. Donepezil 5. Docusate Sodium 6. Escitalopram\n Oxalate\n 7. Haloperidol 8. Hydrochlorothiazide 9. Influenza Virus Vaccine 10.\n Magnesium Sulfate 11. Metoprolol Succinate XL\n 12. Nexium 13. Ondansetron 14. Potassium Chloride 15. Promethazine 16.\n Ramipril\n 24 Hour Events:\n Repeat CT head 6am\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 52 (52 - 69) bpm\n BP: 124/44(64) {124/42(64) - 164/63(132)} mmHg\n RR: 15 (15 - 21) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 50 kg (admission): 50 kg\n Total In:\n 500 mL\n PO:\n Tube feeding:\n IV Fluid:\n 500 mL\n Blood products:\n Total out:\n 0 mL\n 775 mL\n Urine:\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -275 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular, Irregular), intermittent irregular\n rhythm\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis:\n Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis:\n Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 412 K/uL\n 9.6 g/dL\n 120 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 21 mg/dL\n 97 mEq/L\n 132 mEq/L\n 28.2 %\n 13.7 K/uL\n [image002.jpg]\n 03:39 AM\n WBC\n 13.7\n Hct\n 28.2\n Plt\n 412\n Creatinine\n 0.9\n Glucose\n 120\n Other labs: PT / PTT / INR:13.3//1.1, CK / CK-MB / Troponin T:42//,\n Ca:8.5 mg/dL, Mg:1.9 mg/dL, PO4:3.2 mg/dL\n Imaging: - Acute left subdural hematoma measuring 1.5 cm maximal\n dimensions with leftward\n subfalcine herniation of 8 mm, downward transtentorial herniation with\n obliteration of the left suprasellar cistern, and uncal herniation. No\n fx,\n destructive infiltrative lesion involving the skull base.\n Assessment and Plan\n SUBARACHNOID HEMORRHAGE (SAH), TRAUMA, S/P\n Assessment and Plan: yo female w/ SDH\n Neurologic: Neuro checks Q: 2 hr, F/U CT head final read, F/U Nsurg\n regarding plan. Keep SBP <140-160\n Cardiovascular: - baseline bradycardia/PAFib - continue rate control\n with lopressor.\n Pulmonary: IS, - no active issues; OOB/upright position\n Gastrointestinal / Abdomen: - no active issues\n - GERD at baseline - cont PPI.\n - bowel regimen - colace\n Nutrition: NPO, - NPO until further planning\n Renal: Adequate UO, - no active issues\n Hematology: - stable baseline anemia\n Endocrine: RISS\n Infectious Disease: no active issues\n Lines / Tubes / Drains: Foley, PIV\n Wounds: - head lac - sutures C/D/I\n Imaging: CT scan head today, f/u final read\n Fluids: NS, on NS @ 80ml/hr\n Consults: Neuro surgery\n Billing Diagnosis: Closed head injury\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 01:24 AM\n 20 Gauge - 01:24 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 541571,
"text": "TSICU\n HPI:\n F found unresponsive on ground at nursing home. Pt was\n in dining room and found by staff. Unresponsive for 1 min after\n found. Pt cannot recollect events preceding fall but with some\n c/o HA and some neck/shoulder discomfort. Taken to \n where NCHCT preformed at 18:32 showed ~9mm L parietal SDH.\n C-spine negative. Pt xferred to for further eval.\n Chief complaint:\n loss of consciousness\n PMHx:\n dementia, HTN, afib, CAD\n Current medications:\n Calcium Gluconate 4. Donepezil 5. Docusate Sodium 6. Escitalopram\n Oxalate\n 7. Haloperidol 8. Hydrochlorothiazide 9. Influenza Virus Vaccine 10.\n Magnesium Sulfate 11. Metoprolol Succinate XL\n 12. Nexium 13. Ondansetron 14. Potassium Chloride 15. Promethazine 16.\n Ramipril\n 24 Hour Events:\n Repeat CT head 6am\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 52 (52 - 69) bpm\n BP: 124/44(64) {124/42(64) - 164/63(132)} mmHg\n RR: 15 (15 - 21) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 50 kg (admission): 50 kg\n Total In:\n 500 mL\n PO:\n Tube feeding:\n IV Fluid:\n 500 mL\n Blood products:\n Total out:\n 0 mL\n 775 mL\n Urine:\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -275 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular, Irregular), intermittent irregular\n rhythm\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis:\n Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis:\n Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 412 K/uL\n 9.6 g/dL\n 120 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 21 mg/dL\n 97 mEq/L\n 132 mEq/L\n 28.2 %\n 13.7 K/uL\n [image002.jpg]\n 03:39 AM\n WBC\n 13.7\n Hct\n 28.2\n Plt\n 412\n Creatinine\n 0.9\n Glucose\n 120\n Other labs: PT / PTT / INR:13.3//1.1, CK / CK-MB / Troponin T:42//,\n Ca:8.5 mg/dL, Mg:1.9 mg/dL, PO4:3.2 mg/dL\n Imaging: - Acute left subdural hematoma measuring 1.5 cm maximal\n dimensions with leftward\n subfalcine herniation of 8 mm, downward transtentorial herniation with\n obliteration of the left suprasellar cistern, and uncal herniation. No\n fx,\n destructive infiltrative lesion involving the skull base.\n Assessment and Plan\n SUBARACHNOID HEMORRHAGE (SAH), TRAUMA, S/P\n Assessment and Plan: yo female w/ SDH\n Neurologic: Neuro checks Q: 2 hr, F/U CT head final read, F/U Nsurg\n regarding plan. Keep SBP <140-160\n Cardiovascular: - baseline bradycardia/PAFib - continue rate control\n with lopressor.\n Pulmonary: IS, - no active issues; OOB/upright position\n Gastrointestinal / Abdomen: - no active issues\n - GERD at baseline - cont PPI.\n - bowel regimen - colace\n Nutrition: NPO, - NPO until further planning\n Renal: Adequate UO, - no active issues\n Hematology: - stable baseline anemia\n Endocrine: RISS\n Infectious Disease: no active issues\n Lines / Tubes / Drains: Foley, PIV\n Wounds: - head lac - sutures C/D/I\n Imaging: CT scan head today, f/u final read\n Fluids: NS, on NS @ 80ml/hr\n Consults: Neuro surgery\n Billing Diagnosis: Closed head injury\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 01:24 AM\n 20 Gauge - 01:24 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI per neurosurgery this AM\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n"
},
{
"category": "ECG",
"chartdate": "2174-10-21 00:00:00.000",
"description": "Report",
"row_id": 259431,
"text": "Atrial fibrilltion at a rate of 117. Non-specific ST segment changes\nin leads I, II, III, aVF and V2-V6. Compared to the previous tracing\nof the ST segment changes in the lateral precordial leads are\nnew and may be related to ischemia. Clinical correlation is suggested.\n\n"
}
] |
64,578 | 172,412 | The details of the patient's elective cardiac catheterization on and PCI on are described in the HPI. She was montiored overnight in the CCU, where she remained asymptomatic and hemodynamically stable. Her hematocrit was trended due to moderate blood loss (quantity unclear) during the procedure; after an initial drop, it remained stable. Her femoral puncture sites showed no bleeding, hematoma, or bruits and distal pulses remained intact. She was started on clopidogrel 75mg daily and her ASA was increased from 81mg to 325mg daily for the next month. She was continued on all of her other outpatient medications and discharged in stable condition. Her code status during this admission was DNR/DNI. | 77 yo F w/ CAD s/p CABG in (LIMA-LAD, SVG-OM, SVG-diag, SVG-LVbranch, SVG-AM), SVGs known TO in ; p/w intermittent anginal sxs x 1 mo. # GERD: Cont PPI . # GERD: Cont PPI . # GERD: Cont PPI . # GERD: Cont PPI . 77 y/o F with hx of CAD, HTN admitted for elective cath for anginal symptoms now s/p stents to LIMA-LAD and left main-LCx. referred to from PCP in for cath d/t chest heaviness. referred to from PCP in for cath d/t chest heaviness. referred to from PCP in for cath d/t chest heaviness. - Cont metoprolol, losartan, imdur . - Cont metoprolol, losartan, imdur . - Cont metoprolol, losartan, imdur . - Cont metoprolol, losartan, imdur . # HLD: Cont statin . # HLD: Cont statin . # HLD: Cont statin . # HLD: Cont statin . # CODE: DNR/DNI . # CODE: DNR/DNI . # CODE: DNR/DNI . # CODE: DNR/DNI . 2+ DP and PT pulses. 2+ DP and PT pulses. 2+ DP and PT pulses. 2+ DP and PT pulses. OFFPUMP CABG with LIMA-LAD, SVG to the left ventricular branch, the obtuse marginal and diagonal, and an SVG to the acute marginal. Impella pulled after PCI (was placed via R groin, 10 Fr sheath). Impella pulled after PCI (was placed via R groin, 10 Fr sheath). Impella pulled after PCI (was placed via R groin, 10 Fr sheath). Labs / Radiology 29.0 % [image002.jpg] 11:28 PM Hct 29.0 Assessment and Plan 77 y/o F with hx of CAD, HTN admitted for elective cath for anginal symptoms now s/p stents to LIMA-LAD and left main-LCx. As per Dr , d/c home . As per Dr , d/c home . As per Dr , d/c home . Had transient HR 40's with Rotoblator, received 0.6 mg atropine with resolution. Had transient HR 40's with Rotoblator, received 0.6 mg atropine with resolution. Had transient HR 40's with Rotoblator, received 0.6 mg atropine with resolution. CV: in sinus rhythm, SBP 90-114, DP/PT palp bilaterally. CV: in sinus rhythm, SBP 90-114, DP/PT palp bilaterally. CV: in sinus rhythm, SBP 90-114, DP/PT palp bilaterally. Diffuse T wave flattening in leads V3-V6. Now with distal LIMA and distal left main stenosis s/p stenting at each site. Now with distal LIMA and distal left main stenosis s/p stenting at each site. Now with distal LIMA and distal left main stenosis s/p stenting at each site. Now with distal LIMA and distal left main stenosis s/p stenting at each site. Clinical correlation issuggested. Labs / Radiology 29.0 % [image002.jpg] 11:28 PM Hct 29.0 Assessment and Plan 77 y/o F with 5V-CABG admitted for elective cath for anginal symptoms now s/p stents to LIMA-LAD and left main-LCx. Labs / Radiology 29.0 % [image002.jpg] 11:28 PM Hct 29.0 Assessment and Plan 77 y/o F with 5V-CABG admitted for elective cath for anginal symptoms now s/p stents to LIMA-LAD and left main-LCx. Hct stable. Hct stable. # PROPHYLAXIS: SC heparin, bowel regimen, home PPI . # PROPHYLAXIS: SC heparin, bowel regimen, home PPI . # PROPHYLAXIS: SC heparin, bowel regimen, home PPI . # PROPHYLAXIS: SC heparin, bowel regimen, home PPI . CARDIAC: RRR, normal S1, S2. CARDIAC: RRR, normal S1, S2. CARDIAC: RRR, normal S1, S2. CARDIAC: RRR, normal S1, S2. ------ Protected Section Addendum Entered By: , RN on: 19:43 ------ HEENT: NCAT. HEENT: NCAT. HEENT: NCAT. HEENT: NCAT. Labs / Radiology 1.0 4.3 27.2 <- 34.5 [image002.jpg] ECG: Ectopic atrial rhythm at 64 bpm Assessment and Plan 77 y/o F with hx of CAD, HTN admitted for elective cath for anginal symptoms now s/p stents to LIMA-LAD and left main-LCx. Skin: intact, continues to lye flat d/t groin bleed ID: afeb. Skin: intact, continues to lye flat d/t groin bleed ID: afeb. Skin: intact, continues to lye flat d/t groin bleed ID: afeb. LM rotoblator followed by PTCA and Stent. LM rotoblator followed by PTCA and Stent. LM rotoblator followed by PTCA and Stent. T waveinversions in leads II, III and aVF. NABS. NABS. NABS. NABS. WWP. WWP. WWP. WWP. TITLE: Chief Complaint: Chest pain HPI: This is a 77 y.o. Cardiac review of systems is notable for chest pressure as above (none currently), longstanding intermittent lightheadedness (stable), and absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, or syncope. | 14 | [
{
"category": "Physician ",
"chartdate": "2113-03-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 664533,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n None\n Allergies:\n Percodan (Oral) (Oxycodone Hcl/Aspirin)\n dizziness;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n dizziness;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:31 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 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 72 (66 - 80) bpm\n BP: 121/56(73) {94/40(54) - 121/73(78)} mmHg\n RR: 17 (0 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 3,405 mL\n 1,375 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,925 mL\n 1,375 mL\n Blood products:\n Total out:\n 1,350 mL\n 870 mL\n Urine:\n 1,000 mL\n 870 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,055 mL\n 505 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n GENERAL: WDWN female in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. MM slightly dry.\n NECK: Supple with no JVD.\n CARDIAC: RRR, normal S1, S2. 2/6 SEM at RUSB/LUSB. No rubs or gallops.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi anteriorly.\n ABDOMEN: Soft, NTND. NABS.\n EXTREMITIES: Trace ankle edema. Bilat groin without hematoma,\n tenderness, ecchymoses. 2+ DP and PT pulses. WWP.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 29.0 %\n [image002.jpg]\n 11:28 PM\n Hct\n 29.0\n Assessment and Plan\n 77 y/o F with hx of CAD, HTN admitted for elective cath for anginal\n symptoms now s/p stents to LIMA-LAD and left main-LCx.\n .\n # CAD: s/p CABG x5 in , repeat cath showing occluded grafts x4. Now\n with distal LIMA and distal left main stenosis s/p stenting at each\n site. Impella assist device was placed during procedure preemptively,\n although her hemodynamics have been stable and the device was removed.\n On the floor, she has no CP or SOB and remains hemodynamically stable.\n - Cont ASA 325mg daily, statin, b-blocker, \n - Started on clopidogrel 75mg daily\n .\n # Anemia: Per cards fellow and attending, patient had a moderate amount\n (quantity not clear) of blood loss during the cardiac catheterization\n today. This would explain her hct drop from 34.5 this am to 27.2 after\n the procedure. No hematoma or oozing at groin, so would expect hct to\n stabilize.\n - 11pm and am hct\n - Transfuse if under hct of 23\n .\n # HTN: Well controlled.\n - Cont metoprolol, losartan, imdur\n .\n # HLD: Cont statin\n .\n # GERD: Cont PPI\n .\n # FEN: Cardiac diet, IVF overnight\n .\n # ACCESS: PIVs\n .\n # PROPHYLAXIS: SC heparin, bowel regimen, home PPI\n .\n # CODE: DNR/DNI\n .\n # DISPO: likely d/c tomorrow if blood volume and BP stable\n .\n # Contact: , home phone \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:16 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2113-03-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664536,
"text": "77 y/o F with hx of CAD, HTN admitted for elective cath for anginal\n symptoms now s/p stents to LIMA-LAD and left main-LCx.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct drop post PCI today from 35 to 27, some blood loss during\n procedure, R groin line pul in cath lab.\n Action:\n Repeat hct at 2300 was up to 29\n Response:\n Had bleeding with removal of sheath from R groin, pressure held\n dressing applied and no further bleeding overnight, pulses palp\n Plan:\n Cont to monitor hct, signs of bleeding\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Denies CP/pressure s/p PCI yesterday\n Action:\n ASA dose increased. Given plavix 600 in cath\n Response:\n Stable overnight\n Plan:\n Plan is to send home today if remains stable.\n"
},
{
"category": "Physician ",
"chartdate": "2113-03-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 664557,
"text": "TITLE:\n Chief Complaint: No chest pain or SOB.\n 24 Hour Events:\n None\n Allergies:\n Percodan (Oral) (Oxycodone Hcl/Aspirin)\n dizziness;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n dizziness;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:31 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 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 72 (66 - 80) bpm\n BP: 121/56(73) {94/40(54) - 121/73(78)} mmHg\n RR: 17 (0 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 3,405 mL\n 1,375 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,925 mL\n 1,375 mL\n Blood products:\n Total out:\n 1,350 mL\n 870 mL\n Urine:\n 1,000 mL\n 870 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,055 mL\n 505 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n GENERAL: WDWN female in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. MM slightly dry.\n NECK: Supple with no JVD.\n CARDIAC: RRR, normal S1, S2. 2/6 SEM at RUSB/LUSB. No rubs or gallops.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi anteriorly.\n ABDOMEN: Soft, NTND. NABS.\n EXTREMITIES: Trace ankle edema. Bilat groin without hematoma,\n tenderness, ecchymoses. 2+ DP and PT pulses. WWP.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 29.0 %\n [image002.jpg]\n 11:28 PM\n Hct\n 29.0\n Assessment and Plan\n 77 y/o F with 5V-CABG admitted for elective cath for anginal symptoms\n now s/p stents to LIMA-LAD and left main-LCx.\n .\n # CAD: s/p CABG x5 in , repeat cath showing occluded grafts x4. Now\n with distal LIMA and distal left main stenosis s/p stenting at each\n site. Impella assist device was placed during procedure preemptively,\n although her hemodynamics have been stable and the device was removed.\n On the floor, she has no CP or SOB and remains hemodynamically stable.\n - Cont ASA 325mg daily, statin, b-blocker, \n - Started on clopidogrel 75mg daily\n .\n # Anemia: Per cards fellow and attending, patient had a moderate amount\n (quantity not clear) of blood loss during the cardiac catheterization.\n Hct stable.\n .\n # HTN: Well controlled.\n - Cont metoprolol, losartan, imdur\n .\n # HLD: Cont statin\n .\n # GERD: Cont PPI\n .\n # FEN: Cardiac diet, IVF overnight\n .\n # ACCESS: PIVs\n .\n # PROPHYLAXIS: SC heparin, bowel regimen, home PPI\n .\n # CODE: DNR/DNI\n .\n # DISPO: likely d/c today or tomorrow\n .\n # Contact: , home phone \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:16 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2113-03-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 664558,
"text": "TITLE:\n Chief Complaint: No chest pain or SOB.\n 24 Hour Events:\n None\n Allergies:\n Percodan (Oral) (Oxycodone Hcl/Aspirin)\n dizziness;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n dizziness;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:31 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 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 72 (66 - 80) bpm\n BP: 121/56(73) {94/40(54) - 121/73(78)} mmHg\n RR: 17 (0 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 3,405 mL\n 1,375 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,925 mL\n 1,375 mL\n Blood products:\n Total out:\n 1,350 mL\n 870 mL\n Urine:\n 1,000 mL\n 870 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,055 mL\n 505 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n GENERAL: WDWN female in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. MM slightly dry.\n NECK: Supple with no JVD.\n CARDIAC: RRR, normal S1, S2. 2/6 SEM at RUSB/LUSB. No rubs or gallops.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi anteriorly.\n ABDOMEN: Soft, NTND. NABS.\n EXTREMITIES: Trace ankle edema. Bilat groin without hematoma,\n tenderness, ecchymoses. 2+ DP and PT pulses. WWP.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 29.0 %\n [image002.jpg]\n 11:28 PM\n Hct\n 29.0\n Assessment and Plan\n 77 y/o F with 5V-CABG admitted for elective cath for anginal symptoms\n now s/p stents to LIMA-LAD and left main-LCx.\n .\n # CAD: s/p CABG x5 in , repeat cath showing occluded grafts x4. Now\n with distal LIMA and distal left main stenosis s/p stenting at each\n site. Impella assist device was placed during procedure preemptively,\n although her hemodynamics have been stable and the device was removed.\n On the floor, she has no CP or SOB and remains hemodynamically stable.\n - Cont ASA 325mg daily, statin, b-blocker, \n - Started on clopidogrel 75mg daily\n .\n # Anemia: Per cards fellow and attending, patient had a moderate amount\n (quantity not clear) of blood loss during the cardiac catheterization.\n Hct stable.\n .\n # HTN: Well controlled.\n - Cont metoprolol, losartan, imdur\n .\n # HLD: Cont statin\n .\n # GERD: Cont PPI\n .\n # FEN: Cardiac diet, IVF overnight\n .\n # ACCESS: PIVs\n .\n # PROPHYLAXIS: SC heparin, bowel regimen, home PPI\n .\n # CODE: DNR/DNI\n .\n # DISPO: likely d/c today or tomorrow\n .\n # Contact: , home phone \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:16 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ------ Protected Section ------\n 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 Doing very well after PCI. No chest pain, dyspnea, groin issues\n Physical Examination\n No JVD\n MR murmur\n lungs clear\n groins stable without oozing\n Medical Decision Making\n OOB --> ambulate\n PT consult\n ASA 325 mg/day for 1 month, then 81 mg/day\n Plavix for at least 1 year, then at the discretion of Dr. \n If ambulation not a problem, may go home later today\n ------ Protected Section Addendum Entered By: , MD\n on: 09:03 ------\n"
},
{
"category": "Physician ",
"chartdate": "2113-03-23 00:00:00.000",
"description": "Cardiology Fellow Admission Addendum",
"row_id": 664466,
"text": "TITLE: Cardiology Fellow Admission Note Addendum\n Pt examined, discussed with housestaff.\n 77 yo F w/ CAD s/p CABG in (LIMA-LAD, SVG-OM, SVG-diag,\n SVG-LVbranch, SVG-AM), SVGs known TO in ; p/w intermittent anginal\n sxs x 1 mo. Cath yesterday revealed LIMA-LAD 80% at , distal\n LM 80-90% and ostial LCx 80%, RCA with diffuse disease. Today planned\n PCI with impella preemptively successful, with 2.5x12 mm Xience placed\n in LIMA-LAD and rotablation\n 2.5x15 mm Xience (postdilated to 3.5mm) in\n LM into LCx. Impella d/c\nd in lab prior to arrival in CCU. On exam\n hemodynamically stable, no complaints, groin sites c/d/I after perclose\n bilaterally. Plan to continue bedrest, ASA/Plavix/statin/ and other\n home meds, closely monitor.\n"
},
{
"category": "ECG",
"chartdate": "2113-03-23 00:00:00.000",
"description": "Report",
"row_id": 241469,
"text": "Baseline artifact. Ectopic atrial rhythm. Inferior T wave abnormalities.\nSince the previous tracing of probably no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2113-03-22 00:00:00.000",
"description": "Report",
"row_id": 241470,
"text": "Normal sinus rhythm. Diffuse T wave flattening in leads V3-V6. T wave\ninversions in leads II, III and aVF. These changes are non-specific.\nNo previous tracing available for comparison. Clinical correlation is\nsuggested.\n\n"
},
{
"category": "Nursing",
"chartdate": "2113-03-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664506,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct drop post PCI today from 35 to 27, some blood loss during\n proceedure\n Action:\n Repeat hct at 2300 was up to 29\n Response:\n Had sm ooz with removal of sheath from R groin, pressure held dression\n applied and no further bleeding overnight, pulses palp\n Plan:\n Cont to monitor hct, signs of bleeding\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Denies CP/pressure s/p PCI yesterday\n Action:\n ASA dose increased. Given plavix 600 in cath\n Response:\n Stable overnight\n Plan:\n Plan is to send home today if remains stable.\n"
},
{
"category": "Physician ",
"chartdate": "2113-03-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 664490,
"text": "TITLE:\n Chief Complaint: Chest pain\n HPI:\n This is a 77 y.o. female with history of HTN, HLD and CAD s/p CABG x5\n who presented as an outpatient with chest pressure. The patient spent\n the winter in and returned about 2 weeks ago. Two weeks before\n she was to return home she experienced an episode of nonradiating chest\n heaviness that resolved with NGT and rest, although was not worse with\n exertion. She attributed this to anxiety that she was feeling while\n planning the return home. She has been home for 2 weeks, and had two\n more similar episodes, also potentially related to anxiety. She had\n angina prior to her CABG in , but that was a heartburn sensation,\n rather than the current pressure. She presented yesterday to for\n elective cardiac catherization, which showed 80% stenosis at the\n LIMA-LAD touchdown, 80-90% distal left main stenosis, 80% ostial LCx\n stenosis, RCA with diffuse disease. CT surgery felt redo CABG was too\n risky due to LIMA being stuck to the sternum. On the following day, she\n returned to the cath lab and had stenting of the LIMA with a 2.5 x 12mm\n Xience stent, rotablation and 2.5x15 mm Xience (postdilated to 3.5mm)\n stent in LM into LCx. An Impella assist device was placed preemptively\n for the procedure, but removed in the cath lab. She was admitted to the\n CCU for close monitoring.\n .\n On review of systems, she has a chronic dry cough and occasional blood\n drops at the end of a BM, but denies any prior history of stroke, TIA,\n deep venous thrombosis, pulmonary embolism, bleeding at the time of\n surgery, myalgias, joint pains, hemoptysis, or black stools. She denies\n recent fevers, chills or rigors. She confirms hip pain, that she\n relates to sciatica, but denies exertional calf pain. All of the other\n review of systems were negative.\n .\n Cardiac review of systems is notable for chest pressure as above (none\n currently), longstanding intermittent lightheadedness (stable), and\n absence of dyspnea on exertion, paroxysmal nocturnal dyspnea,\n orthopnea, ankle edema, palpitations, or syncope.\n Allergies:\n Percodan (Oral) (Oxycodone Hcl/Aspirin)\n dizziness;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n dizziness;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Imdur 30mg daily\n Losartan 50mg daily\n Metoprolol 50mg AM, 25mg PM\n sl nitro daily\n Simvastatin 40mg daily\n Aspirin 81mg daily\n Ca/Mg/Zn\n vitamin D 800 IU daily\n Glucosamine 1500mg daily\n Omeprazole 20mg daily\n Past medical history:\n Family history:\n Social History:\n HTN\n CAD s/p off pump cabg with a LIMA to the LAD, SVG to the left\n ventricular branch, the obtuse marginal and the diagonal, and an SVG to\n the acute marginal. All the SVG's reported occluded subsequent caths in\n .\n HLD\n GERD\n Anxiety\n Osteoarthritis\n Sciatica\n Tonsillectomy\n Umbilical Hernia\n Hysterectomy/BSO\n .\n CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension\n .\n CARDIAC HISTORY:\n Prior testing/procedures include:\n .\n OFF\nPUMP CABG with LIMA-LAD, SVG to the left ventricular branch,\n the obtuse marginal and diagonal, and an SVG to the acute marginal.\n .\n Cardiac Cath: native 3vd present including 40-50% left main,\n 60-70% LAD, 70-90% in the OM, and 70% mid RCA. The LIMA graft was\n extremely small and showed competitive filling of the distal LAD. The\n SVG\ns were all totally occluded.\n .\n Cardiac Cath: Pressure wire without significant gradients\n across the Left Main, the entire LAD, the entire RCA, and the\n proximal to mid circumflex. Medical therapy was recommended.\n .\n TTE: Normal LV size and reported ejection fraction of 60-65%.\n Trace MR. Mild to moderate TR with right ventricular systolic pressure\n of 45mmhg.\n .\n Duplex Carotid Imaging: No hemodynamically significant stenosis\n in either carotid system. An incidental finding of tiny nodules\n measuring 2-4mm were reported, which most likely represented benign\n thyroid adenomas.\n Her twin brother had CAD, he passed away in his 60\ns of lung CA. Father\n died of lung CA.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Quit smoking 43 year ago after smoking 1 pack a day for 10\n years. Lives in NH with her husband . a son . She\n is retired. She reports one glass of wine a couple times a week. She\n has never had any home care services.\n Review of systems:\n Flowsheet Data as of 08:18 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 75 (66 - 78) bpm\n BP: 96/51(61) {94/47(59) - 118/73(78)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 2,348 mL\n PO:\n 360 mL\n TF:\n IVF:\n 1,988 mL\n Blood products:\n Total out:\n 0 mL\n 760 mL\n Urine:\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,588 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GENERAL: WDWN female in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. MM slightly dry.\n NECK: Supple with no JVD.\n CARDIAC: RRR, normal S1, S2. 2/6 SEM at RUSB/LUSB. No rubs or gallops.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi anteriorly.\n ABDOMEN: Soft, NTND. NABS.\n EXTREMITIES: Trace ankle edema. Bilat groin without hematoma,\n tenderness, ecchymoses. 2+ DP and PT pulses. WWP.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 1.0\n 4.3\n 27.2 <- 34.5\n [image002.jpg]\n ECG: Ectopic atrial rhythm at 64 bpm\n Assessment and Plan\n 77 y/o F with hx of CAD, HTN admitted for elective cath for anginal\n symptoms now s/p stents to LIMA-LAD and left main-LCx.\n .\n # CAD: s/p CABG x5 in , repeat cath showing occluded grafts x4. Now\n with distal LIMA and distal left main stenosis s/p stenting at each\n site. Impella assist device was placed during procedure preemptively,\n although her hemodynamics have been stable and the device was removed.\n On the floor, she has no CP or SOB and remains hemodynamically stable.\n - Cont ASA 325mg daily, statin, b-blocker, \n - Started on clopidogrel 75mg daily\n .\n # Anemia: Per cards fellow and attending, patient had a moderate amount\n (quantity not clear) of blood loss during the cardiac catheterization\n today. This would explain her hct drop from 34.5 this am to 27.2 after\n the procedure. No hematoma or oozing at groin, so would expect hct to\n stabilize.\n - 11pm and am hct\n - Transfuse if under hct of 23\n .\n # HTN: Well controlled.\n - Cont metoprolol, losartan, imdur\n .\n # HLD: Cont statin\n .\n # GERD: Cont PPI\n .\n # FEN: Cardiac diet, IVF overnight\n .\n # ACCESS: PIVs\n .\n # PROPHYLAXIS: SC heparin, bowel regimen, home PPI\n .\n # CODE: DNR/DNI\n .\n # DISPO: likely d/c tomorrow if blood volume and BP stable\n .\n # Contact: , home phone \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:16 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2113-03-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664484,
"text": "Pt is a 77 yo female with PMH CABG in\n99, noted occl of SVG\ns but\n patent LIMA to LAD in\n00. Please see FHPA for further PMH. \n referred to from PCP in for cath d/t chest heaviness. Cath\n showed LIMA-LAD 99% stenosis and LM disease. went to cath lab for\n high risk PCI with impella device support. stent placed to LIMA.\n LM rotoblator followed by PTCA and Stent. Had transient HR 40's with\n Rotoblator, received 0.6 mg atropine with resolution. Impella pulled\n after PCI (was placed via R groin, 10 Fr sheath). Perclose device X2\n to R groin, Perclose device to L groin (6 Fr art sheath). Of note\n during case there was a 30% difference in bp between cuff pressure and\n central pressure.\n CV: in sinus rhythm, SBP 90-114, DP/PT palp bilaterally. R groin\n with pressure dressing intact, L groin transparent dsg clean. With\n turning pt, R groin with ooze, fellow in to hold manual\n pressure\nresolving ooze. Pulses remain palpable. Receiving D51/2 NS @\n 250 cc/hour for 3 L. Labs due @2300. Bedrest until 0700 . As per\n Dr , d/c home .\n Resp: lungs clear, sats >96% on 2L , comfortable lying flat\n GI: abd soft, obese, +BS, mouth dry\n GU: foley draining clear yellow urine\n Neuro: alert and oriented X3, MAE, follows requests.\n Skin: intact, continues to lye flat d/t groin bleed\n ID: afeb.\n Access: L hand #20.\n Social: married, husband in NH, called by Dr and updated\n on POC.\n ------ Protected Section ------\n Error in recording: Lungs have L basilar crackles.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:43 ------\n"
},
{
"category": "Nursing",
"chartdate": "2113-03-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664483,
"text": "Pt is a 77 yo female with PMH CABG in\n99, noted occl of SVG\ns but\n patent LIMA to LAD in\n00. Please see FHPA for further PMH. \n referred to from PCP in for cath d/t chest heaviness. Cath\n showed LIMA-LAD 99% stenosis and LM disease. went to cath lab for\n high risk PCI with impella device support. stent placed to LIMA.\n LM rotoblator followed by PTCA and Stent. Had transient HR 40's with\n Rotoblator, received 0.6 mg atropine with resolution. Impella pulled\n after PCI (was placed via R groin, 10 Fr sheath). Perclose device X2\n to R groin, Perclose device to L groin (6 Fr art sheath). Of note\n during case there was a 30% difference in bp between cuff pressure and\n central pressure.\n CV: in sinus rhythm, SBP 90-114, DP/PT palp bilaterally. R groin\n with pressure dressing intact, L groin transparent dsg clean. With\n turning pt, R groin with ooze, fellow in to hold manual\n pressure\nresolving ooze. Pulses remain palpable. Receiving D51/2 NS @\n 250 cc/hour for 3 L. Labs due @2300. Bedrest until 0700 . As per\n Dr , d/c home .\n Resp: lungs clear, sats >96% on 2L , comfortable lying flat\n GI: abd soft, obese, +BS, mouth dry\n GU: foley draining clear yellow urine\n Neuro: alert and oriented X3, MAE, follows requests.\n Skin: intact, continues to lye flat d/t groin bleed\n ID: afeb.\n Access: L hand #20.\n Social: married, husband in NH, called by Dr and updated\n on POC.\n"
},
{
"category": "Nursing",
"chartdate": "2113-03-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664592,
"text": "Pt A&O X3- ambulating without difficulty- hemodynamically stable on\n cardiac meds- taking Po qs- foley D/C\n voiding qs- seen by CCU team-\n OK to discharge home- discharge instructions reviewed & understood- IV\n D/C\nd- awaiting family .\n Family arrived @ 1445- patient discharged to home with husband & son @\n 1500- all personal belongings sent with patient.\n"
},
{
"category": "Nursing",
"chartdate": "2113-03-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664463,
"text": "Pt is a 77 yo female with PMH CABG in\n99, noted occl of SVG\ns but\n patent LIMA to LAD in\n00. Please see FHPA for further PMH. \n referred to from PCP in for cath d/t chest heaviness. Cath\n showed LIMA-LAD 99% stenosis and LM disease. went to cath lab for\n high risk PCI with impella device support. stent placed to LIMA.\n LM rotoblator followed by PTCA and Stent. Had transient HR 40's with\n Rotoblator, received 0.6 mg atropine with resolution. Impella pulled\n after PCI (was placed via R groin, 10 Fr sheath). Perclose device X2\n to R groin, Perclose device to L groin (6 Fr art sheath). Of note\n during case there was a 30% difference in bp between cuff pressure and\n central pressure.\n CV: in sinus rhythm, SBP 90-114, DP/PT palp bilaterally. R groin\n with pressure dressing intact, L groin transparent dsg clean. With\n turning pt, R groin with ooze, fellow in to hold manual\n pressure\nresolving ooze. Pulses remain palpable. Receiving D51/2 NS @\n 250 cc/hour for 3 L. Labs due @2300. Bedrest until 0700 . As per\n Dr , d/c home .\n Resp: lungs clear, sats >96% on 2L , comfortable lying flat\n GI: abd soft, obese, +BS, mouth dry\n GU: foley draining clear yellow urine\n Neuro: alert and oriented X3, MAE, follows requests.\n Skin: intact, continues to lye flat d/t groin bleed\n ID: afeb.\n Access: L hand #20.\n Social: married, husband in NH, called by Dr and updated\n on POC.\n"
},
{
"category": "Nursing",
"chartdate": "2113-03-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664590,
"text": "Pt A&O X3- ambulating without difficulty- hemodynamically stable on\n cardiac meds- taking Po qs- foley D/C\n voiding qs- seen by CCU team-\n OK to discharge home- discharge instructions reviewed & understood- IV\n D/C\nd- awaiting family @ present.\n"
}
] |
18,776 | 195,218 | Pt is a 49 yo woman w/ h/o Hodkin's Lymphoma, s/p XRT to chest and chemotherapy who p/w CP and palpitations, found to have high filling pressures on R heart cath. . 1) Pump/hemodynamics: Pt found to have elvated PAP and PCWP on cardiac cath today. Otherwise high CO. Unclear etiology at this time. ?PE, as pt presented w/ palpitations and CP and w/ high filling pressures, but would have expected low CO. TSH was low/nl at OSH. Patient was briefly on hep gtt for empiric rx of PE until CTA of the chest came back negative for PE. TSH was rechecked during this admission and came back at 0.28. Patient was monitored on tele and discharged chest pain free and hemodynamically stable. There was 1+ MR on LV-gram. The patient should have an outpatient echo in weeks after discharge in order to assess for any MV prolaps or other valvular dysfunction. . 2) CAD: No CAD on cardiac cath. CP resolved. . 3) Rhythm: Pt persistently tachycardic. Patient appears to be tachycardic at baseline. Etiology could be thyroid disease vs. anxiety vs. infection vs. PE. ?continued tachycardia epi given at OSH. Patient was monitored on telemetry. Patient remained slightly tachycardic (sinus) which seems to be her baseline. TSH was rechecked during this admission and came back at 0.28. . 4) Hypoxia: Patient had desats to mid-80s on RA per OSH record. Continued to have oxygen requirement initially. Etiology infection vs. PE vs. edema. CXR from OSH c/w edema. Also has high filling pressures on cath. ? pulm. edema following IVF bolus and epi at OSH. No recent symptoms suggestive of infection. CTA came back negative for PE. Lasix prn, but patient was autodiuresing and off oxygen upon discharge. . 5) Hypothyroidism: Continued outpt levoxyl. Rechecked TSH which came back at 0.28. Further follow up is recommended as an outpatient given that the level was on the lower end of normal. . 6) S/p L hip fracture: Continued percocet prn. . 7) FEN: Reg low salt diet, monitored and repleted lytes PRN. . 8) PPX: hep gtt briefly, then Heparin sc. . 9) Access: PIV . 10) Code: Full | Heparin gtt restarted post cath and sent to CT of chest which was negative - PE ruled out. PATIENT/TEST INFORMATION:Indication: hypoxiaHeight: (in) 66Weight (lb): 150BSA (m2): 1.77 m2BP (mm Hg): 130/70HR (bpm): 110Status: InpatientDate/Time: at 10:09Test: TTE (Focused views)Doppler: Color Doppler onlyContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded. Mild (1+) mitral regurgitation is seen.IMPRESSION: Technically limited emergency study, suggesting preserved overallleft ventricular function with mild mitral regurgitation. PT TO CATH LAB - CLEAN CORONARIES, 1+ MR, HIGH FILLING PRESSURES AND LOW O2 SATS REQUIRING 6L N/C. ADMITTED TO CCU AT 0400 - AUTODIURESING VIA FOLEY, O2 WEANED AND D/C'D BY 0800 W/SATS HIGH 90'S, NO FURTHER C/O CP, SOB; CPKS NEGATIVE AT OSH. Consider left atrial abnormality.Non-specific ST-T wave changes with probable prolonged QTc interval, althoughthis is difficult to measure. R femoral sheath remains in - angioseal of art line in cath lab.PLAN: have fellow d/c R femoral sheath. R FEM VENOUS SHEATH IN PLACE UNTIL 12PM - BEDREST UNTIL 6PM - AMBULATED W/O DIFFICULTY - VSS, HR HIGH AT BASELING, RUNNING 90'S TO LOW 100'S SR-ST, K+/MG REPLETED THIS AM W/REPEAT WNL. IVF 1/2NS INFUSING FROM 9A-5PM THEN D/, PT TOLERATING FLUIDS AND REGULAR DIET WELL, R GROIN SITE D+I PEDAL PULSES 3+/3+ BILAT. Overall normal LVEF (>55%).MITRAL VALVE: Mild (1+) MR.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Atrial premature beat. Emergencystudy performed by the cardiology fellow on call.Conclusions:Overall left ventricular systolic function appears normal (LVEF>55%). admit note49yo female w/ extensive PMHX was out gardening in yard and developed palpitations - noting several insect bites - didn't feel well, went to outside hospital - treated for ?allergic reaction - developed SSCP w/ ekg changes, CXR showed pulmonary edema- asa, heparin gtt, morphine, ntg and lopressor given - sent to to cath - showed clean coronaries but high wedge 25 PAD 31. no post cath fluids due to fluid overload on CXR. PT ALERT AND ORIENTED X3 - PLEASANT AND COOPERATIVE; INSTRUCTED IN POST-CATH DISCHARGE INSTRUCTIONS AND WILL F/U W/PCP FOR APPT AND F/U ECHO TO EVALUATE MR. PT FOR FAMILY TO PICK PATIENT UP FOR RIDE HOME. continue work up as to what caused palpitations and SSCP and pulmonary edema. Due tosuboptimal technical quality, a focal wall motion abnormality cannot be fullyexcluded. CCU NURSING DISCHARGE NOTEPT 49 YO WOMAN ADMITTED WITH PULNOARY EDEMA, CHEST PAIN AFTER BEING TREATED FOR ?ANAPHYLACTIC REACTION TO INSECT BITES AT OSH. Pt autodiuresing so no lasix given. Clinical correlation is suggested. Sinus rhythm. No previoustracing available for comparison. Daughter and family in to visit during night. | 4 | [
{
"category": "Nursing/other",
"chartdate": "2136-04-30 00:00:00.000",
"description": "Report",
"row_id": 1509200,
"text": "CCU NURSING DISCHARGE NOTE\nPT 49 YO WOMAN ADMITTED WITH PULNOARY EDEMA, CHEST PAIN AFTER BEING TREATED FOR ?ANAPHYLACTIC REACTION TO INSECT BITES AT OSH. PT TO CATH LAB - CLEAN CORONARIES, 1+ MR, HIGH FILLING PRESSURES AND LOW O2 SATS REQUIRING 6L N/C. ADMITTED TO CCU AT 0400 - AUTODIURESING VIA FOLEY, O2 WEANED AND D/C'D BY 0800 W/SATS HIGH 90'S, NO FURTHER C/O CP, SOB; CPKS NEGATIVE AT OSH. R FEM VENOUS SHEATH IN PLACE UNTIL 12PM - BEDREST UNTIL 6PM - AMBULATED W/O DIFFICULTY - VSS, HR HIGH AT BASELING, RUNNING 90'S TO LOW 100'S SR-ST, K+/MG REPLETED THIS AM W/REPEAT WNL. IVF 1/2NS INFUSING FROM 9A-5PM THEN D/, PT TOLERATING FLUIDS AND REGULAR DIET WELL, R GROIN SITE D+I PEDAL PULSES 3+/3+ BILAT. PT ALERT AND ORIENTED X3 - PLEASANT AND COOPERATIVE; INSTRUCTED IN POST-CATH DISCHARGE INSTRUCTIONS AND WILL F/U W/PCP FOR APPT AND F/U ECHO TO EVALUATE MR. PT FOR FAMILY TO PICK PATIENT UP FOR RIDE HOME.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-04-30 00:00:00.000",
"description": "Report",
"row_id": 1509199,
"text": "admit note\n49yo female w/ extensive PMHX was out gardening in yard and developed palpitations - noting several insect bites - didn't feel well, went to outside hospital - treated for ?allergic reaction - developed SSCP w/ ekg changes, CXR showed pulmonary edema- asa, heparin gtt, morphine, ntg and lopressor given - sent to to cath - showed clean coronaries but high wedge 25 PAD 31. Pt autodiuresing so no lasix given. no post cath fluids due to fluid overload on CXR. Heparin gtt restarted post cath and sent to CT of chest which was negative - PE ruled out. Daughter and family in to visit during night. R femoral sheath remains in - angioseal of art line in cath lab.\n\nPLAN: have fellow d/c R femoral sheath. obtain act. continue work up as to what caused palpitations and SSCP and pulmonary edema.\n"
},
{
"category": "Echo",
"chartdate": "2136-04-30 00:00:00.000",
"description": "Report",
"row_id": 101480,
"text": "PATIENT/TEST INFORMATION:\nIndication: hypoxia\nHeight: (in) 66\nWeight (lb): 150\nBSA (m2): 1.77 m2\nBP (mm Hg): 130/70\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 10:09\nTest: TTE (Focused views)\nDoppler: Color Doppler only\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%).\n\nMITRAL VALVE: Mild (1+) MR.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Emergency\nstudy performed by the cardiology fellow on call.\n\nConclusions:\nOverall left ventricular systolic function appears normal (LVEF>55%). Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Mild (1+) mitral regurgitation is seen.\n\nIMPRESSION: Technically limited emergency study, suggesting preserved overall\nleft ventricular function with mild mitral regurgitation.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2136-04-30 00:00:00.000",
"description": "Report",
"row_id": 301000,
"text": "Sinus rhythm. Atrial premature beat. Consider left atrial abnormality.\nNon-specific ST-T wave changes with probable prolonged QTc interval, although\nthis is difficult to measure. Clinical correlation is suggested. No previous\ntracing available for comparison.\n\n"
}
] |
20,248 | 151,412 | The patient was emergently transferred to the Hospital from Hospital with evidence of an evolving acute lateral wall myocardial infarction. He was noted to be hemodynamically stable however. The patient emergently presented to the cardiac catheterization lab where he was noted to have a normal left main and LAD with 90% small D1, left circ with 100% occlusion of a large OM1 which was noted to have thrombus in distal extension. His coronary artery had less than 40% luminal stenosis. The patient underwent angio-jet percutaneous transluminal coronary angioplasty and stent of his large OM1. He was noted to have elevated pressures in the catheterization lab which included a RA pressure of 20, a PA pressure of 65/30, a wedge of 32 and a RV pressure of 45/20. The patient was transferred to the CCU Service following his intervention. He was maintained on Integrilin X18 hours, IV nitroglycerin for blood pressure control, IV heparin and Plavix. He also received aspirin, small doses of Lopressor which were titrated as he was weaned from the IV nitroglycerin, and small doses of an Ace inhibitor. He was aggressively diuresed on the first two hospital days given his elevated left heart filling pressures during catheterization. He was monitored on telemetry without evident. His CK's peaked at 3225 with an MB of 118 and an index of 3.7. This index was down from his first CK which was 3049 with an MB of 158 and an index of 5.2. In addition, the patient had a fasting lipid panel checked. He was noted to have a normal cholesterol and LDH of 95 and HDL of 34. Since his normal outpatient anti-hyperlipidemic was not on formulary, he was transiently put on Lipitor throughout his hospitalization. After the patient was felt to be stable from a cardiac standpoint, he was transferred from the CCU to 11 where he continued to be monitored. He had serial EKG's performed which revealed persistent tall R waves in V1 through V2, Q. waves in I, L, V5 and V6 and mild ST segment elevations of to 1.5 millimeters in V2through V6. An echocardiogram was performed on the morning of hospital day #4, revealed an ejection fraction of 35%, bilateral atrial enlargement, mild global RV hypokinesis, LVH with a dilated LV cavity, and segmental LV wall motion abnormalities specifically akinesis in the inferoposterior lateral segments. The hospital course was somewhat complicated by intermittent episodes of chest pain which occurred 1-2X a day both at rest and with exertion. The symptoms were often quite nebulous in presentation and were never corresponding to the pain which brought him to Hospital. They were occasionally associated with shortness of breath but there was never associated nausea, vomiting, or diaphoresis. The episodes were never associated with EKG changes and were never relieved with sublingual nitroglycerin. IV Morphine sulfate was the only medication which seemed to relieve the symptoms. After long discussions with the Cardiology team involved in this patient's care, it was decided that these were highly unlikely to represent post myocardial infarction angina or acute ischemic events. The patient's normal doses of pain medications specifically Percocet which he takes for low back pain was titrated for improved relief and he subsequently remained symptom free. The patient also had multiple other issues arise throughout his hospital course. First off, the patient was noted to have a leukocytosis, cough and sputum production on presentation. Repeat chest x-rays never revealed evolution of infiltrates, consolidations or effusions. His sputum was sent for culture however the sample was noted to have greater than 10 epithelial cells in addition to greater than 25 PMN's. There was no one predominant organism cultured from his sputum. His symptoms were perceived to be most likely consistent with a tracheobronchitis in this known smoker. He was treated with Levaquin X5 days with slow resolution of his symptoms. The patient was also noted to have a somewhat low hematocrit on presentation which dropped from the mid 30's to 31 following his catheterization. It remained stable in the mid to low 30's. He was noted to have a borderline macrocytosis on presentation with an MCV of 99. B12 and Folate studies were sent off but both came back normal. A full iron panel was also sent off and other than a low serum iron of 27, the rest of his serum iron panel was within normal limits. The patient's low hematocrit was believed to be most likely secondary to blood loss associated with his cardiac catheterization and he was subsequently started on a multivitamin for dietary supplementation. The patient was also noted to have a mild transaminitis upon presentation to the Hospital with an AST of 288, and an ALT of 63. His alkaline phosphatase was normal, however his total bilirubin was mildly elevated at 1.4 on presentation. His levels were monitored every day following admission and were noted to decrease, however on the day of discharge, they had still not normalized and remained mildly elevated at an AST of 76, and an ALT of 81. A hepatitis panel was sent and was negative for hepatitis B and C. An acetaminophen level was also checked given this patient's known use of chronic Percocet at baseline. However this level also came back negative. The patient was noted to take a statin chronically at baseline and it was reported that his transaminases might be mildly elevated in the setting of an HMG COA reductase inhibitor. It was recommended that he follow up with these studies with his outpatient physician. was discharged to home on the morning of hospital day #5 with plans to follow up with his primary care physician. much discussion with the patient, it was decided that he would preferentially seek cardiology care in the area near his home. It was decided that he would talk with his primary care physician in order to adequately choose a primary care physician. was told to follow up in weeks time with his primary care physician as well as his new cardiologist. | Significant pulmonicregurgitation is seen.PERICARDIUM: There is a small pericardial effusion. The ascending aorta is mildlydilated. FINDINGS: There is mild left ventricular enlargement. There is mild concentric left ventricular hypertrophy. There is moderate regional leftventricular systolic dysfunction.RIGHT VENTRICLE: Right ventricular systolic function appears depressed.AORTA: The aortic root is normal in diameter. Noaortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild mitral regurgitation is seen. The effusion appearscircumferential.Conclusions:The left atrium is mildly dilated and is elongated. The ascending aorta is mildly dilated. Moderate tricuspidregurgitation is seen. Theleft ventricular cavity is moderately dilated. Theleft ventricular cavity is moderately dilated. Mild mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are normal. Right ventricular systolic functionappears depressed. The rightventricular cavity may be mildly dilated. Tracing is consistent with acute inferolateral and posteriormyocardial infarction as previously noted. There is moderate regional leftventricular systolic dysfunction with akinesis of most of theinferoposterolateral wall. Sinus rhythm with bradycardia. There is nomitral valve prolapse. There is asmall circumferential pericardial effusion. There is minimal bibasilar atelectasis and a small left-sided effusion, otherwise the lungs are clear. The pulmonary artery systolic pressure could not bedetermined.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal. Compared to the previous tracing of nosignificant change, other than appearance of bradycardia. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. The septum and anterior wall are normal. The mediastinal and hilar contours are stable. The right atrium ismoderately dilated. Compared to the previous tracing of there is nodiagnostic change. R:S ratio greater than one in lead VI. IMPRESSION: Minimal bibasilar atelectasis and small left effusion without evidence for failure or pneumonia. QS deflections in leads I and II with prominent Q waves inlead aVL. PATIENT/TEST INFORMATION:Indication: Myocardial infarction.Assess ventricular function.Height: (in) 79Weight (lb): 250BSA (m2): 2.51 m2BP (mm Hg): 100/60Status: InpatientDate/Time: at 14:13Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated.LEFT VENTRICLE: There is mild concentric left ventricular hypertrophy. Abnormal Q waves in lead V5and QS deflections in lead V6. Compared to the previous tracing no significant change.TRACING #2 The mitralleaflets are mildly thickened. Compared to the previous tracingof no diagnostic change.TRACING #1 The aortic leaflets(3) appear structurally normal with good leaflet excursion. This study is technically limited. FINAL REPORT The left costophrenic angle is excluded from this study. ST segment elevations in I, II, aVL and V5-V6.INT: Acute inferolateral myocardial infarction, probab ly involving theposterior wall.TRACING #1 IMPRESSION: 1. No 2D echo or Doppler evidence of coarctation of the distal aorticarch.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion. Clinical correlation is suggested.TRACING #2 2:28 PM CHEST (PORTABLE AP) Clip # Reason: Pt w/ AMI s/p cath w/ temp & leukocytosis. Low lung volumes combined with supine technique make complete evaluation of lung parenchyma difficult. There is no significant aortic valve stenosis. Comparison to prior exam from . Swan-Ganz catheter extends from the IVC to lie with its tip in the left main pulmonary artery. Please evaluate for pneumonia or chf. EVALUATE FOR PNEUMONIA OR CHF. 2. Given these limitations, there is no evidence of consolidation or pulmonary edema. The patient may undergo a repeat study at no additional cost. There is no pulmonic valve stenosis. No evidence of consolidation or pulmonary edema. MEDICAL CONDITION: 47 year old man with CAD REASON FOR THIS EXAMINATION: Pt w/ AMI s/p cath w/ temp & leukocytosis. REASON FOR THIS EXAMINATION: Evaluate for pneumonia, CHF FINAL REPORT INDICATION: 47 YEAR OLD MAN WITH RECENT MRI WITH FEVERS AND COUGH. | 8 | [
{
"category": "Echo",
"chartdate": "2116-01-09 00:00:00.000",
"description": "Report",
"row_id": 63649,
"text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction.\nAssess ventricular function.\nHeight: (in) 79\nWeight (lb): 250\nBSA (m2): 2.51 m2\nBP (mm Hg): 100/60\nStatus: Inpatient\nDate/Time: at 14:13\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 moderately dilated.\n\nLEFT VENTRICLE: There is mild concentric left ventricular hypertrophy. The\nleft ventricular cavity is moderately dilated. There is moderate regional left\nventricular systolic dysfunction.\n\nRIGHT VENTRICLE: Right ventricular systolic function appears depressed.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\ndilated. No 2D echo or Doppler evidence of coarctation of the distal aortic\narch.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. There is no significant aortic valve stenosis. No\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. Mild mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Moderate tricuspid\nregurgitation is seen. The pulmonary artery systolic pressure could not be\ndetermined.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal. There is no pulmonic valve stenosis. Significant pulmonic\nregurgitation is seen.\n\nPERICARDIUM: There is a small pericardial effusion. The effusion appears\ncircumferential.\n\nConclusions:\nThe left atrium is mildly dilated and is elongated. The right atrium is\nmoderately dilated. There is mild concentric left ventricular hypertrophy. The\nleft ventricular cavity is moderately dilated. There is moderate regional left\nventricular systolic dysfunction with akinesis of most of the\ninferoposterolateral wall. The septum and anterior wall are normal. The right\nventricular cavity may be mildly dilated. Right ventricular systolic function\nappears depressed. The ascending aorta is mildly dilated. The aortic leaflets\n(3) appear structurally normal with good leaflet excursion. The mitral\nleaflets are mildly thickened. Mild mitral regurgitation is seen. There is a\nsmall circumferential pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2116-01-09 00:00:00.000",
"description": "Report",
"row_id": 124417,
"text": "Sinus rhythm with bradycardia. Compared to the previous tracing of no\nsignificant change, other than appearance of bradycardia.\n\n"
},
{
"category": "ECG",
"chartdate": "2116-01-08 00:00:00.000",
"description": "Report",
"row_id": 124418,
"text": "Sinus rhythm. Compared to the previous tracing of there is no\ndiagnostic change. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2116-01-08 00:00:00.000",
"description": "Report",
"row_id": 124419,
"text": "Sinus rhythm. Tracing is consistent with acute inferolateral and posterior\nmyocardial infarction as previously noted. Compared to the previous tracing\nof no diagnostic change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2116-01-07 00:00:00.000",
"description": "Report",
"row_id": 124420,
"text": "Sinus rhythm. Compared to the previous tracing no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2116-01-06 00:00:00.000",
"description": "Report",
"row_id": 124421,
"text": "Sinus rhythm. QS deflections in leads I and II with prominent Q waves in\nlead aVL. R:S ratio greater than one in lead VI. Abnormal Q waves in lead V5\nand QS deflections in lead V6. ST segment elevations in I, II, aVL and V5-V6.\nINT: Acute inferolateral myocardial infarction, probab ly involving the\nposterior wall.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-01-08 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 738491,
"text": " 9:06 AM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate for pneumonia, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with recent acute MI presents with fevers and cough. Please\n evaluate for pneumonia or chf.\n REASON FOR THIS EXAMINATION:\n Evaluate for pneumonia, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47 YEAR OLD MAN WITH RECENT MRI WITH FEVERS AND COUGH. EVALUATE\n FOR PNEUMONIA OR CHF.\n\n Comparison to prior exam from .\n\n FINDINGS: There is mild left ventricular enlargement. The mediastinal and\n hilar contours are stable. There is minimal bibasilar atelectasis and a small\n left-sided effusion, otherwise the lungs are clear.\n\n IMPRESSION: Minimal bibasilar atelectasis and small left effusion without\n evidence for failure or pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-01-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 738483,
"text": " 2:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt w/ AMI s/p cath w/ temp & leukocytosis.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with CAD\n REASON FOR THIS EXAMINATION:\n Pt w/ AMI s/p cath w/ temp & leukocytosis.\n ______________________________________________________________________________\n FINAL REPORT\n The left costophrenic angle is excluded from this study. Swan-Ganz catheter\n extends from the IVC to lie with its tip in the left main pulmonary artery.\n Low lung volumes combined with supine technique make complete evaluation of\n lung parenchyma difficult. Given these limitations, there is no evidence of\n consolidation or pulmonary edema.\n\n IMPRESSION:\n\n 1. This study is technically limited. The patient may undergo a repeat study\n at no additional cost.\n\n 2. No evidence of consolidation or pulmonary edema.\n\n"
}
] |
62,543 | 108,932 | The patient was admitted to the General Surgical Service with duodenal perforation status post ERCP. The patient was made NPO with NGT, started on IV fluids and IV Zosyn, and Dilaudid PCA for pain control. CT scan on HD # 2 demonstrated large amount of fluid in the right anterior and posterior pararenal spaces tracking down to the lower quadrant of the abdomen and large amount of free air. Nutritional consult was called for TPN recommendations and PICC line was placed. The patient continued to spike low grade fever and her blood cultures were positive for STAPHYLOCOCCUS EPIDERMIDIS, Vancomycin Iv was added on HD # 6. Repeat abdominal CT demonstrated decreased but persistent large intraperitoneal and retroperitoneal free air with a large amount of fluid in the right retroperitoneum is seen with anterior displacement of the right kidney. The patient continued to spike fever and IR drainage of the right retroperitoneal fluid collection was ordered. The patient underwent CT-guided percutaneous drainage catheter placement into the right perinephric space on HD # 6 and fluid was sent for cultures. The patient's diet was advanced as tolerated on POD # 8, and was well tolerated. The cultures were positive for Albicans and IV Fluconazole was added. Despite antibiotics treatment patient continued to spike fever and her abdominal pain was continued to be significantly high requiring large amount of IV Dilaudid, Ativan and Ketorolac to manage it, patient's WBC also continued to increased (16->38).Repeat abdominal CT scan on HD # 10 revealed slight decrease in fluid component of right perinephric collection, extensive multi loculated phlegmonous change with no significant large fluid component to target for drainage and persistent extensive free intra-abdominal air with multiple pockets of air surrounding the second part of duodenum. The decision was made to take the patient in OR for washout. On , the patient underwent wide incision and drainage of retroperitoneal abscess/infection/hematoma, patch of potential duodenal perforation region with drainage and antecolic isoperistaltic side-to-side gastrojejunostomy and JP drains placement x 4, which went well without complication (reader referred to the Operative Note for details). Intraoperatively patient received 2 units of pRBC, she was extubated post op and was transferred in ICU for observation. On POD # 2, patient received 2 units of pRBC for HCT 23.4, her post transfusion Hct was 28.3. The patient was transferred to the floor on POD # 3, NPO on TPN and IV fluids, and Dilaudid PCA for pain control. The patient was continued to have low grade fever and she was continued on IV Vancomycin, Zosyn and Fluconazole. The patient was hydrodynamically stable. | Unchanged right pleural effusion and slightly increased left effusion. FINDINGS: A small simple right pleural effusion is seen, with compressive atelectasis of a portion of the right lower lobe. Continued mild right hydronephrosis. A small amount of air is seen in the decompressed gallbladder, likely related to the biliary stents with the proximal end in the common duct and the distal end in the duodenum, unchanged in position. FINDINGS: Right PICC and NG tube terminate in the standard position. Mild right hydronephrosis is similar to prior. Decreased pneumomediastinum. Decreased pneumomediastinum. The Foley has been removed and a small amount of intravesicular air remains. A small simple right pleural effusion with right basilar atelectasis. Previously noted small right pleural effusion has since resolved. Intraperitoneal free air has slightly decreased in the peritoneal cavity and the retroperitoneal spaces. There has been a small decrease in right pleural effusion. Compared to : Multiloculated retroperitoneal fluid collection is again seen. FINDINGS: The patient has received a new right-sided PICC line which ends approximately at the level of the lower SVC or the cavoatrial junction. There is a right-sided pigtail drain present within posterior right periphrenic location with slight decrease in amount of surrounding perinephric fluid. Resolution of right pleural effusion. Resolution of right pleural effusion. Persistent intraperitoneal free air present with slight decrease in amount of perihepatic free air. Decreased but persistent large intraperitoneal and retroperitoneal free air. Decreased but persistent large intraperitoneal and retroperitoneal free air. Again visualized is a right lower lobe consolidation which appears less confluent in comparison to prior study from . The visualized small and large bowel appear normal. The visualized small and large bowel appear normal. IMPRESSION: Stable mild hydronephrosis on the right. CT ABDOMEN: A small right pleural effusion is unchanged from the prior study. Moderate right and minimal left, non-loculated pleural effusions associated with lower lung atelectasis is new. The spleen, stomach, and visualized loops of small and large bowel are within normal limits. Right PICC tip is in the mid-to-lower SVC. Small right pleural effusion with adjacent atelectasis is unchanged allowing the difference in positioning of the patient and better inspiratory effort. The gallbladder appears normal. Improvement in right lower lobe consolidation and decrease in right pleural effusion. Small amount of pneumomediastinum. A small amount of pneumobilia relates to the presence of the biliary stent. Moderate right and minimal left pleural effusion associated with lower lung atelectasis is new. pneumobilia attests to stent patency. Slight decrease in fluid component of right perinephric collection at site of Drain. 2 Right-sided abdominal drains. An intrauterine device is again noted. The rectum and sigmoid colon are normal. The right kidney is anteriorly displaced by retroperitoneal fluid, but is slightly more posterior than on the prior study. Small pericholecystic fluid is nonspecific in the setting of ascites. 2-mm non-obstructive left renal stone. Although a tiny left effusion is slightly larger than on the prior study, left lower lobe atelectasis is unchanged. FINDINGS: Right lower lobe opacity likely represents atelectasis and has slightly decreased in size. There is enlarging right pleural effusion as well as low lung volumes and bibasilar atelectasis. Incidental note is made of a duodenal diverticulum. Bilateral pleural effusions with adjacent atelectasis as described above. FINDINGS: Again seen is a right pleural effusion with associated atelectasis of the right lower lobe. FINDINGS: There has been slight interval improvement in right lower lobe consolidation. The rectum and sigmoid are normal in appearance. The right ureteral jet is seen. TECHNIQUE: Contiguous axial images through the abdomen and pelvis were performed without IV or oral contrast. There has been interval decrease in amount of air surrounding the right kidney. Compared to most recent study on , there has been near resolution of intra-abdominal free air. The rectum, sigmoid colon, and bladder are normal. Extensive free intraperitoneal gas is present. A duodenal diverticulum is again noted. Mild left basilar atelectasis. Bibasilar atelectasis, right more than left, persists. Multiple adjacent collections with air and fluid are again noted and appear relatively stable to minimally decreased in size. Multiple pockets of air surrounding the duodenum remain unchanged in (Over) 11:24 AM CT ABD & PELVIS WITH CONTRAST Clip # Reason: please evaluate/compare previous fluid collections and asses Admitting Diagnosis: POST ERCP FINAL REPORT (Cont) appearance consistent with duodenal perforation. TECHNIQUE: Axial MDCT images acquired through the abdomen and pelvis following uneventful IV Omnipaque administration. Coronal and sagittal reformats were obtained. The gallbladder has a small amount of air. There was minimal return of blood-tinged fluid. Slight improvement in right lower lobe consolidation; however, slight increase in right pleural effusion. Biliary stent in situ. Two biliary stents are seen in unchanged position. Significant resolution of intra-abdominal free air. The abdominal aorta is normal in course and caliber. The abdominal aorta is normal in course and caliber. A small amount of pelvic free fluid is present. The cardiomediastinal silhouette is unchanged. Left basal atelectasis is noted. Two biliary stents are in place with the proximal end terminating at the common hepatic duct and the distal end in the duodenum. | 14 | [
{
"category": "Radiology",
"chartdate": "2113-03-15 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1234667,
"text": " 3:28 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Please evaluate intraabdominal fluid collection for possible\n Admitting Diagnosis: POST ERCP\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with duodenal perforation, known intra abdominal fluid\n collection and free air, now febrile.\n REASON FOR THIS EXAMINATION:\n Please evaluate intraabdominal fluid collection for possible drainage.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MDAg WED 6:27 PM\n 1. Decreased but persistent large intraperitoneal and retroperitoneal free\n air. A large amount of fluid in the right retroperitoneum is seen with\n anterior displacement of the right kidney which is improved from the prior\n study. No rim-enhancing fluid collection is seen.\n 2. Decreased pneumomediastinum.\n 3. Unchanged right pleural effusion and slightly increased left effusion.\n Right basilar atelectasis has increased, with unchanged left lower lobe\n atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 35-year-old woman with duodenal perforation and known\n intra-abdominal fluid collection and free air, now febrile. Evaluate\n intra-abdominal fluid collection for possible drainage.\n\n COMPARISON: CT .\n\n TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic\n symphysis were displayed with 5-mm slice thickness with oral and 130 mL\n Omnipaque intravenous contrast. Coronal and sagittal reformats were displayed\n with 5-mm slice thickness.\n\n CT ABDOMEN: A small right pleural effusion is unchanged from the prior study.\n Adjacent right lower lobe atelectasis has increased. Although a tiny left\n effusion is slightly larger than on the prior study, left lower lobe\n atelectasis is unchanged. Small amount of pneumomediastinum has decreased from\n the prior study.\n\n There is no focal liver lesion. A small amount of air is seen in the\n decompressed gallbladder, likely related to the biliary stents with the\n proximal end in the common duct and the distal end in the duodenum, unchanged\n in position. Small pericholecystic fluid is nonspecific in the setting of\n ascites. The spleen, pancreas, and bilateral adrenal glands are normal. The\n kidneys enhance symmetrically and excrete contrast promptly. The right kidney\n is anteriorly displaced by retroperitoneal fluid, but is slightly more\n posterior than on the prior study. Small and large bowel are normal in course\n and caliber without obstruction. The duodenum is medially displaced. There is\n no obvious leak of oral contrast. The abdominal aorta is normal in course and\n caliber. Intraperitoneal free air has slightly decreased in the peritoneal\n cavity and the retroperitoneal spaces. A large amount of slightly complex\n (Over)\n\n 3:28 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Please evaluate intraabdominal fluid collection for possible\n Admitting Diagnosis: POST ERCP\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fluid ( 27-35) in the right retroperitoneum cause anterior displacement of\n the right kidney. No rim-enhancing fluid collection is seen.\n\n CT PELVIS: A small amount of slightly complex fluid tracks into the pelvis,\n increased from the prior study. The rectum, sigmoid colon, and bladder are\n normal. The Foley has been removed and a small amount of intravesicular air\n remains. The right ureteral jet is seen. An intrauterine device is in the\n uterus. There is no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.\n\n IMPRESSION:\n 1. Decreased but persistent large intraperitoneal and retroperitoneal free\n air. A large amount of fluid in the right retroperitoneum is seen with\n anterior displacement of the right kidney. No rim-enhancing fluid collection\n is seen.\n 2. Decreased pneumomediastinum.\n 3. Bilateral pleural effusions with adjacent atelectasis as described above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-03-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1234308,
"text": " 9:52 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: New right arm 42cm PICC line. ? PICC tip location\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with new right arm 42cm PICC. ? PICC tip location\n REASON FOR THIS EXAMINATION:\n New right arm 42cm PICC line. ? PICC tip location\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New right arm PICC line, to assess for PICC location.\n\n TECHNIQUE: Semi-erect portable chest view was reviewed in comparison with\n prior chest radiograph from .\n\n FINDINGS: The patient has received a new right-sided PICC line which ends\n approximately at the level of the lower SVC or the cavoatrial junction.\n Orogastric tube is seen to course below the diaphragm into the stomach.\n Moderate right and minimal left pleural effusion associated with lower lung\n atelectasis is new. Cardiomediastinal silhouette is stable. There is no\n pneumothorax. Pneumoperitoneum is persisting.\n\n IMPRESSION:\n 1. New right PICC line ends approximately at lower SVC or cavoatrial\n junction.\n 2. Moderate right and minimal left, non-loculated pleural effusions\n associated with lower lung atelectasis is new.\n 3. Persisting pneumoperitoneum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-03-10 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1234064,
"text": " 7:46 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Please evaluate for pneumoperitoneum\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman s/p ERCP and sphincterotomy c/b perforation\n REASON FOR THIS EXAMINATION:\n Please evaluate for pneumoperitoneum\n ______________________________________________________________________________\n WET READ: KKgc FRI 8:27 PM\n Large amount of intra and retroperitoneal free air. Kkaliann,noted at 8:13 p.m\n d/w Dr. at 8:15 p.m on . NGT in the distal stomach. Two bilairy\n stents in place.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post-procedure, to assess for pneumoperitoneum.\n\n FINDINGS: No previous images. There is a large amount of free\n intraperitoneal gas as well as a substantial retroperitoneal free air. This\n information was discussed with Dr. by the resident on call.\n\n Biliary stents are in place as well as tubal ligation devices. Nasogastric\n tube extends to the distal stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-03-12 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1234227,
"text": " 12:19 PM\n CT ABD & PELVIS W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: ? leak (delayed scan discussed with )\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 with new HCV, jaundice, s/p ERCP c/b duodenal perforation\n REASON FOR THIS EXAMINATION:\n ? leak (delayed scan discussed with )\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 35-year-old female with HCV and jaundice, status post ERCP,\n complicated by duodenal perforation. Please evaluate for leak.\n\n COMPARISON: CT of the abdomen and pelvis from earlier the same day.\n\n TECHNIQUE: Contiguous axial images through the abdomen and pelvis were\n performed without IV or oral contrast. Total exam DLP equals 736.13.\n\n FINDINGS: Again seen is a right pleural effusion with associated atelectasis\n of the right lower lobe. Atelectasis can be seen in the left lower lobe as\n well. There is an enteric tube extending into the patient's stomach.\n\n As noted previously, there is a large amount of air within the peritoneal and\n retroperitoneal cavities with extension into the right perinephric space and\n mediastinum. The previously seen free fluid and phlegmanous change is stable\n from earlier. While some oral contrast can be seen in small bowel loops as\n well as within the bilateral collecting systems, no extraluminal contrast is\n seen to suggest a large duodenal perforation.\n\n Please refer to the CT scan performed earlier the same day with IV and oral\n contrast for better evaluation of the intra-abdominal and pelvic organs.\n\n IMPRESSION: Since the study performed eight hours prior to this examination,\n no extraluminal oral contrast is seen to suggest an active duodenal\n perforation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-03-12 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1234182,
"text": " 3:46 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: s/p perforation with peritonitis, tachycardia, Please use PO\n Admitting Diagnosis: POST ERCP\n Field of view: 36 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with s/p perforation with peritonitis, tachycardia,\n REASON FOR THIS EXAMINATION:\n s/p perforation with peritonitis, tachycardia, Please use PO and IV contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old woman status post perforation with peritonitis and\n tachycardia.\n\n COMPARISON: Abdomen radiograph .\n\n TECHNIQUE: Multidetector CT imaging of the abdomen and pelvis was obtained\n after the administration of oral administration of 130 cc of Omnipaque\n intravenous contrast and water-soluble oral contrast. Sagittal and coronal\n reformats were generated and reviewed.\n\n FINDINGS: A small simple right pleural effusion is seen, with compressive\n atelectasis of a portion of the right lower lobe. Left basal atelectasis is\n noted. There is no pneumothorax. A small amount of pneumomediastinum is seen\n tracking from the abdomen.\n\n The liver enhances homogeneously, without focal lesions. A small amount of\n pneumobilia relates to the presence of the biliary stent. The gallbladder has\n a small amount of air. Two biliary stents are in place with the proximal end\n terminating at the common hepatic duct and the distal end in the duodenum.\n The adrenal glands, spleen and pancreas are normal. Both kidneys enhance and\n excrete contrast symmetrically, without evidence of hydroureteronephrosis.\n\n There is a large amount of intraperitoneal and retroperitoneal air. The\n retroperitoneal air is predominantly seen on the right side. Also seen is a\n large amount of fluid in the anterior and posterior pararenal spaces on the\n right causing anterior displacement of the right kidney. The fluid tracks down\n into the lower quadrant of the abdomen.\n\n The stomach, small and large bowel loops are normal. The duodenum is medially\n shifted. No duodenal wall hematoma is seen. No obvious leak of administered\n oral contrast is seen in this study. The abdominal aorta is normal in course\n and caliber. No significant retroperitoneal lymphadenopathy is seen.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder is nearly\n empty with a Foley catheter in place. An IUD is seen within the uterine\n cavity. Bilateral tubal ligation devices are present. The rectum and sigmoid\n colon are normal. A small amount of pelvic free fluid is present.\n\n BONES AND SOFT TISSUES: No bone lesions suspicious for infection or\n malignancy are detected.\n (Over)\n\n 3:46 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: s/p perforation with peritonitis, tachycardia, Please use PO\n Admitting Diagnosis: POST ERCP\n Field of view: 36 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Large amount of intraperitoneal and retroperitoneal free air. A large\n amount of fluid in the right anterior and posterior pararenal spaces tracking\n down to the lower quadrant of the abdomen. No obvious leak of contrast to\n identify the site of perforation. If needed a delayed non-contrast CT abdomen\n can be obtained to assess for a delayed leak.\n 2. Small amount of pneumomediastinum.\n 3. A small simple right pleural effusion with right basilar atelectasis.\n\n The above findings were discussed with Dr. at 4:40 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-03-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1234180,
"text": " 12:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement, free air\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with NGT\n REASON FOR THIS EXAMINATION:\n NGT placement, free air\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement and free air.\n\n FINDINGS: No previous images. Nasogastric tube tip lies in the lower body or\n antrum of the stomach. Extensive free intraperitoneal gas is present. Areas\n of opacification at the bases are consistent with atelectasis. No vascular\n congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-03-16 00:00:00.000",
"description": "DRAINAGE HEMATOMA/FLUID",
"row_id": 1234762,
"text": " 9:50 AM\n DRAINAGE HEMATOMA/FLUID; CT GUIDANCE DRAINAGE Clip # \n Reason: Please drain R. peritoneal fluid collection, place drainge b\n Admitting Diagnosis: POST ERCP\n ********************************* CPT Codes ********************************\n * DRAINAGE HEMATOMA/FLUID CT GUIDANCE DRAINAGE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman s/p ERCP complicated by duodenal perforation, with\n persistently elevated WBC count in 20s and spiking fevers to 102, with\n persistent R peritoneal fluid collection.\n REASON FOR THIS EXAMINATION:\n Please drain R. peritoneal fluid collection, place drainge bag as needed.\n Please send fluid for microbiology.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT-GUIDED PERCUTANEOUS DRAINAGE CATHETER PLACEMENT\n\n INDICATION: 35-year-old female status post ERCP, complicated by duodenal\n perforation and right retroperitoneal fluid collection.\n\n COMPARISON: CT of the abdomen and pelvis dated .\n\n OPERATORS: Dr. and Dr. . Dr. was present\n for the entire duration of the procedure and personally supervised it.\n\n PROCEDURE: After explaining the risks, benefits and alternatives to the\n procedure, written informed consent was obtained from the patient. The\n patient was laid in a left lateral decubitus position on the CT table. A\n preprocedure timeout was performed using three unique patient identifiers as\n per standard protocol.\n\n Limited preprocedure CT images of the abdomen were performed for the purposes\n of skin entry site localization. The obtained images demonstrated ill-defined\n fluid and phlegmonous changes involving the right pararenal and perirenal\n spaces, with multiple foci of free intraperitoneal gas, and foci of gas in the\n retroperitoneal regions bilaterally. There was again noted anterior\n displacement of the right kidney by these changes. A CBD stent is partially\n visualized.\n\n An appropriate skin entry site was marked in the right flank. The region was\n prepped and draped in the usual sterile fashion. 1% lidocaine was used to\n anesthetize the skin and subcutaneous soft tissues. Under CT fluoroscopic\n guidance, an 18-gauge needle was advanced into the right perinephric\n fluid/phlegmonous changes. There was return of blood-tinged fluid. A floppy\n tip wire was advanced over the needle into the right perinephric space\n and the needle was exchanged for an 8 French pigtail drainage\n catheter. The position was confirmed with CT images and the loop of the\n pigtail was formed in the right perinephric space. There was minimal return\n of blood-tinged fluid. Sample of the fluid was sent for microbiological\n analysis.\n (Over)\n\n 9:50 AM\n DRAINAGE HEMATOMA/FLUID; CT GUIDANCE DRAINAGE Clip # \n Reason: Please drain R. peritoneal fluid collection, place drainge b\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The drainage catheter was attached to a drainage bag and was secured to the\n anterior abdominal wall.\n\n The patient tolerated the procedure well without any immediate peri-procedural\n complications.\n\n Moderate sedation was provided by administering divided doses of Versed (3 mg)\n and Fentanyl (150 mcg) throughout the total intraservice time of 20 minutes\n during which the patient's hemodynamic parameters were continuously monitored.\n\n IMPRESSION: Successful CT-guided percutaneous drainage catheter placement\n into the right perinephric space with return of minimal blood-tinged fluid.\n Sample of fluid sent for microbiological analysis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-03-20 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1235228,
"text": " 11:24 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please evaluate/compare previous fluid collections and asses\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35F with new HCV, jaundice, s/p ERCP c/b duodenal perforation, s/p IR drainage\n of retroperitoneal collection and GPC bacteremia, persistent fevers to 102 and\n elevated WBC to 30's.\n REASON FOR THIS EXAMINATION:\n please evaluate/compare previous fluid collections and assess for new ones.\n With IV contrast only\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT DATED \n\n INDICATION: 35-year-old female with new HCV, jaundice, status post ERCP\n complicated by duodenal perforation status post prior drainage of\n retroperitoneal collection and GPC bacteremia. Persistent fevers and elevated\n white blood cell. Please evaluate and compare previous fluid and assess for\n new one.\n\n COMPARISON: Comparison is made to previous CT dated .\n\n TECHNIQUE: Axial MDCT images acquired through the abdomen and pelvis\n following uneventful IV Omnipaque administration. Coronal and sagittal\n reformats were obtained.\n\n DLP: 707.93 mGy-cm.\n\n FINDINGS: There has been slight interval improvement in right lower lobe\n consolidation. There has been a small decrease in right pleural effusion.\n Persistent atelectasis within the left lower lobe. No left pleural effusion.\n The heart is normal in size. No pleural effusion.\n\n The liver is normal in attenuation. No focal liver lesions are identified.\n No significant intra or extrahepatic duct dilation. The spleen is normal in\n size. The pancreas is normal in appearance. Both adrenal glands are normal\n in appearance. Both kidneys enhance and excrete contrast symmetrically\n without evidence of hydronephrosis or suspicious renal lesion.\n Biliary stent in situ.\n\n There is a right-sided pigtail drain present within posterior right\n periphrenic location with slight decrease in amount of surrounding perinephric\n fluid. Persistent extensive perinephric phlegmonous change with multiple\n septations. The perinephric phlegmonous change measures 8.8 x 9.9 cm\n inferiorly, previously 11 x 10.2 cm (2:54). There has been interval decrease\n in amount of air surrounding the right kidney. Persistent large amount of\n retroperitoneal free air present. Persistent intraperitoneal free air present\n with slight decrease in amount of perihepatic free air. The visualized small\n and large bowel appear normal.\n Multiple pockets of air surrounding the duodenum remain unchanged in\n (Over)\n\n 11:24 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please evaluate/compare previous fluid collections and asses\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appearance consistent with duodenal perforation.\n\n CT PELVIS: The urinary bladder is normal in appearance with left ureteric jet\n identified. The rectum and sigmoid are normal in appearance. IUD in situ\n within the uterus.\n There is no significant pelvic or inguinal adenopathy.\n\n OSSEOUS STRUCTURES: No suspicious osseous sclerotic or lucent lesions are\n identified.\n\n IMPRESSION:\n 1. Improvement in right lower lobe consolidation and decrease in right\n pleural effusion.\n 2. Slight decrease in fluid component of right perinephric collection at site\n of Drain. Extensive multiloculated phlegmonous change with no significant\n large fluid component to target for drainage.\n 3. No new collections are identified.\n 4. Persistent extensive free intra-abdominal air with multiple pockets of air\n surrounding the second part of duodenum, likely at site of duodenal\n perforation.\n\n Findings were discussed with surgical team in person on at 17:00 with\n Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-03-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1235757,
"text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f pulmonary process\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman w/ retroperitoneal abscess who continues to be febrile\n despite broad-spectrum antibiotics\n REASON FOR THIS EXAMINATION:\n e/f pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Retroperitoneal abscess with continued fever. Concern for\n pulmonary process.\n\n COMPARISON: Multiple priors from .\n\n FINDINGS: Right PICC and NG tube terminate in the standard position. There\n are two right upper quadrant drains. There is enlarging right pleural\n effusion as well as low lung volumes and bibasilar atelectasis. The\n cardiomediastinal silhouette is unchanged. There is no pneumothorax.\n MJMgb\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-03-31 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1236650,
"text": " 10:22 AM\n RENAL U.S. Clip # \n Reason: Please evaluate known hydronephrosis\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with c/b duodenal perforation s/p ex lap, RP washout and\n drain placementx4\n REASON FOR THIS EXAMINATION:\n Please evaluate known hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND\n\n DATE: .\n\n CORRELATION: CT, .\n\n CLINICAL INDICATION: 35-year-old woman with a duodenal perforation status\n post exploratory laparotomy, retroperitoneal washout and drain placement x4.\n Please evaluate known hydronephrosis.\n\n TECHNIQUE: Multiple son grayscale images of the kidneys and bladder\n were obtained with select images supplemented with color Doppler imaging.\n\n FINDINGS:\n\n There is stable mild hydronephrosis in the right kidney. Adjacent to the\n lower pole, is a partially imaged complex fluid collection containing a drain.\n The right kidney measures approximately 14 cm.\n\n The left kidney measures approximately 14.2 cm. There is no hydronephrosis,\n renal lesion or nephrolithiasis.\n\n The bladder is minimally distended limiting evaluation and grossly\n unremarkable.\n\n IMPRESSION:\n\n Stable mild hydronephrosis on the right.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2113-03-20 00:00:00.000",
"description": "Report",
"row_id": 305473,
"text": "Sinus tachycardia. Diffuse non-specfic ST-T wave changes. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-03-29 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1236395,
"text": " 10:22 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Please evaluate for interval changes in multiple inta abdomi\n Admitting Diagnosis: POST ERCP\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with duodenal perforation, s/p IR drainage of retroperit\n collection and GPC bacteremia s/p ex lap, RP washout and drain placement x 4.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval changes in multiple inta abdominal fluid\n collections\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post duodenal perforation from ERCP, status post IR\n drainage of retroperitoneal collection and Gram-positive cocci bacteremia,\n status post ex lap, status post retroperitoneal washout and four drain\n placements. Assess for any changes in intra-abdominal fluid collections.\n\n TECHNIQUE: Helical MDCT images were obtained through the abdomen and pelvis\n following the administration of IV contrast. Coronal and sagittal\n reformations were performed.\n\n FINDINGS: Right lower lobe opacity likely represents atelectasis and has\n slightly decreased in size. A small right pleural effusion has slightly\n increased in size. No left pleural effusion. Visualized heart and\n pericardium are unremarkable. The linear scarring vs. atelectasis in the left\n lower lobe is slightly smaller.\n\n The liver enhances homogeneously. There is no focal lesion. There is no\n significant intrahepatic or extrahepatic biliary duct dilatation. Two biliary\n stents are seen in unchanged position. Incidental note is made of a duodenal\n diverticulum. There is a small amount of pneumobilia. Spleen is\n unremarkable. The adrenal glands are unremarkable. The pancreas is\n unremarkable. The right kidney is slightly larger in size compared to study\n on , now measuring approximately 8.2 cm transversely and there is\n a delayed in the nephrogram and hydronephrosis. This may be due to a proximal\n ureteral stricture from adjacent inflammatory reaction from fluid collections.\n The left kidney is unremarkable and left ureter is unremarkable. There is a\n drain from a left anterior abdominal approach traversing the abdomen and\n appears to be ending just below the gallbladder fossa. Another drain is seen\n in the right lateral anterior abdominal wall ending posterior to the liver. A\n third drain also from right anterior approach ends anterior to the liver. A\n fourth drain from a right lateral approach ends posterior to the right kidney.\n Compared to most recent study on , there has been near resolution\n of intra-abdominal free air. There are gas-fluid loculated collections seen\n along the right retroperitoneal space and adjacent to the liver and right\n kidney. These collections have all decreased in size compared to study on\n . An area of phlegmonous change in the right perinephric area\n now measures approximately 8.7 x 6.0 cm, significantly decreased in size\n compared to prior study when it measured 9.9 x 8.8 cm. Small pockets of\n gas-fluid collections may not be adequately drained (601b,27).\n (Over)\n\n 10:22 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Please evaluate for interval changes in multiple inta abdomi\n Admitting Diagnosis: POST ERCP\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The stomach is unremarkable. The visualized small and large bowel appear\n normal. The rectum and sigmoid are unremarkable.\n\n IUD is seen in appropriate position in the uterus. The bladder is\n unremarkable. There is no significant lymphadenopathy.\n\n The bones demonstrate no suspicious osseous lytic or sclerotic lesions.\n\n IMPRESSION:\n 1. Decrease in size of loculated gas-fluid collections with four drains in\n place. There are small pockets of loculated collections that may not be\n adequately drained. Significant resolution of intra-abdominal free air.\n\n 2. Right hydronephrosis likely from obstruction of ureter due to surrounding\n inflammation.\n\n 3. Slight improvement in right lower lobe consolidation; however, slight\n increase in right pleural effusion.\n\n These findings were discussed with Dr. at 3:30 pm on .\n Time of discovery was 3:15 pm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-04-06 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1237537,
"text": " 10:14 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: NO IV CONTRAST GIVEN . PO contrast OK. Please evaluate f\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35F w/new HCV, jaundice, s/p ERCP c/b duodenal perforation, s/p IR drainage of\n retroperit collection and GPC bacteremia s/p ex lap, RP washout and drain\n placementx4, gastrojej, with multiple abdominal collections (1 JP remaining),\n continuing to spike fevers.\n REASON FOR THIS EXAMINATION:\n NO IV CONTRAST GIVEN . PO contrast OK. Please evaluate for resolution of\n abdominal collections and any new collections given persistent fevers.\n CONTRAINDICATIONS for IV CONTRAST:\n right now\n ______________________________________________________________________________\n WET READ: 10:57 PM\n Very limited study without IV contrast. Additionally, Pt had difficulty with\n PO contrast and there is little bowel opacification.\n 1. Compared to : Multiloculated retroperitoneal fluid collection is\n again seen. The largest collection is slightly smaller, now 8.0 x 3.0 cm,\n previously 8.4 x 4.2cm. Multiple small collections are similar. Interval\n removal of 3 drains with one drain remaining, still within the largest\n collection. No new collection definitely identified within limitations of the\n study.\n 2. Resolution of right pleural effusion. Bibasilar atelectasis, right more\n than left, persists.\n 3. Two CBD stents in place. pneumobilia attests to stent patency.\n 4. Mild right hydronephrosis is similar to prior.\n 5. 2mm nonobstructing left renal stone (2:22).\n -MAgarwal d/w Dr (surgery) by phone at 10:45pm .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with history of duodenal perforation from\n an ERCP, status post drainage of retroperitoneal collection, exlap, and\n retroperitoneal washout for interval change.\n\n COMPARISON: Multiple prior studies, with the most recent being CT abdomen and\n pelvis from .\n\n TECHNIQUE: MDCT-acquired axial images were obtained from the base of the\n lungs to pubic symphysis without administration of oral and intravenous\n contrast. Multiplanar reformatted images were prepared and reviewed.\n\n FINDINGS:\n\n CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST:\n\n Evaluation of abdominal structures is limited due to lack of intravenous\n contrast. Again visualized is a right lower lobe consolidation which appears\n less confluent in comparison to prior study from . Previously\n noted small right pleural effusion has since resolved. The visualized left\n lung base is clear.\n (Over)\n\n 10:14 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: NO IV CONTRAST GIVEN . PO contrast OK. Please evaluate f\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Again noted are multiple gas-fluid loculated collections along the right\n retroperitoneal space and adjacent to the liver and right kidney. Overall, it\n is difficult to delineate these foci due to lack of oral or intravenous\n contrast. However, a phlegmonous collection in the right perinephric area has\n decreased in size and now measures 8.0 x 3.0 cm compared to 8.1 x 4.2 cm\n previously. Small pockets of gas-fluid collections are still noted adjacent\n and appear relatively stable to minimally decreased in size. No new\n collections are identified. A single drain is identified within these\n collections and three of the prior drains have since been removed.\n\n Two drains are again noted in the common bile duct and there is pneumobilia.\n Otherwise, the unopacified liver appears unremarkable. The gallbladder\n appears normal. The right kidney again demonstrates hydronephrosis which may\n be due to a stricture of the imaged proximal right ureter, though not clearly\n identified given lack of intravenous contrast. The left kidney appears stable\n and contains a nonobstructive tiny sub-2-mm stone in the interpolar region\n (2:22).\n\n The spleen, stomach, and visualized loops of small and large bowel are within\n normal limits. A duodenal diverticulum is again noted. There is no residual\n free air in the abdomen.\n\n CT OF THE PELVIS WITHOUT ORAL OR INTRAVENOUS CONTRAST:\n\n Evaluation of the pelvic structures is limited due to lack of intravenous\n contrast. An intrauterine device is again noted. Metallic structure is\n visualized in the region of the left ovary (2:21). There is no free fluid or\n free air in the pelvis. There is no pelvic or inguinal lymphadenopathy.\n\n OSSEOUS STRUCTURES: There are no lytic or sclerotic osseous lesions\n suspicious for malignancy.\n\n IMPRESSION:\n 1. Limited study due to lack of intravenous and oral contrast demonstrates an\n interval decrease in the phlegmonous collection in the right perinephric space\n now measuring 8.0 x 3.0 cm with a drain in place. Multiple adjacent\n collections with air and fluid are again noted and appear relatively stable to\n minimally decreased in size. Three of the previously visualized drains have\n since been removed.\n 2. Continued mild right hydronephrosis.\n 3. Resolution of right pleural effusion. Right lower lobe opactiy has\n decreased in size.\n 4. Two common bile duct stents are in place with pneumobilia.\n 5. 2-mm non-obstructive left renal stone.\n (Over)\n\n 10:14 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: NO IV CONTRAST GIVEN . PO contrast OK. Please evaluate f\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-03-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1235457,
"text": " 7:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35F s/p exlap, gastrojej, washout\n REASON FOR THIS EXAMINATION:\n postop\n ______________________________________________________________________________\n WET READ: MXAk TUE 8:24 PM\n Small right pleural effusion and adjacent atelectasis/consolidation appears\n improved compared to . Mild left basilar atelectasis. No new\n consolidations. Enteric tube traverses through the stomach. 2 Right-sided\n abdominal drains. The degree of pneumoperitoneum is incompletely assessed due\n to supine positioning.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post expiratory laparotomy, gastrojejunostomy.\n\n Comparison is made with prior study, .\n\n Cardiomediastinal contours are normal. There are low lung volumes. Right\n PICC tip is in the mid-to-lower SVC. NG tube tip is in the stomach. Small\n right pleural effusion with adjacent atelectasis is unchanged allowing the\n difference in positioning of the patient and better inspiratory effort. Left\n lower lobe atelectasis has minimally improved.\n\n Drains project in the right abdomen. There are no new lung abnormalities or\n pulmonary edema.\n\n\n"
}
] |
96,091 | 132,418 | A 67 yo woman with a history of very severe COPD on home O2 presents with pneumonia and COPD exacerbation requiring MICU admission. . #Respiratory failure: Pt had multifactorial hypoxia, secondary to pneumonia, very severe COPD, and, after resuscitation, volume overload. She was intubated after several hours in the ICU for primarily hypercarbic respiratory failure. She was treated with Vancomycin, Cefepime, Azithromycin for hospital acquired pneumonia and atypical pathogens. She was intubated shortly after admission. She required pressors to maintain MAP > 65 in the setting of intubation, was weaned from pressors by the following morning. She completed an 8 day course of antibiotics, continued on methylprednisolone q8h and standing nebs which were tapered off during her ICU stay. She also required 15L IVF resucitation on admission and became volume overloaded, contributing to her requirement of ventilatory support, requiring aggressive diuresis prior to extubation. She was difficult to wean from the ventilator and finally extubated to bipap on hospital day 13. She was then transferred to the floor where remained clinically stable. Oxygen requirement improved to baseline of 2L and she was discharged to rehab on nebulizers. . # h/o hypertension: Antihypertensives were held initially when requiring pressor. After extubation syhe was restarted on her amlodpine. Captopril was discontinued. IF she becomes hypertensive at rehab, would consider starting a low dose ACEI. . | # Hx of hypertension: BP running low normal -change captopril to lisinopril, with holding parameters . Pt is on triple abx: Vanco, Cefepime & Azithromycin. Pt is on triple abx: Vanco, Cefepime & Azithromycin. ABG 7.25/63/71, lactate 1.0. ABG 7.25/63/71, lactate 1.0. Shock- likely multifactorial, sepsis vs meds -recent echo w/ nl echo -CVP goal, MAP goals reached; wean norepi gtt as tolerated -might become more conservative w/ fluids (will use LR given high Cl) given high FiO2 req't and little gross pulse pressure variation or CVP variation 3. ABG 7.25/63/71, lactate 1.0. Rec 8L NS bolus for hypotension o/n. Rec 8L NS bolus for hypotension o/n. Rec 8L NS bolus for hypotension o/n. Rec 8L NS bolus for hypotension o/n. Rec 8L NS bolus for hypotension o/n. Rec 8L NS bolus for hypotension o/n. Multiple vent changes and ABG done shows resp acidosis. Multiple vent changes and ABG done shows resp acidosis. ICU Care Nutrition: NPO for now advance pending stability of respiratory distress Glycemic Control: Lines: Multi Lumen - 04:24 AM and Arterial Line - 02:41 PM Prophylaxis: DVT: Heparin subQ / SCDs Stress ulcer: PPI VAP: N/A for now Comments: Communication: Comments: Code status: Full code Disposition : MICU for now. Plan: Will go with cool neb for now- can replace bipap prn Brief review of systems- CV- continues with some hypertension- was started on captopril 12.5 mgs. ICU Care Nutrition: NPO for now advance pending stability of respiratory distress Glycemic Control: Lines: Multi Lumen - 04:24 AM and Arterial Line - 02:41 PM Prophylaxis: DVT: Heparin subQ / SCDs Stress ulcer: PPI VAP: N/A for now Comments: Communication: Comments: Code status: Full code Disposition : MICU for now. Respiratory failue: COPD, PNA. Respiratory failue: COPD, PNA. continues on prednisone. Goal is trach when vent settings stabilize. Goal is trach when vent settings stabilize. Goal is trach when vent settings stabilize. ------ Protected Section Addendum Entered By: , MD on: 13:57 ------ CC: 30 minutes ------ Protected Section Addendum Entered By: , MD on: 13:57 ------ ------ Protected Section Addendum Entered By: , MD on: 16:29 ------ Continue lasix gtt, plan for goal I/O negative 1 liter. PM lytes done and ABG: 7.45/67/62. Ambulate >/= 30' with stable HDR 4. COPD: wean prednisone. Adjust free water flushes as necessary Respiratory failure, chronic Assessment: Pt remains vented on PSV 12/14 5 70%. Decreasing lasix gtt to 3mg/hr t/o shift systolics < 90s. Will c/w PSV as tolerated while Fentanyl being tapered and reevaluate in the AM. Respiratory failure Assessment: Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with O2 sats 90-92%, last ABG- L/S clear to diminished @ bases. Respiratory failure Assessment: Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with O2 sats 90-92%, last ABG- L/S clear to diminished @ bases. Respiratory failure Assessment: Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with O2 sats 90-92%, last ABG- L/S clear to diminished @ bases. Continue lasix gtt, plan for goal I/O negative 1 liter. Continue lasix gtt, plan for goal I/O negative 1 liter. Constipation (Obstipation, FOS) Assessment: Passing malodorous stool via flexiseal today. Action: Pt given last dose methylprednisolone @ MN. Action: Pt given last dose methylprednisolone @ MN. Cont albuterol and atrovent mdi. Cont albuterol and atrovent mdi. Cont albuterol and atrovent mdi. GPC from sputum most likely coag-neg Stap. Dr. made aware and lactulose 30cc q 6 hours prn ordered. Dr. made aware and lactulose 30cc q 6 hours prn ordered. Cont albuterol and atrovent mdi. Cont albuterol and atrovent mdi. Cont albuterol and atrovent mdi. v HR 60-90s SR with occasional ectopy. v HR 60-90s SR with occasional ectopy. v HR 60-90s SR with occasional ectopy. WBC 35.6, Action: Levo Gtt stopped, IV antibxs were increased. Respiratory failure Assessment: Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with O2 sats 90-92%, last ABG- 7.27/53/70/-. Response: Plan: Constipation (Obstipation, FOS) Assessment: Passing malodorous stool via flexiseal today. L/S clear to diminished @ bases., sputum spec has GPCs. Adjust free water flushes as necessary Respiratory failure, chronic Assessment: Pt remains vented on PSV 12/14 5 70%. WBC 35.6, Action: Levo Gtt stopped, IV antibxs were increased. Respiratory failure Assessment: Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with O2 sats 90-92%, last ABG- 7.27/53/70/-. L/S clear to diminished @ bases., sputum spec has GPCs. Possible aspiration- has not had BM since admit; constipation might be contributing -replace OGT -aggressive bowel regimen w/ Dulcolax and PO Narcan; hold on enteral feee H20 and tube feeds till bowels are moving ICU Care Nutrition: Comments: replaced OGT Glycemic Control: Blood sugar well controlled Lines: Multi Lumen - 04:24 AM Arterial Line - 04:31 AM Prophylaxis: DVT: SQ UF Heparin(Systemic anticoagulation: Heparin gtt) Stress ulcer: PPI VAP: HOB elevation, Mouth care, Daily wake up Comments: Communication: Comments: Code status: Full code Disposition :ICU Total time spent: 30 minutes Patient is critically ill Remains with 2+ generalized edema. Remains with 2+ generalized edema. # Hx of hypertension: now normotensive. Cont on albuterol and atrovent mdis. Cont on albuterol and atrovent mdis. Response: Sating low 90 Plan: Will accept ph of down to 7.20 on ards net vent. ABG @ 0600: 7.37/69/85 Plan: Cont to diurese with Lasix gtt. restart free h20 boluses via ogt once confirmation of tube confirmed Constipation (Obstipation, FOS) Assessment: Passing malodorous stool via flexiseal today. Severe enlargement of the cardiac silhouette is unchanged, and mediastinal vascular engorgement suggests a component of cardiac decompensation. Right IJ catheter terminates in the superior vena cava. Bilateral pleural effusions, right greater than left are unchanged. ET tube is in standard placement, right internal jugular line ends just proximal to the junction with the left brachiocephalic vein where the left internal jugular line ends. ET tube is in standard placement and nasogastric tube passes into the stomach and out of view. | 253 | [
{
"category": "Physician ",
"chartdate": "2192-04-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 728891,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 01:33 PM\n INVASIVE VENTILATION - STOP 04:00 AM\n - was agitated, restless during the day with stable vitals and ABGs\n - received diazepam PO and IV and restlessness resolved; concerning for\n benzo withdrawal\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:33 AM\n Lorazepam (Ativan) - 12:14 PM\n Diazepam (Valium) - 07:30 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:10 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: 37\nC (98.6\n HR: 82 (75 - 109) bpm\n BP: 152/80(105) {114/64(83) - 174/96(191)} mmHg\n RR: 22 (16 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 838 mL\n 380 mL\n PO:\n 550 mL\n 380 mL\n TF:\n IVF:\n 288 mL\n Blood products:\n Total out:\n 1,335 mL\n 380 mL\n Urine:\n 1,335 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -497 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n PS : 12 cmH2O\n PEEP: 5 cmH2O\n FiO2: 50%\n SpO2: 95%\n ABG: 7.46/54/131/35/13\n PaO2 / FiO2: 262\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 446 K/uL\n 10.6 g/dL\n 90 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 50 mg/dL\n 101 mEq/L\n 147 mEq/L\n 33.4 %\n 19.2 K/uL\n [image002.jpg]\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n 09:57 AM\n 12:26 PM\n 12:51 PM\n 05:36 PM\n 04:49 AM\n WBC\n 22.7\n 19.2\n Hct\n 32.9\n 33.4\n Plt\n 465\n 446\n Cr\n 0.9\n 0.9\n 1.0\n 0.9\n TCO2\n 38\n 39\n 43\n 39\n 39\n 40\n Glucose\n 121\n 93\n 127\n 90\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 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": "2192-04-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 728892,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 01:33 PM\n INVASIVE VENTILATION - STOP 04:00 AM\n - was agitated, restless during the day with stable vitals and ABGs\n - received diazepam PO and IV and restlessness resolved; concerning for\n benzo withdrawal\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:33 AM\n Lorazepam (Ativan) - 12:14 PM\n Diazepam (Valium) - 07:30 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:10 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: 37\nC (98.6\n HR: 82 (75 - 109) bpm\n BP: 152/80(105) {114/64(83) - 174/96(191)} mmHg\n RR: 22 (16 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 838 mL\n 380 mL\n PO:\n 550 mL\n 380 mL\n TF:\n IVF:\n 288 mL\n Blood products:\n Total out:\n 1,335 mL\n 380 mL\n Urine:\n 1,335 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -497 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n PS : 12 cmH2O\n PEEP: 5 cmH2O\n FiO2: 50%\n SpO2: 95%\n ABG: 7.46/54/131/35/13\n PaO2 / FiO2: 262\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: no edema, no sacral edema\n Labs / Radiology\n 446 K/uL\n 10.6 g/dL\n 90 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 50 mg/dL\n 101 mEq/L\n 147 mEq/L\n 33.4 %\n 19.2 K/uL\n [image002.jpg]\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n 09:57 AM\n 12:26 PM\n 12:51 PM\n 05:36 PM\n 04:49 AM\n WBC\n 22.7\n 19.2\n Hct\n 32.9\n 33.4\n Plt\n 465\n 446\n Cr\n 0.9\n 0.9\n 1.0\n 0.9\n TCO2\n 38\n 39\n 43\n 39\n 39\n 40\n Glucose\n 121\n 93\n 127\n 90\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS, now\n extubated after prolonged intubation.\n # Respiratory failure: now extubated. Now tachypneic, anxious. ABG\n 7.51/47/124/39, suggesting respiratory alkalosis on top of ongoing\n metabolic alkalosis from hyperventilation.\n - benzo for anxiety\n - monitor closely\n - BiPAP prn\n - continue gentle furosemide gtt for pulm edema\n # Pneumonia: s/p course of broad-spectrum abx.\n # Metabolic alkalosis: secondary to aggressive diuresis, improving\n # Hx of hypertension:\n - increase captopril to 25 tid\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ\n # CODE: Full\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 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": "2192-04-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 728630,
"text": "Chief Complaint:\n 24 Hour Events:\n - extubated to bipap - 7.43/58/61 after ~1 hour on %\n - bipap off for 6 hours - pt stated uncomfortable although O2 Sat OK\n and RR 15 (ABG 7.43/53/108, same as on bipap and as when intubated) -\n back to bipap for a bit just for her comfort but quickly back to face\n tent.\n - lasix gtt @ 3, making ~150cc/h urine\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.1\nC (97\n HR: 89 (73 - 89) bpm\n BP: 160/88(113) {109/66(84) - 178/96(128)} mmHg\n RR: 16 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 155 mL\n PO:\n 350 mL\n 50 mL\n TF:\n 140 mL\n IVF:\n 340 mL\n 105 mL\n Blood products:\n Total out:\n 3,065 mL\n 400 mL\n Urine:\n 3,065 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,935 mL\n -245 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (400 - 540) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 18 cmH2O\n SpO2: 93%\n ABG: 7.44/61/147/37/14\n Ve: 9.6 L/min\n PaO2 / FiO2: 294\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: no edema, no sacral edema\n Labs / Radiology\n 465 K/uL\n 10.7 g/dL\n 93 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 100 mEq/L\n 148 mEq/L\n 32.9 %\n 22.7 K/uL\n [image002.jpg]\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n 10:27 AM\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n WBC\n 20.8\n 22.7\n Hct\n 31.3\n 32.9\n Plt\n 435\n 465\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 42\n 40\n 40\n 38\n 39\n 43\n Glucose\n 143\n 93\n 121\n 93\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.6 mg/dL, Mg++:2.5 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Day 11 of intubation today for multilobar\n pneumonia & COPD c/b ARDS. Able to wean PEEP down to 5. Currently on\n PSV 8/5. Diuresed 2 liters negative yesterday and continues to be\n somewhat negative today. Fully treated for PNA, currently with ARDS.\n -SBT\n -possibly attempt to extubate today or tomorrow, if fails will need\n trach\n - continue acetazolamide\n - continue 30mg prednisone today, decrease to 20mg daily on \n -d/c po narcan\n # Alkalosis: secondary to aggressive diuresis\n - continue acetazolamide as above\n # Hx of hypertension: now normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds (will concentrate\n to assist with tube feeds)\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ\n # CODE: Full\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 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": "2192-04-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 728394,
"text": "Chief Complaint:\n 24 Hour Events:\n - Lasix shut off for hypotension briefly, restarted at 3mg / hr,\n diuesing well\n - PEEP titrated down to 5\n - tube feeds to stop at 4 a.m. in case of extubation in a.m.\n - as fentanyl is being weaned have weaned PO naloxone to 1mg po qid\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Furosemide (Lasix) - 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 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.7\nC (98\n HR: 79 (72 - 82) bpm\n BP: 129/67(88) {89/45(60) - 143/76(100)} mmHg\n RR: 19 (17 - 28) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 1,851 mL\n 262 mL\n PO:\n TF:\n 1,137 mL\n 140 mL\n IVF:\n 574 mL\n 121 mL\n Blood products:\n Total out:\n 3,840 mL\n 680 mL\n Urine:\n 3,840 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,989 mL\n -418 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 356 (320 - 424) mL\n PS : 8 cmH2O\n RR (Set): 20\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 97\n PIP: 14 cmH2O\n Plateau: 17 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 90%\n ABG: 7.39/63/73./38/9\n NIF: -30 cmH2O\n Ve: 8.8 L/min\n PaO2 / FiO2: 146\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 435 K/uL\n 10.0 g/dL\n 93 mg/dL\n 0.8 mg/dL\n 38 mEq/L\n 4.4 mEq/L\n 63 mg/dL\n 101 mEq/L\n 148 mEq/L\n 31.3 %\n 20.8 K/uL\n [image002.jpg]\n 03:41 PM\n 08:24 PM\n 03:24 AM\n 03:40 AM\n 05:03 AM\n 06:16 AM\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n WBC\n 19.9\n 20.8\n Hct\n 30.2\n 31.3\n Plt\n 425\n 435\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n TCO2\n 44\n 43\n 42\n 41\n 42\n 40\n Glucose\n 136\n 112\n 143\n 93\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.0 mg/dL, Mg++:2.7 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Day 11 of intubation today for multilobar\n pneumonia & COPD c/b ARDS. Able to wean PEEP down to 5. Currently on\n PSV 8/5. Diuresed 2 liters negative yesterday and continues to be\n somewhat negative today. Fully treated for PNA, currently with ARDS.\n -SBT\n -possibly attempt to extubate today or tomorrow, if fails will need\n trach\n - continue acetazolamide\n - continue 30mg prednisone today, decrease to 20mg daily on \n # Alkalosis: secondary to aggressive diuresis\n - continue acetazolamide as above\n # Hx of hypertension: now normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds (will concentrate\n to assist with tube feeds)\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ\n # CODE: Full\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 728395,
"text": "Chief Complaint:\n 24 Hour Events:\n - Lasix shut off for hypotension briefly, restarted at 3mg / hr,\n diuesing well\n - PEEP titrated down to 5\n - tube feeds to stop at 4 a.m. in case of extubation in a.m.\n - as fentanyl is being weaned have weaned PO naloxone to 1mg po qid\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Furosemide (Lasix) - 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 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.7\nC (98\n HR: 79 (72 - 82) bpm\n BP: 129/67(88) {89/45(60) - 143/76(100)} mmHg\n RR: 19 (17 - 28) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 1,851 mL\n 262 mL\n PO:\n TF:\n 1,137 mL\n 140 mL\n IVF:\n 574 mL\n 121 mL\n Blood products:\n Total out:\n 3,840 mL\n 680 mL\n Urine:\n 3,840 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,989 mL\n -418 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 356 (320 - 424) mL\n PS : 8 cmH2O\n RR (Set): 20\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 97\n PIP: 14 cmH2O\n Plateau: 17 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 90%\n ABG: 7.39/63/73./38/9\n NIF: -30 cmH2O\n Ve: 8.8 L/min\n PaO2 / FiO2: 146\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: no edema, no sacral edema\n Labs / Radiology\n 435 K/uL\n 10.0 g/dL\n 93 mg/dL\n 0.8 mg/dL\n 38 mEq/L\n 4.4 mEq/L\n 63 mg/dL\n 101 mEq/L\n 148 mEq/L\n 31.3 %\n 20.8 K/uL\n [image002.jpg]\n 03:41 PM\n 08:24 PM\n 03:24 AM\n 03:40 AM\n 05:03 AM\n 06:16 AM\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n WBC\n 19.9\n 20.8\n Hct\n 30.2\n 31.3\n Plt\n 425\n 435\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n TCO2\n 44\n 43\n 42\n 41\n 42\n 40\n Glucose\n 136\n 112\n 143\n 93\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.0 mg/dL, Mg++:2.7 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Day 11 of intubation today for multilobar\n pneumonia & COPD c/b ARDS. Able to wean PEEP down to 5. Currently on\n PSV 8/5. Diuresed 2 liters negative yesterday and continues to be\n somewhat negative today. Fully treated for PNA, currently with ARDS.\n -SBT\n -possibly attempt to extubate today or tomorrow, if fails will need\n trach\n - continue acetazolamide\n - continue 30mg prednisone today, decrease to 20mg daily on \n # Alkalosis: secondary to aggressive diuresis\n - continue acetazolamide as above\n # Hx of hypertension: now normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds (will concentrate\n to assist with tube feeds)\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ\n # CODE: Full\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 728419,
"text": "Chief Complaint:\n 24 Hour Events:\n - Lasix shut off for hypotension briefly, restarted at 3mg / hr,\n diuesing well\n - PEEP titrated down to 5\n - tube feeds to stop at 4 a.m. in case of extubation in a.m.\n - as fentanyl is being weaned have weaned PO naloxone to 1mg po qid\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Furosemide (Lasix) - 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 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.7\nC (98\n HR: 79 (72 - 82) bpm\n BP: 129/67(88) {89/45(60) - 143/76(100)} mmHg\n RR: 19 (17 - 28) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 1,851 mL\n 262 mL\n PO:\n TF:\n 1,137 mL\n 140 mL\n IVF:\n 574 mL\n 121 mL\n Blood products:\n Total out:\n 3,840 mL\n 680 mL\n Urine:\n 3,840 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,989 mL\n -418 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 356 (320 - 424) mL\n PS : 8 cmH2O\n RR (Set): 20\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 97\n PIP: 14 cmH2O\n Plateau: 17 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 90%\n ABG: 7.39/63/73./38/9\n NIF: -30 cmH2O\n Ve: 8.8 L/min\n PaO2 / FiO2: 146\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: no edema, no sacral edema\n Labs / Radiology\n 435 K/uL\n 10.0 g/dL\n 93 mg/dL\n 0.8 mg/dL\n 38 mEq/L\n 4.4 mEq/L\n 63 mg/dL\n 101 mEq/L\n 148 mEq/L\n 31.3 %\n 20.8 K/uL\n [image002.jpg]\n 03:41 PM\n 08:24 PM\n 03:24 AM\n 03:40 AM\n 05:03 AM\n 06:16 AM\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n WBC\n 19.9\n 20.8\n Hct\n 30.2\n 31.3\n Plt\n 425\n 435\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n TCO2\n 44\n 43\n 42\n 41\n 42\n 40\n Glucose\n 136\n 112\n 143\n 93\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.0 mg/dL, Mg++:2.7 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Day 11 of intubation today for multilobar\n pneumonia & COPD c/b ARDS. Able to wean PEEP down to 5. Currently on\n PSV 8/5. Diuresed 2 liters negative yesterday and continues to be\n somewhat negative today. Fully treated for PNA, currently with ARDS.\n -SBT\n -possibly attempt to extubate today or tomorrow, if fails will need\n trach\n - continue acetazolamide\n - continue 30mg prednisone today, decrease to 20mg daily on \n -d/c po narcan\n # Alkalosis: secondary to aggressive diuresis\n - continue acetazolamide as above\n # Hx of hypertension: now normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds (will concentrate\n to assist with tube feeds)\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ\n # CODE: Full\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727162,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:30 AM\n Cefipime - 10:00 PM\n Vancomycin - 07:56 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:55 AM\n Furosemide (Lasix) - 08:05 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 08:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.8\nC (96.4\n HR: 75 (68 - 86) bpm\n BP: 103/54(69) {86/50(62) - 131/87(100)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,783 mL\n 1,518 mL\n PO:\n TF:\n 1,339 mL\n 546 mL\n IVF:\n 1,309 mL\n 447 mL\n Blood products:\n Total out:\n 3,450 mL\n 1,865 mL\n Urine:\n 3,450 mL\n 1,865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 333 mL\n -347 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 442 (389 - 442) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 14 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n SpO2: 91%\n ABG: 7.36/68/71/40/9\n Ve: 7.7 L/min\n PaO2 / FiO2: 142\n Physical Examination\n Gen:\n HEENT:\n CV:\n PULM:\n ABD:\n EXTREM:\n SKIN:\n NEURO:\n Labs / Radiology\n 10.0 g/dL\n 537 K/uL\n 133 mg/dL\n 0.8 mg/dL\n 40 mEq/L\n 4.1 mEq/L\n 40 mg/dL\n 97 mEq/L\n 143 mEq/L\n 32.0 %\n 23.1 K/uL\n [image002.jpg]\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n WBC\n 28.5\n 26.2\n 23.1\n Hct\n 30.2\n 30.6\n 32.0\n Plt\n 446\n 535\n 537\n Cr\n 0.9\n 0.8\n 0.8\n 0.8\n 0.7\n 0.8\n TCO2\n 33\n 33\n 34\n 40\n Glucose\n 194\n 166\n 168\n 150\n 171\n 133\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "Physician ",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727160,
"text": "Chief Complaint:\n 24 Hour Events:\n - Started on lasix gtt with good UOP\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:30 AM\n Cefipime - 10:00 PM\n Vancomycin - 07:56 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:55 AM\n Furosemide (Lasix) - 08:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.8\nC (96.4\n HR: 75 (68 - 86) bpm\n BP: 103/54(69) {86/50(62) - 131/87(100)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,783 mL\n 1,513 mL\n PO:\n TF:\n 1,339 mL\n 543 mL\n IVF:\n 1,309 mL\n 446 mL\n Blood products:\n Total out:\n 3,450 mL\n 1,865 mL\n Urine:\n 3,450 mL\n 1,865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 333 mL\n -352 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 417 (389 - 422) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 14 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n SpO2: 90%\n ABG: 7.36/68/71/40/9\n Ve: 7.6 L/min\n PaO2 / FiO2: 142\n Physical Examination\n Labs / Radiology\n 537 K/uL\n 10.0 g/dL\n 133 mg/dL\n 0.8 mg/dL\n 40 mEq/L\n 4.1 mEq/L\n 40 mg/dL\n 97 mEq/L\n 143 mEq/L\n 32.0 %\n 23.1 K/uL\n [image002.jpg]\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n WBC\n 28.5\n 26.2\n 23.1\n Hct\n 30.2\n 30.6\n 32.0\n Plt\n 446\n 535\n 537\n Cr\n 0.9\n 0.8\n 0.8\n 0.8\n 0.7\n 0.8\n TCO2\n 33\n 33\n 34\n 40\n Glucose\n 194\n 166\n 168\n 150\n 171\n 133\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-04-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 729180,
"text": "Chief Complaint:\n 24 Hour Events:\n - decreased urine output 10cc/hr--> gave NS 125cc/hr total 1L (later\n found on that foley was leaking)\n - 95% on 4L NC\n - Central line and A-line removed, Single PIV placed\n - Na 142 on recheck\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:22 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 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: 36.3\nC (97.3\n HR: 70 (59 - 99) bpm\n BP: 91/54(79) {89/50(60) - 118/77(87)} mmHg\n RR: 20 (17 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,389 mL\n 77 mL\n PO:\n 1,360 mL\n TF:\n IVF:\n 1,029 mL\n 77 mL\n Blood products:\n Total out:\n 937 mL\n 350 mL\n Urine:\n 937 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,452 mL\n -273 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///33/\n Physical Examination\n Labs / Radiology\n 415 K/uL\n 9.3 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 52 mg/dL\n 101 mEq/L\n 141 mEq/L\n 28.4 %\n 16.9 K/uL\n [image002.jpg]\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n 09:57 AM\n 12:26 PM\n 12:51 PM\n 05:36 PM\n 04:49 AM\n 03:27 AM\n WBC\n 22.7\n 19.2\n 16.9\n Hct\n 32.9\n 33.4\n 28.4\n Plt\n 465\n 446\n 415\n Cr\n 0.9\n 0.9\n 1.0\n 0.9\n 1.0\n TCO2\n 39\n 43\n 39\n 39\n 40\n Glucose\n 121\n 93\n 127\n 90\n 96\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n A 67 yo woman with a history of very severe COPD with PNA/ARDS, now\n extubated after prolonged intubation.\n .\n # Respiratory failure: Extubated. Resp status remains stable on 4L\n NC.\n --cont O2 to keep sats 88-92%\n --BIPAP overnight\n - continue prednisone taper at 20mg daily x 2 days\n - cont albuterol,fluticasone\n - encourage incentive spirometry\n .\n # Pneumonia: s/p course of broad-spectrum abx.\n .\n # Hx of hypertension: BP running low normal\n -change captopril to lisinopril, with holding parameters\n .\n # Hypernatremia: Resolved with IVF and free water intake\n ICU Care\n Nutrition: HH/Diabetic\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 03:12 PM\n Prophylaxis:\n DVT: Hep SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 729207,
"text": "Chief Complaint:\n 24 Hour Events:\n - decreased urine output 10cc/hr--> gave NS 125cc/hr total 1L (later\n found on that foley was leaking)\n - 95% on 4L NC\n - Central line and A-line removed, Single PIV placed\n - Na 142 on recheck\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:22 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 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: 36.3\nC (97.3\n HR: 70 (59 - 99) bpm\n BP: 91/54(79) {89/50(60) - 118/77(87)} mmHg\n RR: 20 (17 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,389 mL\n 77 mL\n PO:\n 1,360 mL\n TF:\n IVF:\n 1,029 mL\n 77 mL\n Blood products:\n Total out:\n 937 mL\n 350 mL\n Urine:\n 937 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,452 mL\n -273 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///33/\n Physical Examination\n Labs / Radiology\n 415 K/uL\n 9.3 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 52 mg/dL\n 101 mEq/L\n 141 mEq/L\n 28.4 %\n 16.9 K/uL\n [image002.jpg]\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n 09:57 AM\n 12:26 PM\n 12:51 PM\n 05:36 PM\n 04:49 AM\n 03:27 AM\n WBC\n 22.7\n 19.2\n 16.9\n Hct\n 32.9\n 33.4\n 28.4\n Plt\n 465\n 446\n 415\n Cr\n 0.9\n 0.9\n 1.0\n 0.9\n 1.0\n TCO2\n 39\n 43\n 39\n 39\n 40\n Glucose\n 121\n 93\n 127\n 90\n 96\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n A 67 yo woman with a history of very severe COPD with PNA/ARDS, now\n extubated after prolonged intubation.\n .\n # Respiratory failure: Extubated. Resp status remains stable on 4L\n NC.\n --cont O2 to keep sats 88-92%\n --BIPAP overnight\n - continue prednisone taper\n reduce to 10mg daily today () x 3\n days then taper\n - cont albuterol,fluticasone\n - encourage incentive spirometry\n - prior to discharged should be switched to spiriva (and off of\n atrovent)\n .\n # Pneumonia: s/p course of broad-spectrum abx.\n .\n # Hx of hypertension: BP running low normal\n -discontinue antihypertensives (only getting doses of captopril due\n to low normal BPs)\n # Hypernatremia: Resolved with IVF and free water intake\n # Anemia: Hct drop 33 to 28 today (). No source of bleeding.\n Continue home PPI and trend for now.\n ICU Care\n Nutrition: HH/Diabetic\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 03:12 PM\n Prophylaxis:\n DVT: Hep SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n ------ Protected Section ------\n PHYSICAL EXAM FROM \n GEN: on nasal cannula, appears very comfortable.\n HEENT:JVP not elevated\n CHEST: good air movement, no wheezes\n CARDIAC: distant, regular, no murmurs audible\n ABDOMEN: obese, soft, nontender; prominent bowel sounds\n EXTREMITIES: no edema, no sacral edema, 2+ distal pulses\n ------ Protected Section Addendum Entered By: , MD\n on: 10:42 ------\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 726135,
"text": "TITLE: Intensivist\n I saw and examined the patient, and was physically present with the ICU\n resident (Dr. for the key portions of the services provided. I\n agree with her note, including the assessment and plan. To that I\n would add the following:\n This is a 67 yo woman with severe COPD (FEV1 of 0.63, 28% pred) who\n presented to ED with SOB and hypoxemia. CXR shows dense airspace\n opacities in RUL, RLL, as well as possible involvement of LLL. WBC of\n 56.3 with 7% bands. Tachypneic and requiring 100% NRB in ED to\n maintain sats in 90s. Given vanc/ctx/azithro. Transferred to MICU for\n further management. In MICU, SBPs of 90s-100s with known history of\n hypertension. HR in 90s. ABG 7.25/63/71, lactate 1.0. Cr 1.8 with\n unknown baseline. On exam dyspneic appearing in moderate distress but\n able to speak. Diminished BS through but coarse crackles heard\n throughout right lung.\n A/P: Multifocal pneumonia, hypoxemia in setting of severe COPD. Will\n treat with azitho/vanc/cefepime. Bring steroid dose down to MP 40mg q8\n for now. Lactate normal but BP lower than baseline\n follow urine\n output, give 1 additional L NS. Pt did have a post seg RUL collapse in\n \n current pneumonia could be involving same area, though cannot\n tell with single AP film. Will require further imaging and perhaps\n even bronchoscopy when she stabilizes. (Did have a negative PET scan\n last year in eval of RUL collapse)\n Patient is critically ill. Time spent 40 minutes.\n ------ Protected Section ------\n Ms. has continued to have increasing work of breathing over\n the course of the evening. Repeat ABG 7.15/80/56 on 70% face tent plus\n 4L nasal cannula. Decision made to intubate. Anaesthesia called and\n ETT tube placed. Confirmatory CXR pending. Will plan to try to set TV\n at 6cc/kg IBW if possible but will need to get an idea of her\n ventilatory needs with repeat ABG and make adjustments accordingly.\n Patient is critically ill. Time spent 32 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 23:34 ------\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 726136,
"text": "TITLE: Intensivist\n I saw and examined the patient, and was physically present with the ICU\n resident (Dr. for the key portions of the services provided. I\n agree with her note, including the assessment and plan. To that I\n would add the following:\n This is a 67 yo woman with severe COPD (FEV1 of 0.63, 28% pred) who\n presented to ED with SOB and hypoxemia. CXR shows dense airspace\n opacities in RUL, RLL, as well as possible involvement of LLL. WBC of\n 56.3 with 7% bands. Tachypneic and requiring 100% NRB in ED to\n maintain sats in 90s. Given vanc/ctx/azithro. Transferred to MICU for\n further management. In MICU, SBPs of 90s-100s with known history of\n hypertension. HR in 90s. ABG 7.25/63/71, lactate 1.0. Cr 1.8 with\n unknown baseline. On exam dyspneic appearing in moderate distress but\n able to speak. Diminished BS through but coarse crackles heard\n throughout right lung.\n A/P: Multifocal pneumonia, hypoxemia in setting of severe COPD. Will\n treat with azitho/vanc/cefepime. Bring steroid dose down to MP 40mg q8\n for now. Lactate normal but BP lower than baseline\n follow urine\n output, give 1 additional L NS. Pt did have a post seg RUL collapse in\n \n current pneumonia could be involving same area, though cannot\n tell with single AP film. Will require further imaging and perhaps\n even bronchoscopy when she stabilizes. (Did have a negative PET scan\n last year in eval of RUL collapse)\n Patient is critically ill. Time spent 40 minutes.\n ------ Protected Section ------\n Ms. has continued to have increasing work of breathing over\n the course of the evening. Repeat ABG 7.15/80/56 on 70% face tent plus\n 4L nasal cannula. Decision made to intubate. Anaesthesia called and\n ETT tube placed. Confirmatory CXR pending. Will plan to try to set TV\n at 6cc/kg IBW if possible but will need to get an idea of her\n ventilatory needs with repeat ABG and make adjustments accordingly.\n Patient is critically ill. Time spent 32 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 23:34 ------\n CXR shows worsening infiltrates throughout R lung and ETT in position.\n RLL infiltrate appears heterogeneous with areas of lucency,\n particularly near minor fissure across from dense RUL infiltrate.\n Patient is critically ill. Time spent 10 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 23:45 ------\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726362,
"text": "67 y/o pt with long standing history of severe COPD & chronic asthma.\n Pt lives in an facility and had been c/o SOB x 1 wk.\n EMS found pt to have a 70% O2 sat on RA. Placed on NRB and given\n nebs. Also found to be tachypneic to the 40's with obvious increased\n WOB. CXR significant for large right sided PNA. Given Azithromycin,\n Ceftriaxone, nebs and steroids in ED. Admitted to MICU for further\n observation.\n Sepsis without organ dysfunction\n Assessment:\n Received pt w/ WBC 59. Lactate flat. Levophed running @ 0.06mcgkg/min.\n SBP 90\ns-100\ns w/ MAPs 60\ns-70\ns. Of note, pt does have confirmed GPC\n in pairs within sputum. CVP ~ 16. CXR showing white out of right\n lung. Suctioning Q2-4hrs for thick, white/yellow sputum. Strong\n cough/impaired gag. O2 sats ranging 92-96%\n Action:\n Titrating Levophed gtt to MAPs > 60. Currently @ 0.03mcg/kg/min.\n Levophed turned off for ~ 1 hr. Pt initially did well, yet began to\n linger with MAPs in the 50\ns and SBP\ns in the 80\ns. Pt is on triple\n abx: Vanco, Cefepime & Azithromycin. Chest PT PRN. Q2hr turning.\n Elevate right lung as much as possible.\n Response:\n MAP\ns >/= 60 @ this time.\n Plan:\n Titrate Levophed as tolerated for goal MAP >60. Trend labs/culture\n data. ? bronch for clean out and additional spec.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received pt vented on AC 70% x 450 x 24 w/ 10 PEEP. Versed @ 3mg/hr,\n Fentanyl @ 125mcg/kg/min. Pt is easily arousable & is able to respond\n to yes/no questions. Follows simple commands (great strengths in all\n extremeties) LS originally diminished w/ IW in BUL. O2 sat as noted\n above. ABG this AM on noted settings 7.31/47/98.\n Action:\n ABG much improved this AM (7.31/47/98). Pt originally presenting w/\n severe respiratory acidosis. Abx, stress dose steroids & inhalers via\n RT ATC. Attempt to wean vent settings to 60% FiO2 & 8 PEEP\n multiple\n ABG\ns (please see Metavision for results)\n Response:\n WBC improved 59\n 35.6. Tolerating TF\ns w/ minimal 5-10cc residuals.\n Electrolytes stable @ this time. Current settings 60% x 450 x 24 w/ 10\n PEEP.\n Plan:\n Trend ABG\ns & follow sats. ? Repeat CT chest to evaluate for malignant\n process on top of PNA given elevated WBC. Cont to titrate TF as\n tolerated with goal 65cc/hr. Wean vent settings as warranted.\n R IJ TLC\n L Radial ALINE\n PIV x 2\n Full Code\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726187,
"text": "67 y/o pt with longstanding history of severe COPD, chronic bronchitis,\n emphysema and chronic asthma. Pt lives in an facility\n and had been c/o SOB x 1 wk. EMS found pt to have a 70% o2 sat on RA.\n Placed on NRB and given nebs. Also found to be tachypnic to the 40's\n with obvious increased WOB. CXR significant for large rt sided PNA.\n Given Azithromycin, Ceftriaxone, nebs and steroids in ED- admitted to\n MICU for further observation.\n Sepsis without organ dysfunction\n Assessment:\n WBC 56 w/ normal lactate. SBP in 70\ns to 90\ns most of the shift\n Action:\n Received totally 8lit fluid bolus for this shift but cont to be\n hypotensive. Started peripheral dopa and switched to levophed after\n RIJ placement. A line placed . T max 98.1 Sputum and urine cx done. On\n abx vanco, cefepime, azithromycin.\n Response:\n Currently SBP maintaining > 100\ns on levophed 0.1mics/kg/min.\n Plan:\n Titrate levophed as per BP. Follow lytes and replace as needed.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt admitted w/ severe COPD and pneumonia. Received the pt on O2 100%\n face tent and NC 4 lit sating >95%. Breathing was laboured and pt cont\n to claim to have difficulty breathing.\n Action:\n Multiple ABG\ns done her acidosis was progressing worse and Intubated\n around 2315pm . Started on propofol @ 30mics/kg/min but pt cont to\n drop BP and sedation changed to fentanyl and versed. Multiple vent\n changes and ABG done shows resp acidosis.\n Response:\n Vent setting are AC/450/24/5. sedated on fentanyl 10mics/min and versed\n @ 2mg/hr. WBC bump for 56 to 59.\n Plan:\n Check frequent ABG.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726343,
"text": "67 y/o pt with long standing history of severe COPD & chronic asthma.\n Pt lives in an facility and had been c/o SOB x 1 wk.\n EMS found pt to have a 70% O2 sat on RA. Placed on NRB and given\n nebs. Also found to be tachypneic to the 40's with obvious increased\n WOB. CXR significant for large right sided PNA. Given Azithromycin,\n Ceftriaxone, nebs and steroids in ED. Admitted to MICU for further\n observation.\n Sepsis without organ dysfunction\n Assessment:\n Received pt w/ WBC 59. Lactate flat. Levophed running @ 0.06mcgkg/min.\n SBP 90\ns-100\ns w/ MAPs 60\ns-70\ns. Of note, pt does have confirmed GPC\n in pairs within sputum. CVP ~ 16. CXR showing white out of right\n lung. Suctioning Q2-4hrs for thick, white/yellow sputum. Strong\n cough/impaired gag. O2 sats ranging 92-96%\n Action:\n Titrating Levophed gtt to MAPs > 60. Currently @ 0.03mcg/kg/min.\n Levophed turned off for ~ 1 hr. Pt initially did well, yet began to\n linger with MAPs in the 50\ns and SBP\ns in the 80\ns. Pt is on triple\n abx: Vanco, Cefepime & Azithromycin. Chest PT PRN. Q2hr turning.\n Elevate right lung as much as possible.\n Response:\n MAP\ns >/= 60 @ this time.\n Plan:\n Titrate Levophed as tolerated for goal MAP >60. Trend labs/culture\n data. ? bronch for clean out and additional spec.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received pt vented on AC 70% x 450 x 24 w/ 10 PEEP. Versed @ 3mg/hr,\n Fentanyl @ 125mcg/kg/min. Pt is easily arousable & is able to respond\n to yes/no questions. Follows simple commands (great strengths in\n BUE/BLE) LS originally diminished w/ IW in BUL. O2 sat as noted above.\n ABG this AM on noted settings 7.31/47/98.\n Action:\n ABG much improved this AM. Pt originally presenting w/ severe\n respiratory acidosis. Abx, stress dose steroids & inhalers via RT ATC.\n Attempt to wean vent settings to 60% FiO2 & 8 PEEP.\n Response:\n WBC improved 59\n 35.6. Tolerating TF\ns w/ minimal 5-10cc residuals.\n Electrolytes stable @ this time.\n Plan:\n Trend ABG\ns & follow sats. ? repeat CT chest to evaluate for malignant\n process on top of PNA given elevated WBC. Cont to titrate TF as\n tolerated with goal 65cc/hr. Wean vent settings as warranted.\n R IJ TLC\n L Radial ALINE\n PIV x 2\n Full Code\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726098,
"text": "67 y/o pt with longstanding history of severe COPD, chronic bronchitis,\n emphysema and chronic asthma. Pt lives in an facility\n and had been c/o SOB x 1 wk. EMS found pt to have a 70% o2 sat on RA.\n Placed on NRB and given nebs. Also found to be tachypnic to the 40's\n with obvious increased WOB. CXR significant for large rt sided PNA.\n Given Azithromycin, Ceftriaxone, nebs and steroids in ED- admitted to\n MICU for further observation.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726220,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 11:18 PM\n MULTI LUMEN - START 04:24 AM\n ARTERIAL LINE - START 04:31 AM\n - mildly hypotensive to SBP 85-90, bolused 3 L NS\n - repeat ABG deteriorated to 7.15/80/56 on FM-->intubated\n - very difficult to ventilate, increasing RR and TV up to 450(now @\n ~9cc/kg/min), oxygenating well\n - tried for 2 hours to place a-line, patient more hypotensive with\n propofol-->changed to fent/midaz, IVF wide open x 6L more\n - still hypotensive with MAPs 45-50, UOP holding steady @\n ~50cc/h-->started peripheral dopamine, placed CVL. CVP 13.\n - changed dopamine to levophed via CVL. FYI RIJ is superior SVC vs\n brachiocephalic, ok for pressors per pharmacy.\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 05:51 PM\n Cefipime - 08:30 PM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 11:55 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 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.4\nC (97.6\n HR: 72 (72 - 99) bpm\n BP: 102/58(74) {98/50(66) - 108/58(74)} mmHg\n RR: 24 (0 - 31) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 14 (14 - 14)mmHg\n Total In:\n 3,316 mL\n 5,232 mL\n PO:\n TF:\n IVF:\n 3,316 mL\n 5,232 mL\n Blood products:\n Total out:\n 120 mL\n 355 mL\n Urine:\n 120 mL\n 355 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,196 mL\n 4,877 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (350 - 450) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 80%\n RSBI Deferred: FiO2 > 60%\n PIP: 37 cmH2O\n Plateau: 28 cmH2O\n Compliance: 25.7 cmH2O/mL\n SpO2: 94%\n ABG: 7.21/57/75/21/-5\n Ve: 10.1 L/min\n PaO2 / FiO2: 94\n Physical Examination\n GEN: moderate respiratory distress, speaking in 3 word phrases, pursed\n lipped breathing, + accessory muscle use\n SKIN: No rashes or skin changes noted\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender\n EXTREMITIES: trace bilaterally pitting edema\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact\n Labs / Radiology\n 319 K/uL\n 10.3 g/dL\n 174 mg/dL\n 1.4 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 50 mg/dL\n 113 mEq/L\n 146 mEq/L\n 34.1 %\n 59.7 K/uL\n [image002.jpg]\n 06:52 PM\n 10:50 PM\n 12:54 AM\n 02:05 AM\n 02:20 AM\n 04:36 AM\n 06:37 AM\n WBC\n 59.7\n Hct\n 34.1\n Plt\n 319\n Cr\n 1.4\n TCO2\n 29\n 29\n 27\n 38\n 24\n 24\n Glucose\n 174\n Other labs: PT / PTT / INR:11.6/27.4/1.0, Differential-Neuts:92.0 %,\n Band:5.0 %, Lymph:2.0 %, Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.4 mmol/L,\n Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:4.4 mg/dL\n Sputum gram stain: GPC in pairs\n Legionella urinary antigen: negative\n Blood cx : NGTD\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n # Respiratory failure: Multilobar Pneumonia & COPD. Possible that she\n has some sort of endobronchial lesion (? malignancy given smoking hx)\n contributing. In any case, because of her very severe baseline\n obstructive disease, she is in a very tenuous respiratory place right\n now. GPCs in pairs, Legionella (-)\n - vancomycin, cefepime, and azithromycin for broad bacterial coverage\n including atypical pathogens. (Lives in facility,\n chronic respiratory disease so will treat as if HCAP.)\n - F/U blood cx\n - ABG on current settings, tolerate large tidal volumes\n - Plateaus <30 as most ventilation is going to the L lung, maintain\n ARDSnet ventilation as pH tolerates\n - methylprednisolone to 125 mg q8h\n - fluticasone inh\n - albuterol nebs q1h for now, decrease to q6h as tolerated\n - ipratropium nebs q6h\n #. Shock: Septic from PNA, leukocytosis, requiring pressors but is\n fluid responsive. No recent abx exposure.\n - Abx as above\n - Norepi as needed to keep MAP >65, allow for sedation\n - trend WBC (will be complicated by steroids)\n - Send C. Diff\n - Measure SvO2 to r/o cardiogenic shock\n # kidney injury: Unclear if this is acute or chronic, but did improve\n with signficant fluid hydration.\n - F/U urine lytes\n - trend creatinine\n # hx hypertension: hypotensive on pressors\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , patient does not know # and none in chart; will consult social\n work\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 726221,
"text": "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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation\n 24 Hour Events:\n Intubated for progressive failure overnight, as per admission notes.\n Started on norepi gtt for fluid-unresponsive hypotension.\n Persistent autoPEEP of 9 noted.\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 08:30 PM\n Vancomycin - 07:48 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 11:55 PM\n Other medications:\n Serevent , SoluMedrol 40 q8, Heparin sc tid, Colace, azithromycin\n qd, Atrovent q6, Albuterol q2, famotidine, Peridex,\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 09:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 74 (72 - 99) bpm\n BP: 107/61(77) {98/50(66) - 108/61(77)} mmHg\n RR: 24 (0 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 14 (14 - 14)mmHg\n Total In:\n 3,316 mL\n 5,560 mL\n PO:\n TF:\n IVF:\n 3,316 mL\n 5,500 mL\n Blood products:\n Total out:\n 120 mL\n 495 mL\n Urine:\n 120 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,196 mL\n 5,065 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (350 - 450) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 80%\n RSBI Deferred: FiO2 > 60%\n PIP: 32 cmH2O\n Plateau: 29 cmH2O\n Compliance: 22.5 cmH2O/mL\n SpO2: 95%\n ABG: 7.21/57/75/21/-5\n Ve: 11.3 L/min\n PaO2 / FiO2: 94\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : left, Crackles : right\n laterally, Rhonchorous: on right)\n Abdominal: Soft, Non-tender, Bowel sounds present, reducible ventral\n hernia present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Movement: Not assessed, Sedated, Tone: Normal\n Labs / Radiology\n 10.3 g/dL\n 319 K/uL\n 174 mg/dL\n 1.4 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 50 mg/dL\n 113 mEq/L\n 146 mEq/L\n 34.1 %\n 59.7 K/uL\n [image002.jpg]\n 06:52 PM\n 10:50 PM\n 12:54 AM\n 02:05 AM\n 02:20 AM\n 04:36 AM\n 06:37 AM\n WBC\n 59.7\n Hct\n 34.1\n Plt\n 319\n Cr\n 1.4\n TCO2\n 29\n 29\n 27\n 38\n 24\n 24\n Glucose\n 174\n Other labs: PT / PTT / INR:11.6/27.4/1.0, Differential-Neuts:92.0 %,\n Band:5.0 %, Lymph:2.0 %, Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.4 mmol/L,\n Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:4.4 mg/dL\n Imaging: CXR- panlobar R-sided opacification, LLL atelectasis vs\n infiltrate\n Microbiology: Sputum- GPC in pairs\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia. Prior partial RUL\n collapse from will need further evaluation down the road and might\n have predisposed to current pna\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -stay as close to ARDSnet ventilation as acidemia allows, currently at\n about 8-9cc/kg for Vt\n -wean FiO2 to maintain PaO2 > 60\n -tolerate autoPEEP for now as Pplat < 30 and hemodyn stable\n -vanco + cefepime + azithro (change to IV) for now\n -f/u GPCs in sputum, other cx data\n -tx COPD exac w/ Solu-Medrol --> incr to 125 q8 and scheduled nebs\n -will need CT scan at some point to re-evaluate\n 2. Shock- likely multifactorial, sepsis vs meds\n -recent echo w/ nl echo\n -CVP goal, MAP goals reached; wean norepi gtt as tolerated\n -might become more conservative w/ fluids (will use LR given high Cl)\n given high FiO2 req't and little gross pulse pressure variation or CVP\n variation\n 3. ARF- supportive mgmt, due to #2 as above\n ICU Care\n Nutrition:\n Comments: start tube feeds today\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 05:47 PM\n 18 Gauge - 04:00 AM\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n Prophylaxis:\n DVT: SQ UF Heparin\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: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726192,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 11:18 PM\n MULTI LUMEN - START 04:24 AM\n ARTERIAL LINE - START 04:31 AM\n - mildly hypotensive to SBP 85-90, bolused 3 L NS\n - repeat ABG deteriorated to 7.15/80/56 on FM-->intubated\n - very difficult to ventilate, increasing RR and TV up to 450(now @\n ~9cc/kg/min), oxygenating well\n - tried for 2 hours to place a-line, patient more hypotensive with\n propofol-->changed to fent/midaz, IVF wide open x 6L more\n - still hypotensive with MAPs 45-50, UOP holding steady @\n ~50cc/h-->started peripheral dopamine, placed CVL. CVP 13.\n - changed dopamine to levophed via CVL. FYI RIJ is superior SVC vs\n brachiocephalic, ok for pressors per pharmacy.\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 05:51 PM\n Cefipime - 08:30 PM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 11:55 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 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.4\nC (97.6\n HR: 72 (72 - 99) bpm\n BP: 102/58(74) {98/50(66) - 108/58(74)} mmHg\n RR: 24 (0 - 31) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 14 (14 - 14)mmHg\n Total In:\n 3,316 mL\n 5,232 mL\n PO:\n TF:\n IVF:\n 3,316 mL\n 5,232 mL\n Blood products:\n Total out:\n 120 mL\n 355 mL\n Urine:\n 120 mL\n 355 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,196 mL\n 4,877 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (350 - 450) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 80%\n RSBI Deferred: FiO2 > 60%\n PIP: 37 cmH2O\n Plateau: 28 cmH2O\n Compliance: 25.7 cmH2O/mL\n SpO2: 94%\n ABG: 7.21/57/75/21/-5\n Ve: 10.1 L/min\n PaO2 / FiO2: 94\n Physical Examination\n VS: T 97.6, HR 99, BP 96/50, O2 97% on 50% FM\n GEN: moderate respiratory distress, speaking in 3 word phrases, pursed\n lipped breathing, + accessory muscle use\n SKIN: No rashes or skin changes noted\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender\n EXTREMITIES: trace bilaterally pitting edema\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact.\n Labs / Radiology\n 319 K/uL\n 10.3 g/dL\n 174 mg/dL\n 1.4 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 50 mg/dL\n 113 mEq/L\n 146 mEq/L\n 34.1 %\n 59.7 K/uL\n [image002.jpg]\n 06:52 PM\n 10:50 PM\n 12:54 AM\n 02:05 AM\n 02:20 AM\n 04:36 AM\n 06:37 AM\n WBC\n 59.7\n Hct\n 34.1\n Plt\n 319\n Cr\n 1.4\n TCO2\n 29\n 29\n 27\n 38\n 24\n 24\n Glucose\n 174\n Other labs: PT / PTT / INR:11.6/27.4/1.0, Differential-Neuts:92.0 %,\n Band:5.0 %, Lymph:2.0 %, Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.4 mmol/L,\n Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n .\n # Pneumonia: Multilobar infiltrates on CXR. Labs with significant\n leukocytosis and L shift, likely indicative of bacterial infection.\n Afebrile currently, although report of \"chills\" at home. Current SBP\n 95-105 is likely low for patient (SBP 120-150 in clinic notes) and may\n be a signal of impending sepsis. Regarding the pneumonia itself, given\n history of idiopathic RUL collapse in , it is possible that she\n has some sort of endobronchial lesion (? malignancy given smoking hx)\n contributing. In any case, because of her very severe baseline\n obstructive disease, she is in a very tenuous respiratory place right\n now.\n - vancomycin, cefepime, and azithromycin for broad bacterial coverage\n including atypical pathogens. (Lives in facility,\n chronic respiratory disease so will treat as if HCAP.)\n - blood cx\n - sputum cx\n - urinary legionella antigen\n - IVF - will give 1 L NS bolus now and continuing with goal MAP >65,\n goal uop >35 cc/h. Previous echo with NL EF.\n - repeat CXR in AM (will get PA/Lat for better visualization)\n - serial ABG (will not repeat overnight unless O2 Saturation falls)\n - trend WBC (will be complicated by steroids)\n - discuss with Dr. whether CT and/or bronchoscopy may be\n indicated for better visualization of possible endobronchial lesion\n that may be contributing to recurrent pathology in that lobe\n .\n # COPD: very severe COPD with FEV1 <30% predicted. No history\n intubation. Currently very tachypneic with poor air movement.\n - serial ABG as above\n - methylprednisolone 40 mg q8h (will hold off on 125mg given\n concominant infecitious picture)\n - fluticasone inh\n - albuterol nebs q1h for now, decrease to q6h as tolerated\n - ipratropium nebs q6h\n - may require intubation if tires\n .\n # hx hypertension: borderline hypotensive currently\n - hold all antihypertensives\n .\n # kidney injury: unclear whether acute or chronic (no baseline labs,\n but no recorded history of renal insufficiency.) She may be prerenal\n in the setting of lower than normal perfusion pressure\n - check urine lytes\n - trend creatinine\n - avoid nephrotoxins\n .\n .\n # FEN: IVF boluses / replete lytes prn / npo for now\n # PPX: PPI per home regimen, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , patient does not know # and none in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 726195,
"text": "Demographics\n Day of intubation: 2\n Day of mechanical ventilation: 2\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 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: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Insp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Prolonged exhalation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726197,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 11:18 PM\n MULTI LUMEN - START 04:24 AM\n ARTERIAL LINE - START 04:31 AM\n - mildly hypotensive to SBP 85-90, bolused 3 L NS\n - repeat ABG deteriorated to 7.15/80/56 on FM-->intubated\n - very difficult to ventilate, increasing RR and TV up to 450(now @\n ~9cc/kg/min), oxygenating well\n - tried for 2 hours to place a-line, patient more hypotensive with\n propofol-->changed to fent/midaz, IVF wide open x 6L more\n - still hypotensive with MAPs 45-50, UOP holding steady @\n ~50cc/h-->started peripheral dopamine, placed CVL. CVP 13.\n - changed dopamine to levophed via CVL. FYI RIJ is superior SVC vs\n brachiocephalic, ok for pressors per pharmacy.\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 05:51 PM\n Cefipime - 08:30 PM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 11:55 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 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.4\nC (97.6\n HR: 72 (72 - 99) bpm\n BP: 102/58(74) {98/50(66) - 108/58(74)} mmHg\n RR: 24 (0 - 31) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 14 (14 - 14)mmHg\n Total In:\n 3,316 mL\n 5,232 mL\n PO:\n TF:\n IVF:\n 3,316 mL\n 5,232 mL\n Blood products:\n Total out:\n 120 mL\n 355 mL\n Urine:\n 120 mL\n 355 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,196 mL\n 4,877 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (350 - 450) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 80%\n RSBI Deferred: FiO2 > 60%\n PIP: 37 cmH2O\n Plateau: 28 cmH2O\n Compliance: 25.7 cmH2O/mL\n SpO2: 94%\n ABG: 7.21/57/75/21/-5\n Ve: 10.1 L/min\n PaO2 / FiO2: 94\n Physical Examination\n VS: T 97.6, HR 99, BP 96/50, O2 97% on 50% FM\n GEN: moderate respiratory distress, speaking in 3 word phrases, pursed\n lipped breathing, + accessory muscle use\n SKIN: No rashes or skin changes noted\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender\n EXTREMITIES: trace bilaterally pitting edema\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact.\n Labs / Radiology\n 319 K/uL\n 10.3 g/dL\n 174 mg/dL\n 1.4 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 50 mg/dL\n 113 mEq/L\n 146 mEq/L\n 34.1 %\n 59.7 K/uL\n [image002.jpg]\n 06:52 PM\n 10:50 PM\n 12:54 AM\n 02:05 AM\n 02:20 AM\n 04:36 AM\n 06:37 AM\n WBC\n 59.7\n Hct\n 34.1\n Plt\n 319\n Cr\n 1.4\n TCO2\n 29\n 29\n 27\n 38\n 24\n 24\n Glucose\n 174\n Other labs: PT / PTT / INR:11.6/27.4/1.0, Differential-Neuts:92.0 %,\n Band:5.0 %, Lymph:2.0 %, Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.4 mmol/L,\n Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:4.4 mg/dL\n Sputum gram stain: GPC in pairs\n Legionella urinary antigen: negative\n Blood cx : NGTD\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n .\n # Pneumonia: Multilobar infiltrates on CXR. Labs with significant\n leukocytosis and L shift, likely indicative of bacterial infection.\n Afebrile currently, although report of \"chills\" at home. Current SBP\n 95-105 is likely low for patient (SBP 120-150 in clinic notes) and may\n be a signal of impending sepsis. Regarding the pneumonia itself, given\n history of idiopathic RUL collapse in , it is possible that she\n has some sort of endobronchial lesion (? malignancy given smoking hx)\n contributing. In any case, because of her very severe baseline\n obstructive disease, she is in a very tenuous respiratory place right\n now.\n - vancomycin, cefepime, and azithromycin for broad bacterial coverage\n including atypical pathogens. (Lives in facility,\n chronic respiratory disease so will treat as if HCAP.)\n - blood cx\n - sputum cx\n - urinary legionella antigen\n - IVF - will give 1 L NS bolus now and continuing with goal MAP >65,\n goal uop >35 cc/h. Previous echo with NL EF.\n - repeat CXR in AM (will get PA/Lat for better visualization)\n - serial ABG (will not repeat overnight unless O2 Saturation falls)\n - trend WBC (will be complicated by steroids)\n - discuss with Dr. whether CT and/or bronchoscopy may be\n indicated for better visualization of possible endobronchial lesion\n that may be contributing to recurrent pathology in that lobe\n .\n # COPD: very severe COPD with FEV1 <30% predicted. No history\n intubation. Currently very tachypneic with poor air movement.\n - serial ABG as above\n - methylprednisolone 40 mg q8h (will hold off on 125mg given\n concominant infecitious picture)\n - fluticasone inh\n - albuterol nebs q1h for now, decrease to q6h as tolerated\n - ipratropium nebs q6h\n - may require intubation if tires\n .\n # hx hypertension: borderline hypotensive currently\n - hold all antihypertensives\n .\n # kidney injury: unclear whether acute or chronic (no baseline labs,\n but no recorded history of renal insufficiency.) She may be prerenal\n in the setting of lower than normal perfusion pressure\n - check urine lytes\n - trend creatinine\n - avoid nephrotoxins\n .\n .\n # FEN: IVF boluses / replete lytes prn / npo for now\n # PPX: PPI per home regimen, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , patient does not know # and none in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 726129,
"text": "TITLE: Intensivist\n I saw and examined the patient, and was physically present with the ICU\n resident (Dr. for the key portions of the services provided. I\n agree with her note, including the assessment and plan. To that I\n would add the following:\n This is a 67 yo woman with severe COPD (FEV1 of 0.63, 28% pred) who\n presented to ED with SOB and hypoxemia. CXR shows dense airspace\n opacities in RUL, RLL, as well as possible involvement of LLL. WBC of\n 56.3 with 7% bands. Tachypneic and requiring 100% NRB in ED to\n maintain sats in 90s. Given vanc/ctx/azithro. Transferred to MICU for\n further management. In MICU, SBPs of 90s-100s with known history of\n hypertension. HR in 90s. ABG 7.25/63/71, lactate 1.0. Cr 1.8 with\n unknown baseline. On exam dyspneic appearing in moderate distress but\n able to speak. Diminished BS through but coarse crackles heard\n throughout right lung.\n A/P: Multifocal pneumonia, hypoxemia in setting of severe COPD. Will\n treat with azitho/vanc/cefepime. Bring steroid dose down to MP 40mg q8\n for now. Lactate normal but BP lower than baseline\n follow urine\n output, give 1 additional L NS. Pt did have a post seg RUL collapse in\n \n current pneumonia could be involving same area, though cannot\n tell with single AP film. Will require further imaging and perhaps\n even bronchoscopy when she stabilizes. (Did have a negative PET scan\n last year in eval of RUL collapse)\n Patient is critically ill. Time spent 40 minutes.\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 726268,
"text": "Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Insp Wheeze\n LUL Lung Sounds: Insp Wheeze\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 response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dy\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": "Nursing",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726171,
"text": "67 y/o pt with longstanding history of severe COPD, chronic bronchitis,\n emphysema and chronic asthma. Pt lives in an facility\n and had been c/o SOB x 1 wk. EMS found pt to have a 70% o2 sat on RA.\n Placed on NRB and given nebs. Also found to be tachypnic to the 40's\n with obvious increased WOB. CXR significant for large rt sided PNA.\n Given Azithromycin, Ceftriaxone, nebs and steroids in ED- admitted to\n MICU for further observation.\n Sepsis without organ dysfunction\n Assessment:\n WBC 56 w/ normal lactate. SBP in 70\ns to 90\ns most of the shift\n Action:\n Received 8lit fluid total for this shift but cont to be hypotensive.\n Started peripheral dopa and switched to levophed after RIJ placement. A\n line placed\n Response:\n Currently SBP maintaining > 100\ns on levophed 0.1mics/kg/min.\n Plan:\n Titrate levophed as per BP. Follow lytes and replace as needed.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726179,
"text": "67 y/o pt with longstanding history of severe COPD, chronic bronchitis,\n emphysema and chronic asthma. Pt lives in an facility\n and had been c/o SOB x 1 wk. EMS found pt to have a 70% o2 sat on RA.\n Placed on NRB and given nebs. Also found to be tachypnic to the 40's\n with obvious increased WOB. CXR significant for large rt sided PNA.\n Given Azithromycin, Ceftriaxone, nebs and steroids in ED- admitted to\n MICU for further observation.\n Sepsis without organ dysfunction\n Assessment:\n WBC 56 w/ normal lactate. SBP in 70\ns to 90\ns most of the shift\n Action:\n Received totally 8lit fluid bolus for this shift but cont to be\n hypotensive. Started peripheral dopa and switched to levophed after\n RIJ placement. A line placed . T max 98.1 Sputum and urine cx done. On\n abx vanco, cefepime, azithromycin.\n Response:\n Currently SBP maintaining > 100\ns on levophed 0.1mics/kg/min.\n Plan:\n Titrate levophed as per BP. Follow lytes and replace as needed.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt admitted w/ severe COPD and pneumonia. Received the pt on O2 100%\n face tent and NC 4 lit sating >95%. Breathing was laboured and pt cont\n to claim to have difficulty breathing.\n Action:\n Multiple ABG\ns done her acidosis was progressing worse and Intubated\n around 2315pm . Started on propofol @ 30mics/kg/min but pt cont to\n drop BP and sedation changed to fentanyl and versed. Multiple vent\n changes and ABG done shows resp acidosis.\n Response:\n Vent setting are AC/450/24/5. sedated on fentanyl 10mics/min and versed\n @ 2mg/hr. WBC bump for 56 to 59.\n Plan:\n Check frequent ABG.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726333,
"text": "67 y/o pt with long standing history of severe COPD & chronic asthma.\n Pt lives in an facility and had been c/o SOB x 1 wk.\n EMS found pt to have a 70% O2 sat on RA. Placed on NRB and given\n nebs. Also found to be tachypneic to the 40's with obvious increased\n WOB. CXR significant for large right sided PNA. Given Azithromycin,\n Ceftriaxone, nebs and steroids in ED. Admitted to MICU for further\n observation.\n Sepsis without organ dysfunction\n Assessment:\n WBC 59 w/ normal lactate. Afebrile. Rec\nd pt on 0.1mcg/kg/min levophed\n gtt. SBP ranging 89-100s. MAPs >60. Sputum with GPC in pairs. Rec\n 8L NS bolus for hypotension o/n. CVP ranging . CXR showing white\n out of right lung, sxning q4h for mod. Amounts of yellow thick sputum.\n Action:\n Titrating levophed gtt to MAPs > 60. See metavision for specifics. On\n abx vanco, cefepime, azithromycin. Chest PT and turning q2h on left\n side with bad lung up.\n Response:\n Currently maintaing MAPs > 60 on levophed 0.06 mcgs/kg/min.\n Plan:\n Titrate levophed as per BP. Follow lytes and replace as needed. Cont.\n antibx, f/u culture data. ? bronch for clean out and spec.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt admitted w/ severe COPD and pneumonia. Received pt vented on 80%\n 450/24/5 peep. Pt is auto-peeping around 9. Rec\nd pt on 2 mg/hr\n versed gtt and 100mcg/kg/min fentanyl gtt- pt easily arousable and\n following commands on this amount of sedation. Nodding\n when\n asked if in pain. LS diminished t/o with intermittent insp./exp.\n Wheezing t/o.\n Action:\n Multiple ABG\ns sent, please see metavision for specifics. ABGs with\n resp. acidosis. Mult. Vent. Changes made. Increased sedation to\n 125mcg/kg/min fentanyl, and 3 mg/hr versed gtts for auto-peeping and\n pain. On antibx, stress dose steroids, and on frequent nebs via\n respiratory.\n - Pt with one episode of acute desaturation to low 80%, LS wheezy t/o,\n sxned ,nebs, vent increased to 100% and 10 peep. Pt noted to take\n awhile to recover, MD aware. ABG with PaO2 60 during this episode.\n Response:\n Pt is no longer auto-peeping, able to wean vent back down to 70%-\n maintaining sats > 90% on current vent settings- 70% 450/24/10.\n Remains sedated on fentanyl 125 mcgs/kg/min and versed @ 3mg/hr. WBC\n remains elevated despite antibx. TF initiated for nutrition this shift\n with goal TF 65cc/hr.\n Plan:\n Check frequent ABG. Follow sats. ? repeat CT chest to eval. For\n malignant process on top of pna with elevated WBCs. Cont. to titrate\n TF as tolerated with goal 65cc/hr.\n"
},
{
"category": "Nutrition",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 726254,
"text": "Subjective\n Intubated therefore unable to assess; family not present\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 100.9 kg\n 34.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 61.2 kg\n 165%\n 71 kg\n unknown\n Diagnosis: PNA, COPD\n PMHx: 1. COPD\n 2. Stab wound in leading to splenectomy and partial\n pancreatectomy.\n 3. Esophageal reflux.\n 4. Intracerebral hemorrhage as a consequence of a hypertensive crises,\n needing craniotomy and a ventricular peritoneal shunt in the\n craniotomy. She has a ventricular peritoneal shunt in place.\n 5. Left hip replacement.\n 6. Hypertension\n 7. Longstanding lower extremity swelling.\n 8. Partial right upper lobe collapse noted in , confirmed\n by CT. PET was negative for any sign of malignancy. A subsequent\n chest x-ray showed improvement.\n Food allergies and intolerances: none noted\n Pertinent medications: Fentanyl drip, versed drip, norepinephrine drip,\n Pantoprazole, Humalog insulin sliding scale, heparin, Colace,\n Solumedrol\n Labs:\n Value\n Date\n Glucose\n 174 mg/dL\n 02:20 AM\n Glucose Finger Stick\n 181\n 12:00 PM\n BUN\n 50 mg/dL\n 02:20 AM\n Creatinine\n 1.4 mg/dL\n 02:20 AM\n Sodium\n 146 mEq/L\n 02:20 AM\n Potassium\n 4.7 mEq/L\n 02:20 AM\n Chloride\n 113 mEq/L\n 02:20 AM\n TCO2\n 21 mEq/L\n 02:20 AM\n PO2 (arterial)\n 60 mm Hg\n 01:11 PM\n PO2 (venous)\n 42 mm Hg\n 09:59 AM\n PCO2 (arterial)\n 52 mm Hg\n 01:11 PM\n PCO2 (venous)\n 65 mm Hg\n 04:39 AM\n pH (arterial)\n 7.27 units\n 01:11 PM\n pH (venous)\n 7.16 units\n 04:39 AM\n pH (urine)\n 6.0 units\n 07:39 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 01:11 PM\n CO2 (Calc) venous\n 24 mEq/L\n 04:39 AM\n Calcium non-ionized\n 7.4 mg/dL\n 02:20 AM\n Phosphorus\n 4.4 mg/dL\n 02:20 AM\n Magnesium\n 2.1 mg/dL\n 02:20 AM\n WBC\n 59.7 K/uL\n 02:20 AM\n Hgb\n 10.3 g/dL\n 02:20 AM\n Hematocrit\n 34.1 %\n 02:20 AM\n Current diet order / nutrition support: Diet: NPO\n GI: soft/distended, positive bowel sounds\n Assessment of Nutritional Status\n Obese\n Patient at risk due to: NPO\n Estimated Nutritional Needs\n Calories: 1420-1775 (20-25 cal/kg)\n Protein: 85-106 (1.2-1.5 g/kg)\n Fluid: 1420-1775 ml\n Calculations based on: Adjusted weight\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n 67 YO female admitted after 1 weeks of SOB at \n facility. CXR showed large right PNA. Intubated overnight. Concern\n for acute versus chronic kidney injury, however improved significantly\n with hydration. Consulted for tube feed recommendations.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations:\n o Begin Replete with Fiber @ 25ml/hr, advance as tolerated to\n goal of 65ml/hr = 1560 calories and 97g protein\n Check residuals, hold tube feed if greater than 200ml\n Multivitamin / Mineral supplement: in tube feed\n Check chemistry 10 panel daily\n BS management, especially with initiation of enteral\n nutrition\n Will follow, page if questions *\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726319,
"text": "67 y/o pt with longstanding history of severe COPD, chronic bronchitis,\n emphysema and chronic asthma. Pt lives in an facility\n and had been c/o SOB x 1 wk. EMS found pt to have a 70% o2 sat on RA.\n Placed on NRB and given nebs. Also found to be tachypnic to the 40's\n with obvious increased WOB. CXR significant for large rt sided PNA.\n Given Azithromycin, Ceftriaxone, nebs and steroids in ED- admitted to\n MICU for further observation.\n Sepsis without organ dysfunction\n Assessment:\n WBC 59 w/ normal lactate. Afebrile. Rec\nd pt on 0.1mcg/kg/min levophed\n gtt. SBP ranging 89-100s. MAPs >60. Sputum with GPC in pairs. Rec\n 8L NS bolus for hypotension o/n. CVP ranging . CXR showing white\n out of right lung, sxning q4h for mod. Amounts of yellow thick sputum.\n Action:\n Titrating levophed gtt to MAPs > 60. See metavision for specifics. On\n abx vanco, cefepime, azithromycin. Chest PT and turning q2h on left\n side with bad lung up.\n Response:\n Currently maintaing MAPs > 60 on levophed 0.06 mcgs/kg/min.\n Plan:\n Titrate levophed as per BP. Follow lytes and replace as needed. Cont.\n antibx, f/u culture data. ? bronch for clean out and spec.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt admitted w/ severe COPD and pneumonia. Received pt vented on 80%\n 450/24/5 peep. Pt is auto-peeping around 9. Rec\nd pt on 2 mg/hr\n versed gtt and 100mcg/kg/min fentanyl gtt- pt easily arousable and\n following commands on this amount of sedation. Nodding\n when\n asked if in pain. LS diminished t/o with intermittent insp./exp.\n Wheezing t/o.\n Action:\n Multiple ABG\ns sent, please see metavision for specifics. ABGs with\n resp. acidosis. Mult. Vent. Changes made. Increased sedation to\n 125mcg/kg/min fentanyl, and 3 mg/hr versed gtts for auto-peeping and\n pain. On antibx, stress dose steroids, and on frequent nebs via\n respiratory.\n - Pt with one episode of acute desaturation to low 80%, LS wheezy t/o,\n sxned ,nebs, vent increased to 100% and 10 peep. Pt noted to take\n awhile to recover, MD aware. ABG with PaO2 60 during this episode.\n Response:\n Pt is no longer auto-peeping, able to wean vent back down to 70%-\n maintaining sats > 90% on current vent settings- 70% 450/24/10.\n Remains sedated on fentanyl 125 mcgs/kg/min and versed @ 3mg/hr. WBC\n remains elevated despite antibx. TF initiated for nutrition this shift\n with goal TF 65cc/hr.\n Plan:\n Check frequent ABG. Follow sats. ? repeat CT chest to eval. For\n malignant process on top of pna with elevated WBCs. Cont. to titrate\n TF as tolerated with goal 65cc/hr.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726266,
"text": "67 y/o pt with longstanding history of severe COPD, chronic bronchitis,\n emphysema and chronic asthma. Pt lives in an facility\n and had been c/o SOB x 1 wk. EMS found pt to have a 70% o2 sat on RA.\n Placed on NRB and given nebs. Also found to be tachypnic to the 40's\n with obvious increased WOB. CXR significant for large rt sided PNA.\n Given Azithromycin, Ceftriaxone, nebs and steroids in ED- admitted to\n MICU for further observation.\n Sepsis without organ dysfunction\n Assessment:\n WBC 59 w/ normal lactate. Afebrile. Rec\nd pt on 0.1mcg/kg/min levophed\n gtt. SBP ranging 89-100s. MAPs >60. Sputum with GPC in pairs. Rec\n 8L NS bolus for hypotension o/n. CVP ranging . CXR showing white\n out of right lung, sxning q4h for mod. Amounts of yellow thick sputum.\n Action:\n Titrating levophed gtt to MAPs > 60. See metavision for specifics. On\n abx vanco, cefepime, azithromycin. Chest PT and turning q2h on left\n side with bad lung up.\n Response:\n Currently maintaing MAPs > 60 on levophed 0.06 mcgs/kg/min.\n Plan:\n Titrate levophed as per BP. Follow lytes and replace as needed. Cont.\n antibx, f/u culture data. ? bronch for clean out and spec.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt admitted w/ severe COPD and pneumonia. Received pt vented on 80%\n 450/24/5 peep. Pt is auto-peeping around 9. Rec\nd pt on 2 mg/hr\n versed gtt and 100mcg/kg/min fentanyl gtt- pt easily arousable and\n following commands on this amount of sedation. Nodding\n when\n asked if in pain. LS diminished t/o with intermittent insp./exp.\n Wheezing t/o.\n Action:\n Multiple ABG\ns sent, please see metavision for specifics. ABGs with\n resp. acidosis. Mult. Vent. Changes made. Increased sedation to\n 125mcg/kg/min fentanyl, and 3 mg/hr versed gtts for auto-peeping and\n pain. On antibx, stress dose steroids, and on frequent nebs via\n respiratory.\n - Pt with one episode of acute desaturation to low 80%, LS wheezy t/o,\n sxned ,nebs, vent increased to 100% and 10 peep. Pt noted to take\n awhile to recover, MD aware. ABG with PaO2 60 during this episode.\n Response:\n Pt is no longer auto-peeping, able to wean vent back down to 70%-\n maintaining sats > 90% on current vent settings- 70% 450/24/10.\n Remains sedated on fentanyl 125 mcgs/kg/min and versed @ 3mg/hr. WBC\n remains elevated despite antibx. TF initiated for nutrition this shift\n with goal TF 65cc/hr.\n Plan:\n Check frequent ABG. Follow sats. ? repeat CT chest to eval. For\n malignant process on top of pna with elevated WBCs. Cont. to titrate\n TF as tolerated with goal 65cc/hr.\n -+\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726243,
"text": "67 y/o pt with longstanding history of severe COPD, chronic bronchitis,\n emphysema and chronic asthma. Pt lives in an facility\n and had been c/o SOB x 1 wk. EMS found pt to have a 70% o2 sat on RA.\n Placed on NRB and given nebs. Also found to be tachypnic to the 40's\n with obvious increased WOB. CXR significant for large rt sided PNA.\n Given Azithromycin, Ceftriaxone, nebs and steroids in ED- admitted to\n MICU for further observation.\n Sepsis without organ dysfunction\n Assessment:\n WBC 59 w/ normal lactate. Afebrile. Rec\nd pt on 0.1mcg/kg/min levophed\n gtt. SBP ranging 89-100s. MAPs >60. Sputum with GPC in pairs. Rec\n 8L NS bolus for hypotension o/n. CVP ranging . CXR showing white\n out of right lung, sxning q4h for mod. Amounts of yellow thick sputum.\n Action:\n Titrating levophed gtt to MAPs > 60. See metavision for specifics. On\n abx vanco, cefepime, azithromycin. Chest PT and turning q2h on left\n side with bad lung up.\n Response:\n Currently maintaing MAPs > 60 on levophed 0.06 mcgs/kg/min.\n Plan:\n Titrate levophed as per BP. Follow lytes and replace as needed. Cont.\n antibx, f/u culture data. ? bronch for clean out and spec.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt admitted w/ severe COPD and pneumonia. Received pt vented on 80%\n 450/24/5 peep. Pt is auto-peeping around 9. Rec\nd pt on 2 mg/hr\n versed gtt and 100mcg/kg/min fentanyl gtt- pt easily arousable and\n following commands on this amount of sedation. Nodding\n when\n asked if in pain. LS diminished t/o with intermittent insp./exp.\n Wheezing t/o.\n Action:\n Multiple ABG\ns sent, please see metavision for specifics. ABGs with\n resp. acidosis. Mult. Vent. Changes made. Increased sedation to\n 125mcg/kg/min fentanyl, and 3 mg/hr versed gtts for auto-peeping and\n pain. On antibx, stress dose steroids, and on frequent nebs via\n respiratory.\n Response:\n Pt is no longer auto-peeping, maintaining sats > 90% on current vent\n settings- 80% 450/24/10. Remains sedated on fentanyl 125 mcgs/kg/min\n and versed @ 3mg/hr. WBC remains elevated despite antibx.\n Plan:\n Check frequent ABG. Follow sats. ? repeat CT chest to eval. For\n malignant process on top of pna with elevated WBCs.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726110,
"text": "67 y/o pt with longstanding history of severe COPD, chronic bronchitis,\n emphysema and chronic asthma. Pt lives in an facility\n and had been c/o SOB x 1 wk. EMS found pt to have a 70% o2 sat on RA.\n Placed on NRB and given nebs. Also found to be tachypnic to the 40's\n with obvious increased WOB. CXR significant for large rt sided PNA.\n Given Azithromycin, Ceftriaxone, nebs and steroids in ED- admitted to\n MICU for further observation.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n BBS= exp/ins wheezing noted in all lung fields. Arrived on 100% NRB.\n No complaints of SOB although appears tachypnic with RR in the 40\n SP02 > or = to 97%. Had received vanco, ceftriazone and azithromycin\n prior to arrival to MICU.\n Action:\n Weaned to 4L NC and 100% OFM.\n Response:\n Tolerating well.\n Plan:\n Continue abx, sputum culture. Goal for SP02 > or = to 90%.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726230,
"text": "67 y/o pt with longstanding history of severe COPD, chronic bronchitis,\n emphysema and chronic asthma. Pt lives in an facility\n and had been c/o SOB x 1 wk. EMS found pt to have a 70% o2 sat on RA.\n Placed on NRB and given nebs. Also found to be tachypnic to the 40's\n with obvious increased WOB. CXR significant for large rt sided PNA.\n Given Azithromycin, Ceftriaxone, nebs and steroids in ED- admitted to\n MICU for further observation.\n Sepsis without organ dysfunction\n Assessment:\n WBC 59 w/ normal lactate. Afebrile. Rec\nd pt on 0.1mcg/kg/min levophed\n gtt. SBP ranging 89-100s. MAPs >60. Sputum with GPC in pairs. Rec\n 8L NS bolus for hypotension o/n. CVP ranging . CXR showing white\n out of right lung, sxning q4h for mod. Amounts of yellow thick sputum.\n Action:\n Titrating levophed gtt to MAPs > 60. See metavision for specifics. On\n abx vanco, cefepime, azithromycin. Chest PT and turning q2h on left\n side with bad lung up.\n Response:\n Currently maintaing MAPs > 60 on levophed 0.06 mcgs/kg/min.\n Plan:\n Titrate levophed as per BP. Follow lytes and replace as needed. Cont.\n antibx, f/u culture data. ? bronch for clean out and spec.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt admitted w/ severe COPD and pneumonia. Received pt vented on 80%\n 450/24/5 peep. Pt is auto-peeping around 9. Rec\nd pt on 2 mg/hr\n versed gtt and 100mcg/kg/min fentanyl gtt- pt\n Action:\n Multiple ABG\ns done her acidosis was progressing worse and Intubated\n around 2315pm . Started on propofol @ 30mics/kg/min but pt cont to\n drop BP and sedation changed to fentanyl and versed. Multiple vent\n changes and ABG done shows resp acidosis.\n Response:\n Vent setting are AC/450/24/5. sedated on fentanyl 10mics/min and versed\n @ 2mg/hr. WBC bump for 56 to 59.\n Plan:\n Check frequent ABG.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726231,
"text": "67 y/o pt with longstanding history of severe COPD, chronic bronchitis,\n emphysema and chronic asthma. Pt lives in an facility\n and had been c/o SOB x 1 wk. EMS found pt to have a 70% o2 sat on RA.\n Placed on NRB and given nebs. Also found to be tachypnic to the 40's\n with obvious increased WOB. CXR significant for large rt sided PNA.\n Given Azithromycin, Ceftriaxone, nebs and steroids in ED- admitted to\n MICU for further observation.\n Sepsis without organ dysfunction\n Assessment:\n WBC 59 w/ normal lactate. Afebrile. Rec\nd pt on 0.1mcg/kg/min levophed\n gtt. SBP ranging 89-100s. MAPs >60. Sputum with GPC in pairs. Rec\n 8L NS bolus for hypotension o/n. CVP ranging . CXR showing white\n out of right lung, sxning q4h for mod. Amounts of yellow thick sputum.\n Action:\n Titrating levophed gtt to MAPs > 60. See metavision for specifics. On\n abx vanco, cefepime, azithromycin. Chest PT and turning q2h on left\n side with bad lung up.\n Response:\n Currently maintaing MAPs > 60 on levophed 0.06 mcgs/kg/min.\n Plan:\n Titrate levophed as per BP. Follow lytes and replace as needed. Cont.\n antibx, f/u culture data. ? bronch for clean out and spec.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt admitted w/ severe COPD and pneumonia. Received pt vented on 80%\n 450/24/5 peep. Pt is auto-peeping around 9. Rec\nd pt on 2 mg/hr\n versed gtt and 100mcg/kg/min fentanyl gtt- pt easily arousable and\n following commands on this amount of sedation. Nodding\n when\n asked if in pain.\n Action:\n Multiple ABG\ns sent, please see metavision for specifics. ABGs with\n resp. acidosis. Mult. Vent. Changes made. Increased sedation to\n 125mcg/kg/min fentanyl, and 3 mg/hr versed gtts for auto-peeping and\n pain. On antibx, stress dose steroids, and on frequent nebs via\n respiratory.\n Response:\n Pt is no longer auto-peeping, maintaining sats > 90% on current vent\n settings. Remains sedated on fentanyl 125 mcgs/kg/min and versed @\n 3mg/hr. WBC remains elevated despite antibx.\n Plan:\n Check frequent ABG. Follow sats. ? repeat CT chest to eval. For\n malignant process on top of pna with elevated WBCs.\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 726235,
"text": "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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation\n 24 Hour Events:\n Intubated for progressive failure overnight, as per admission notes.\n Started on norepi gtt for fluid-unresponsive hypotension.\n Persistent autoPEEP of 9 noted.\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Cefipime - 08:30 PM\n Vancomycin - 07:48 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 11:55 PM\n Other medications:\n Serevent , SoluMedrol 40 q8, Heparin sc tid, Colace, azithromycin\n qd, Atrovent q6, Albuterol q2, famotidine, Peridex,\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 09:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 74 (72 - 99) bpm\n BP: 107/61(77) {98/50(66) - 108/61(77)} mmHg\n RR: 24 (0 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 14 (14 - 14)mmHg\n Total In:\n 3,316 mL\n 5,560 mL\n PO:\n TF:\n IVF:\n 3,316 mL\n 5,500 mL\n Blood products:\n Total out:\n 120 mL\n 495 mL\n Urine:\n 120 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,196 mL\n 5,065 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (350 - 450) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 80%\n RSBI Deferred: FiO2 > 60%\n PIP: 32 cmH2O\n Plateau: 29 cmH2O\n Compliance: 22.5 cmH2O/mL\n SpO2: 95%\n ABG: 7.21/57/75/21/-5\n Ve: 11.3 L/min\n PaO2 / FiO2: 94\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : left, Crackles : right\n laterally, Rhonchorous: on right)\n Abdominal: Soft, Non-tender, Bowel sounds present, reducible ventral\n hernia present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Movement: Not assessed, Sedated, Tone: Normal\n Labs / Radiology\n 10.3 g/dL\n 319 K/uL\n 174 mg/dL\n 1.4 mg/dL\n 21 mEq/L\n 4.7 mEq/L\n 50 mg/dL\n 113 mEq/L\n 146 mEq/L\n 34.1 %\n 59.7 K/uL\n [image002.jpg]\n 06:52 PM\n 10:50 PM\n 12:54 AM\n 02:05 AM\n 02:20 AM\n 04:36 AM\n 06:37 AM\n WBC\n 59.7\n Hct\n 34.1\n Plt\n 319\n Cr\n 1.4\n TCO2\n 29\n 29\n 27\n 38\n 24\n 24\n Glucose\n 174\n Other labs: PT / PTT / INR:11.6/27.4/1.0, Differential-Neuts:92.0 %,\n Band:5.0 %, Lymph:2.0 %, Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.4 mmol/L,\n Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:4.4 mg/dL\n Imaging: CXR- panlobar R-sided opacification, LLL atelectasis vs\n infiltrate\n Microbiology: Sputum- GPC in pairs\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia. Prior partial RUL\n collapse from will need further evaluation down the road and might\n have predisposed to current pna\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -stay as close to ARDSnet ventilation as acidemia allows, currently at\n about 8-9cc/kg for Vt\n -wean FiO2 to maintain PaO2 > 60\n -tolerate autoPEEP for now as Pplat < 30 and hemodyn stable\n -vanco + cefepime + azithro (change to IV) for now\n -f/u GPCs in sputum, other cx data\n -tx COPD exac w/ Solu-Medrol --> incr to 125 q8 and scheduled nebs\n -will need CT scan at some point to re-evaluate\n 2. Shock- likely multifactorial, sepsis vs meds\n -recent echo w/ nl echo\n -CVP goal, MAP goals reached; wean norepi gtt as tolerated\n -might become more conservative w/ fluids (will use LR given high Cl)\n given high FiO2 req't and little gross pulse pressure variation or CVP\n variation\n 3. ARF- supportive mgmt, due to #2 as above\n ICU Care\n Nutrition:\n Comments: start tube feeds today\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 05:47 PM\n 18 Gauge - 04:00 AM\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n Prophylaxis:\n DVT: SQ UF Heparin\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: 45 minutes\n Patient is critically ill\n ------ Protected Section ------\n Patient seen and examined with Dr. , and house staff team.\n I have reviewed his note and agree with assessment and plan. Would\n add/emphasize.\n 67 yo women with COPD, admitted with respiratory failure. CXR with\n multifocal PNA including in area of RUL where he has chronic collapse.\n Was intubated in ICU, required Levophed which has weaned down with\n aggressive IVF. Still requiring hi FiO2 (0.65) but has come down\n somewhat.\n Exam notable for coarse rales throughout right lung. Diminished BS on\n left.\n WBC 60K\n 7.26/49/68\n A/P:\n Respiratory failure: ph improved. Continue current vent setting.\n Severe PNA is cause of hypoxemia and respiratory failure on background\n of severe COPD. Continue steroids and nebs.\n Sputum with GPCs on gram stain so continue vanco.\n Septic shock: still requiring pressors but have weaned down.\n Acute renal failure: likely due to sepsis/pre-renal. Unclear baseline.\n CC45 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 12:18 ------\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-26 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 726130,
"text": "Chief Complaint:\n HPI:\n Ms. is a 67 yo woman COPD on home O2, currently admitted to\n MICU with SOB. She was at baseline at her facility\n until approximately one week ago. Baseline consists of 2L O2 at rest\n and 4L with exertion, able to walk across the room without SOB but mild\n dyspnea with further exertion, no chronic cough. For the past week she\n has noticed new mildly productive cough and progressive SOB with\n exertion around the room. Of note, she ran out of her tiotropium\n inhaler 3 days prior to admission. On the day of admisison, patient\n was found by the nurse at her facility to be Her VNA\n found her to be hypoxic to 70s on RA. She was given 2 nebs without\n significant improvement, so EMS was activated.\n .\n In the ED, initial VS BP 106/66, HR 94, RR 36, O2 Sat 96% on NRB.\n She received albuterol/ipratropium nebulizers, azithromycin 500 mg, and\n solumedrol 125 mg for presumed COPD exacerbation. CXR demonstrated\n R-sided multilobar pneumonia; thus, 1g ceftriaxone and 1g vancomycin\n were administered. After a total 5 combination nebulizers followed by\n albuterol nebulizers every 15 minutes, she remained quite tachypneic\n and uncomfortable, with RR >30 and NRB O2 requirement. She was\n admitted to the MICU for further managment.\n VS prior to transfer: HR 97, RR 32, BP 101/54, 97% on NRB\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 05:51 PM\n Infusions:\n Other ICU medications:\n Medications at home:\n oxygen 4L with exertion, 2L at rest\n albuterol 90 mcg HFA 2 puffs q6h prn\n amlodipine 10 mg daily\n captopril 25 mg tid\n fluticasone-salmeterol (advair) 500-50 1 puff \n omeprazole 20 mg daily\n tiotropium 18 mcg capsule qd\n acetaminophen 1g tid\n Ca/D\n simethicone 250 mg tid\n Past medical history:\n Family history:\n Social History:\n 1. COPD\n 2. Stab wound in leading to splenectomy and partial\n pancreatectomy.\n 3. Esophageal reflux.\n 4. Intracerebral hemorrhage as a consequence of a hypertensive\n crises, needing craniotomy and a ventricular peritoneal shunt in\n the craniotomy. She has a ventricular peritoneal shunt in place.\n 5. Left hip replacement.\n 6. Hypertension\n 7. Longstanding lower extremity swelling.\n 8. Partial R upper lobe collapse noted in , confirmed by\n CT. PET was negative for any sign of malignancy. A subsequent chest\n x-ray showed improvement.\n No history of lung disease\n She currently lives in . She quit smoking 15 years\n ago and had a roughly 40 pack year history. She denies any known\n exposure to asbestos or relevant toxic dust or fumes.\n Review of systems:\n Negative except as above\n Flowsheet Data as of 08:40 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 90 (90 - 99) bpm\n BP: 89/45(55) {89/45(55) - 100/51(63)} mmHg\n RR: 24 (24 - 27) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 1,228 mL\n PO:\n TF:\n IVF:\n 1,228 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 1,228 mL\n Respiratory\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 91%\n ABG: 7.25/63/71//0\n PaO2 / FiO2: 71\n Physical Examination\n VS: T 97.6, HR 99, BP 96/50, O2 97% on 50% FM\n GEN: moderate respiratory distress, speaking in 3 word phrases, pursed\n lipped breathing, + accessory muscle use\n SKIN: No rashes or skin changes noted\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender\n EXTREMITIES: trace bilaterally pitting edema\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact.\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A3/1/ 06:52 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 29\n Other labs: Lactic Acid:1.0 mmol/L\n LABORATORY DATA:\n chem7: 145/3.8/105/27/58/1.8<146\n CBC: 56.4 (84% PMN, 7% bands)>10.4/33.1<293\n Cx data pending\n .\n STUDIES:\n Most recent PFTs show FEV1 28% predicted, FEV1/FVC 77%\n predicted, MMF 12% predicted.\n .\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n .\n # Pneumonia: Multilobar infiltrates on CXR. Labs with significant\n leukocytosis and L shift, likely indicative of bacterial infection.\n Afebrile currently, although report of \"chills\" at home. Current SBP\n 95-105 is likely low for patient (SBP 120-150 in clinic notes) and may\n be a signal of impending sepsis. Regarding the pneumonia itself, given\n history of idiopathic RUL collapse in , it is possible that she\n has some sort of endobronchial lesion (? malignancy given smoking hx)\n contributing. In any case, because of her very severe baseline\n obstructive disease, she is in a very tenuous respiratory place right\n now.\n - vancomycin, cefepime, and azithromycin for broad bacterial coverage\n including atypical pathogens. (Lives in facility,\n chronic respiratory disease so will treat as if HCAP.)\n - blood cx\n - sputum cx\n - urinary legionella antigen\n - IVF - will give 1 L NS bolus now and continuing with goal MAP >65,\n goal uop >35 cc/h. Previous echo with NL EF.\n - repeat CXR in AM (will get PA/Lat for better visualization)\n - serial ABG (will not repeat overnight unless O2 Saturation falls)\n - trend WBC (will be complicated by steroids)\n - discuss with Dr. whether CT and/or bronchoscopy may be\n indicated for better visualization of possible endobronchial lesion\n that may be contributing to recurrent pathology in that lobe\n .\n # COPD: very severe COPD with FEV1 <30% predicted. No history\n intubation. Currently very tachypneic with poor air movement.\n - serial ABG as above\n - methylprednisolone 40 mg q8h (will hold off on 125mg given\n concominant infecitious picture)\n - fluticasone inh\n - albuterol nebs q1h for now, decrease to q6h as tolerated\n - ipratropium nebs q6h\n - may require intubation if tires\n .\n # hx hypertension: borderline hypotensive currently\n - hold all antihypertensives\n .\n # kidney injury: unclear whether acute or chronic (no baseline labs,\n but no recorded history of renal insufficiency.) She may be prerenal\n in the setting of lower than normal perfusion pressure\n - check urine lytes\n - trend creatinine\n - avoid nephrotoxins\n .\n .\n # FEN: IVF boluses / replete lytes prn / npo for now\n # PPX: PPI per home regimen, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , patient does not know # and none in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 729088,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, Now\n extubated () and improving\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received the pt on NC 4L with sat 94%, LS ronchies with occass exp\n wheezing.coopertaive with care\n Action:\n Received MDI\ns,contd on prednisone,on sliding scale,\n Response:\n Satting 92-94%on 4l...much more interactive and co operative with care,\n Plan:\n Wean o2 as tolerated,cont prednisone taper,valium for anxiety,OOB\n daily,PT consult on board.\n Hypernatremia (high sodium) with low urine output.\n Assessment:\n Recived on NS 125cc/hr for poor po intact( last NA 147.\n Action:\n started on regular diet, encouraged PO intake, taking po good\n Response:\n Pt had excellent PO intake,no signs of asipartion,,,feeling thirsty and\n requesting water,uop slowly rising. Evening Na 142\n Plan:\n Will follow the Na level daily,encourage PO intake,follow I/O,\n Pt has foley leak, changed foley to 16fr, no leak notes\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 729079,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, Now\n extubated () and improving\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 729080,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, Now\n extubated () and improving\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received the pt on NC 4L with sat 94%, LS ronchies with occass exp\n wheezing.\n Action:\n Received MDI\ns,contd on prednisone,on sliding scale, o2 weaned to 4L\n nc,received valium for anxiety/restlessness\n Response:\n Satting 92-94%on 4l...much more interactive and co operative with\n care\nwas OOB to the chair ~4 hrs,\n Plan:\n Wean o2 as tolerated,cont prednisone taper,valium for anxiety,OOB\n daily,PT consult on board.\n Hypernatremia (high sodium) with low urine output.\n Assessment:\n Am labs with Na 147, with poor po intake,UOP dropped to this noon,(was\n on lasix drip till yesterday)\n Action:\n Started n NS @125cc/hr x1L,started on regular diet, encouraged PO\n intake\n Response:\n Pt had excellent PO intake,no signs of asipartion,,,feeling thirsty and\n requesting water,uop slowly rising\n Plan:\n Will follow the Na level daily,encourage PO intake,follow I/O,\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 729135,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, Now\n extubated () and improving\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received the pt on NC 4L with sat 94%, LS ronchies with occass exp\n wheezing.coopertaive with care\n Action:\n Received MDI\ns,contd on prednisone,on sliding scale,\n Response:\n Satting 92-94%on 4l...much more interactive and cooperative with care,\n Plan:\n Wean o2 as tolerated,cont prednisone taper,valium for anxiety,OOB\n daily,PT consult on board.\n Hypernatremia (high sodium) with low urine output.\n Assessment:\n Recived on NS 125cc/hr for poor po intact( last NA 147.\n Action:\n started on regular diet, encouraged PO intake, taking po good\n Response:\n Pt had excellent PO intake,no signs of asipartion,,,feeling thirsty and\n requesting water,uop slowly rising. Evening Na 142. morning NA 141/\n u/o 35-45cc/hr, MD ok.\n Plan:\n Will follow the Na level daily,encourage PO intake,follow I/O,\n Pt has foley leak, changed foley to 16fr, around 0500 leak was notes,\n changed foley to 18fr, please cont to folow.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 729145,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, Now\n extubated () and improving\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received the pt on NC 4L with sat 94%, LS ronchies with occass exp\n wheezing.coopertaive with care\n Action:\n Received MDI\ns,contd on prednisone,on sliding scale,\n Response:\n Satting 92-94%on 4l...much more interactive and cooperative with care,\n Plan:\n Wean o2 as tolerated,cont prednisone taper,valium for anxiety,OOB\n daily,PT consult on board.\n Hypernatremia (high sodium) with low urine output.\n Assessment:\n Recived on NS 125cc/hr for poor po intact( last NA 147.\n Action:\n started on regular diet, encouraged PO intake, taking po good\n Response:\n Pt had excellent PO intake,no signs of asipartion,,,feeling thirsty and\n requesting water,uop slowly rising. Evening Na 142. morning NA 141/\n u/o 35-45cc/hr, MD ok.\n Plan:\n Will follow the Na level daily,encourage PO intake,follow I/O,\n Pt has foley leak, changed foley to 16fr, around 0500 leak was notes,\n changed foley to 18fr, please cont to follow.\n"
},
{
"category": "Nutrition",
"chartdate": "2192-04-10 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 729259,
"text": "Subjective\n Reports good appetite, no difficulty swallowing. Denies N/V\n Objective\n Height\n Admit weight\n Daily weight\n 170 cm\n 100.9 kg\n 90.1 kg ( 08:00 AM)\n Pertinent medications: Humalog insulin sliding scale, Colace, Heparin,\n Pantoprazole, Normal saline @ 10ml/hr\n Labs:\n Value\n Date\n Glucose\n 96 mg/dL\n 03:27 AM\n Glucose Finger Stick\n 171\n 12:00 PM\n BUN\n 52 mg/dL\n 03:27 AM\n Creatinine\n 1.0 mg/dL\n 03:27 AM\n Sodium\n 141 mEq/L\n 03:27 AM\n Potassium\n 3.9 mEq/L\n 03:27 AM\n Chloride\n 101 mEq/L\n 03:27 AM\n TCO2\n 33 mEq/L\n 03:27 AM\n PO2 (arterial)\n 131 mm Hg\n 12:51 PM\n PO2 (venous)\n 42 mm Hg\n 09:59 AM\n PCO2 (arterial)\n 54 mm Hg\n 12:51 PM\n PCO2 (venous)\n 65 mm Hg\n 04:39 AM\n pH (arterial)\n 7.46 units\n 12:51 PM\n pH (venous)\n 7.16 units\n 04:39 AM\n pH (urine)\n 6.0 units\n 07:39 PM\n CO2 (Calc) arterial\n 40 mEq/L\n 12:51 PM\n CO2 (Calc) venous\n 24 mEq/L\n 04:39 AM\n Albumin\n 3.0 g/dL\n 03:58 AM\n Calcium non-ionized\n 9.0 mg/dL\n 03:27 AM\n Phosphorus\n 3.6 mg/dL\n 03:27 AM\n Ionized Calcium\n 1.13 mmol/L\n 03:14 AM\n Magnesium\n 2.2 mg/dL\n 03:27 AM\n ALT\n 29 IU/L\n 03:58 AM\n Alkaline Phosphate\n 103 IU/L\n 03:58 AM\n AST\n 13 IU/L\n 03:58 AM\n Total Bilirubin\n 0.2 mg/dL\n 03:58 AM\n WBC\n 16.9 K/uL\n 03:27 AM\n Hgb\n 9.3 g/dL\n 03:27 AM\n Hematocrit\n 28.4 %\n 03:27 AM\n Current diet order / nutrition support: Diet: Heart healthy/diabetic\n GI: soft, positive bowel sounds, positive flatus; small bm x2 \n Assessment of Nutritional Status\n Specifics:\n 67 YO woman with a history of very severe COPD with PNA/ARDS, now\n extubated after prolonged intubation. Tube feed discontinued and diet\n advanced . Patient tolerating po\ns well with good appetite. RN\n notes also report excellent po\ns. Stooling. BS well\n controlled. Patient at low nutrition risk at this time.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: continue to\n encourage po\ns/fluids\n Check chemistry 10 panel daily\n BS management\n Will follow, page if questions *\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728599,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt cont to do well on high flow nebs , Is intermittently having some\n c/o SOB but it looks more like a anxiety attach as she calms down when\n you ask her to do some C&DB and clr her throat\n Action:\n Pt cont on her inhalers, Encouraged to C&DB-clr throat, Cont on lasix\n drip\n Response:\n Has cont to have good ABG for her, Diuresed 2.5l of fluid\n Plan:\n Cont with inhalers and address her needs as able\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727918,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:18 AM\n -decreasing PEEP down to 10, PaO2 OK but CO2 rising-->increased rate\n but gas not improved-->going back up on PEEP\n -BP borderline, 1.5 L negative but had to go down on the lasix gtt\n because of borderline BP\n -lost arterial line\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.6\nC (97.8\n HR: 71 (60 - 79) bpm\n BP: 90/42(54) {90/42(54) - 90/42(54)} mmHg\n RR: 18 (17 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,325 mL\n 313 mL\n PO:\n TF:\n 840 mL\n 189 mL\n IVF:\n 865 mL\n 124 mL\n Blood products:\n Total out:\n 3,620 mL\n 800 mL\n Urine:\n 3,620 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,295 mL\n -487 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n Plateau: 11 cmH2O\n Compliance: 350 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/73./105/45/16\n Ve: 6.9 L/min\n PaO2 / FiO2: 210\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: no edema, no sacral edema\n Labs / Radiology\n 478 K/uL\n 9.7 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 45 mEq/L\n 5.1 mEq/L\n 61 mg/dL\n 95 mEq/L\n 143 mEq/L\n 31.0 %\n 21.0 K/uL\n [image002.jpg]\n 03:59 AM\n 04:03 AM\n 12:58 AM\n 03:59 AM\n 10:04 AM\n 12:37 PM\n 02:56 PM\n 11:01 PM\n 02:46 AM\n 03:07 AM\n WBC\n 24.7\n 21.5\n 21.0\n Hct\n 29.6\n 29.3\n 31.0\n Plt\n \n Cr\n 0.9\n 0.8\n 0.9\n TCO2\n 47\n 49\n 47\n 41\n 46\n 46\n 47\n Glucose\n 114\n 107\n 137\n 115\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/,\n continues to be intubated/sedated.\n # Respiratory failure: Day 10 of intubation today for multilobar\n pneumonia & COPD c/b . Difficult to oxygenate without high\n PEEP/FIO2. I/O neg 1.3 L on furosemide gtt. Bedside u/s showed no\n tappable effusion. Attempt to diurese 1-2 liters again today and plan\n on weaning PEEP as tolerated.\n - continue lasix gtt, plan for goal I/O negative 1 liter-2liter\n - PM lytes\n - continue acetazolamide\n - continue prednisone to 30mg daily for 2 more days\n -attempt A line replacement\n - problem is , PNA has been treated fully, monitor temp and\n WBC\n .\n # Alkalosis: secondary to aggressive diuresis\n - continue acetazolamide as above\n .\n # Hx of hypertension: now normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds (will concentrate\n to assist with tube feeds)\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-05 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727919,
"text": "Chief Complaint:\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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 24 Hour Events:\n a line out this am.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:01 AM\n Other medications:\n Atrovent, Pantoprazole, Peridex, RISS, PO Narcan, Diamox 500 q6\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.6\nC (97.8\n HR: 69 (62 - 79) bpm\n BP: 88/50(60) {86/42(54) - 100/57(67)} mmHg\n RR: 19 (17 - 22) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,326 mL\n 830 mL\n PO:\n TF:\n 841 mL\n 362 mL\n IVF:\n 865 mL\n 218 mL\n Blood products:\n Total out:\n 3,620 mL\n 1,400 mL\n Urine:\n 3,620 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,294 mL\n -570 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 20 cmH2O\n Compliance: 47.3 cmH2O/mL\n SpO2: 92%\n Ve: 6.2 L/min\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress\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 : ant, No(t) Crackles : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.7 g/dL\n 478 K/uL\n 115 mg/dL\n 0.9 mg/dL\n 45 mEq/L\n 5.1 mEq/L\n 61 mg/dL\n 95 mEq/L\n 143 mEq/L\n 31.0 %\n 21.0 K/uL\n [image002.jpg]\n 04:03 AM\n 12:58 AM\n 03:59 AM\n 10:04 AM\n 12:37 PM\n 02:56 PM\n 11:01 PM\n 02:46 AM\n 03:07 AM\n 05:31 AM\n WBC\n 21.5\n 21.0\n Hct\n 29.3\n 31.0\n Plt\n 432\n 478\n Cr\n 0.8\n 0.9\n TCO2\n 47\n 49\n 47\n 41\n 46\n 46\n 47\n 48\n Glucose\n 107\n 137\n 115\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR- decreased effusions\n Microbiology: Sputum - yeast\n All blood cx neg to date\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ . Slow and\n steady decrease in PEEP req't.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -cont ARDSnet ventilation --> A/CV w/ 6cc/kg Vt and permissive\n hypercapnia, tolerating pH down to 7.20\n -wean FiO2 and PEEP to maintain PaO2 > 60\n -day 10 intubation at this point, if PEEP <8 tomorrow will assess for\n spont breathing\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n increase azetazolamide to help w/ HCO3 wasting in the setting of\n contraction alkalosis\n -will concentrate IVF and tube feeds\n -steroids weaning to 20 qd tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:33 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Comments: attempt to replace aline\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728597,
"text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt cont to do well on high flow nebs , Is intermittently having some\n c/o SOB but it looks more like a anxiety attach as she calms down when\n you ask her to do some C&DB and clr her throat\n Action:\n Pt cont on her inhalers, Encouraged to C&DB-clr throat, Cont on lasix\n drip\n Response:\n Has cont to have good ABG for her, Diuresed 2.5l of fluid\n Plan:\n Cont with inhalers and address her needs as able\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727709,
"text": "Chief Complaint:\n 24 Hour Events:\n -negative 1.4 liters at noon, lasix drip decreased to 8mg/hr\n -PEEP decreased from 16 to 14\n -ultrasound w/ minimal effusions\n -antibiotics discontinued and prednisone weaned to 30mg daily (from\n 40mg daily)\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 09:03 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 10:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.6\nC (97.8\n HR: 76 (60 - 79) bpm\n BP: 101/53(67) {91/48(63) - 108/75(83)} mmHg\n RR: 21 (16 - 22) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,898 mL\n 954 mL\n PO:\n TF:\n 1,168 mL\n 369 mL\n IVF:\n 1,050 mL\n 305 mL\n Blood products:\n Total out:\n 4,550 mL\n 1,330 mL\n Urine:\n 4,450 mL\n 1,330 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -1,652 mL\n -376 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 91%\n ABG: 7.43/68/57/49/16\n Ve: 7.8 L/min\n PaO2 / FiO2: 114\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 432 K/uL\n 9.2 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 49 mEq/L\n 3.9 mEq/L\n 55 mg/dL\n 91 mEq/L\n 143 mEq/L\n 29.3 %\n 21.5 K/uL\n [image002.jpg]\n 04:16 AM\n 04:22 AM\n 05:09 PM\n 05:22 PM\n 10:16 PM\n 03:59 AM\n 04:03 AM\n 12:58 AM\n 03:59 AM\n 10:04 AM\n WBC\n 24.5\n 24.7\n 21.5\n Hct\n 30.5\n 29.6\n 29.3\n Plt\n \n Cr\n 0.8\n 0.9\n 0.9\n 0.8\n TCO2\n 43\n 48\n 48\n 47\n 49\n 47\n Glucose\n 132\n 185\n 114\n 107\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:20 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 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": "2192-04-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727710,
"text": "Chief Complaint:\n 24 Hour Events:\n -negative 1.4 liters at noon, lasix drip decreased to 8mg/hr\n -PEEP decreased from 16 to 14\n -ultrasound w/ minimal effusions\n -antibiotics discontinued and prednisone weaned to 30mg daily (from\n 40mg daily)\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 09:03 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 10:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.6\nC (97.8\n HR: 76 (60 - 79) bpm\n BP: 101/53(67) {91/48(63) - 108/75(83)} mmHg\n RR: 21 (16 - 22) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,898 mL\n 954 mL\n PO:\n TF:\n 1,168 mL\n 369 mL\n IVF:\n 1,050 mL\n 305 mL\n Blood products:\n Total out:\n 4,550 mL\n 1,330 mL\n Urine:\n 4,450 mL\n 1,330 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -1,652 mL\n -376 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 91%\n ABG: 7.43/68/57/49/16\n Ve: 7.8 L/min\n PaO2 / FiO2: 114\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 432 K/uL\n 9.2 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 49 mEq/L\n 3.9 mEq/L\n 55 mg/dL\n 91 mEq/L\n 143 mEq/L\n 29.3 %\n 21.5 K/uL\n [image002.jpg]\n 04:16 AM\n 04:22 AM\n 05:09 PM\n 05:22 PM\n 10:16 PM\n 03:59 AM\n 04:03 AM\n 12:58 AM\n 03:59 AM\n 10:04 AM\n WBC\n 24.5\n 24.7\n 21.5\n Hct\n 30.5\n 29.6\n 29.3\n Plt\n \n Cr\n 0.8\n 0.9\n 0.9\n 0.8\n TCO2\n 43\n 48\n 48\n 47\n 49\n 47\n Glucose\n 132\n 185\n 114\n 107\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Day 8 of intubation today for multilobar\n pneumonia & COPD c/b ARDS. Difficult to oxygenate without high\n PEEP/FIO2. Requiring high PEEP and PSV. Still significantly positive\n for the stay- LOS 4.5 liters. She does have RLL effusion that may be\n contributing.\n - bedside ultrasound today to evaluate for effusion that might be\n -able (although this would be risky given high pressure)\n - Continue lasix gtt, plan for goal I/O negative 1 liter-2liter\n - PM lytes\n - continue diamox\n - taper prednisone to 30mg daily today\n .\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, d/c azithromycin for 8-day course to\n end \n - change IV meds to PO if possible\n .\n # Alkalosis: secondary to aggressive diuresis\n - continue acetazolamide\n .\n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds (will concentrate\n to assist with tube feeds)\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:20 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 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": "2192-04-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727713,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 24 Hour Events:\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 09:03 AM\n Other medications:\n Atrovent, Peridex, RISS, Albuterol prn, Narcan PO, Flovent, Lasix gtt,\n Diamox, Prednisone 30 qd\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.6\nC (97.8\n HR: 76 (60 - 79) bpm\n BP: 101/53(67) {91/48(63) - 108/75(83)} mmHg\n RR: 21 (16 - 22) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,898 mL\n 953 mL\n PO:\n TF:\n 1,168 mL\n 369 mL\n IVF:\n 1,050 mL\n 304 mL\n Blood products:\n Total out:\n 4,550 mL\n 1,330 mL\n Urine:\n 4,450 mL\n 1,330 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -1,652 mL\n -377 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 91%\n ABG: 7.43/68/57/49/16\n Ve: 7.8 L/min\n PaO2 / FiO2: 114\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ant)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 9.2 g/dL\n 432 K/uL\n 107 mg/dL\n 0.8 mg/dL\n 49 mEq/L\n 3.9 mEq/L\n 55 mg/dL\n 91 mEq/L\n 143 mEq/L\n 29.3 %\n 21.5 K/uL\n [image002.jpg]\n 04:16 AM\n 04:22 AM\n 05:09 PM\n 05:22 PM\n 10:16 PM\n 03:59 AM\n 04:03 AM\n 12:58 AM\n 03:59 AM\n 10:04 AM\n WBC\n 24.5\n 24.7\n 21.5\n Hct\n 30.5\n 29.6\n 29.3\n Plt\n \n Cr\n 0.8\n 0.9\n 0.9\n 0.8\n TCO2\n 43\n 48\n 48\n 47\n 49\n 47\n Glucose\n 132\n 185\n 114\n 107\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Imaging: CXR- no sig change, bibasilr dz\n Microbiology: Sputum- GPCs, yeast\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -cont ARDSnet ventilation --> A/CV w/ 6cc/kg Vt and permissive\n hypercapnia, tolerating pH down to 7.20\n -wean FiO2 and PEEP to maintain PaO2 > 60\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n increase azetazolamide to help w/ HCO3 wasting in the setting of\n contraction alkalosis\n -will concentrate IVF and tube feeds\n -off ABX yesterday\n -steroids weaning to 20 qd tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:20 AM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\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: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-06 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 728146,
"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 67 yo with respiratory failure, COPD, MRSA PNA. Weaned down to PEEP of\n 8\n 24 Hour Events:\n ARTERIAL LINE - START 02:41 PM\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 10:01 AM\n Infusions:\n Furosemide (Lasix) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 5 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n colace\n atroven\n protonix\n chlorhexi\n midax\n albuterol\n narcan\n flovent\n prednisone 30mg\n diamox\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 35.8\nC (96.4\n HR: 76 (66 - 80) bpm\n BP: 89/45(60) {89/45(60) - 123/67(87)} mmHg\n RR: 20 (18 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,910 mL\n 954 mL\n PO:\n TF:\n 2,069 mL\n 624 mL\n IVF:\n 531 mL\n 269 mL\n Blood products:\n Total out:\n 2,800 mL\n 1,720 mL\n Urine:\n 2,800 mL\n 1,720 mL\n NG:\n Stool:\n Drains:\n Balance:\n 110 mL\n -766 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 23 cmH2O\n Plateau: 17 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 91%\n ABG: 7.37/69/85./39/10\n Ve: 6.5 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present, incarcerated hernia\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 425 K/uL\n 112 mg/dL\n 0.8 mg/dL\n 39 mEq/L\n 4.7 mEq/L\n 63 mg/dL\n 98 mEq/L\n 145 mEq/L\n 30.2 %\n 19.9 K/uL\n [image002.jpg]\n 11:01 PM\n 02:46 AM\n 03:07 AM\n 05:31 AM\n 03:41 PM\n 08:24 PM\n 03:24 AM\n 03:40 AM\n 05:03 AM\n 06:16 AM\n WBC\n 21.0\n 19.9\n Hct\n 31.0\n 30.2\n Plt\n 478\n 425\n Cr\n 0.9\n 1.0\n 0.8\n TCO2\n 46\n 47\n 48\n 44\n 43\n 42\n 41\n Glucose\n 115\n 136\n 112\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.6 mg/dL, Mg++:2.6 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n Respiratory failure: Doing better. Looks good on PSV. Prednisone\n taper.\n Agitation: Wean drips today. Use boluses as needed.\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:41 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 728147,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:41 PM\n - a-line re-inserted\n - PEEP down to 8\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Furosemide (Lasix) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.6\nC (97.8\n HR: 75 (66 - 80) bpm\n BP: 98/54(69) {91/47(61) - 123/67(87)} mmHg\n RR: 20 (18 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,909 mL\n 829 mL\n PO:\n TF:\n 2,069 mL\n 553 mL\n IVF:\n 530 mL\n 216 mL\n Blood products:\n Total out:\n 2,800 mL\n 1,280 mL\n Urine:\n 2,800 mL\n 1,280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 109 mL\n -451 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n Plateau: 19 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 91%\n ABG: 7.37/69/85./39/10\n Ve: 7.1 L/min\n PaO2 / FiO2: 170\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: no edema, no sacral edema\n Labs / Radiology\n 425 K/uL\n 9.5 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 39 mEq/L\n 4.7 mEq/L\n 63 mg/dL\n 98 mEq/L\n 145 mEq/L\n 30.2 %\n 19.9 K/uL\n [image002.jpg]\n 11:01 PM\n 02:46 AM\n 03:07 AM\n 05:31 AM\n 03:41 PM\n 08:24 PM\n 03:24 AM\n 03:40 AM\n 05:03 AM\n 06:16 AM\n WBC\n 21.0\n 19.9\n Hct\n 31.0\n 30.2\n Plt\n 478\n 425\n Cr\n 0.9\n 1.0\n 0.8\n TCO2\n 46\n 47\n 48\n 44\n 43\n 42\n 41\n Glucose\n 115\n 136\n 112\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.6 mg/dL, Mg++:2.6 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/,\n continues to be intubated/sedated.\n # Respiratory failure: Day 10 of intubation today for multilobar\n pneumonia & COPD c/b . Difficult to oxygenate without high\n PEEP/FIO2. I/O neg 1.3 L on furosemide gtt. Bedside u/s showed no\n tappable effusion. Attempt to diurese 1-2 liters again today and plan\n on weaning PEEP as tolerated.\n - continue lasix gtt, plan for goal I/O negative 1 liter-2liter\n - PM lytes\n - continue acetazolamide\n - continue prednisone to 30mg daily for 2 more days\n -attempt A line replacement\n - problem is , PNA has been treated fully, monitor temp and\n WBC\n .\n # Alkalosis: secondary to aggressive diuresis\n - continue acetazolamide as above\n .\n # Hx of hypertension: now normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds (will concentrate\n to assist with tube feeds)\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:41 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 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": "2192-04-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727716,
"text": "Chief Complaint:\n 24 Hour Events:\n -negative 1.4 liters at noon, lasix drip decreased to 8mg/hr\n -PEEP decreased from 16 to 14\n -ultrasound w/ minimal effusions\n -antibiotics discontinued and prednisone weaned to 30mg daily (from\n 40mg daily)\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 09:03 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 10:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.6\nC (97.8\n HR: 76 (60 - 79) bpm\n BP: 101/53(67) {91/48(63) - 108/75(83)} mmHg\n RR: 21 (16 - 22) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,898 mL\n 954 mL\n PO:\n TF:\n 1,168 mL\n 369 mL\n IVF:\n 1,050 mL\n 305 mL\n Blood products:\n Total out:\n 4,550 mL\n 1,330 mL\n Urine:\n 4,450 mL\n 1,330 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -1,652 mL\n -376 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 91%\n ABG: 7.43/68/57/49/16\n Ve: 7.8 L/min\n PaO2 / FiO2: 114\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: trace bilaterally pitting edema, improving\n Labs / Radiology\n 432 K/uL\n 9.2 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 49 mEq/L\n 3.9 mEq/L\n 55 mg/dL\n 91 mEq/L\n 143 mEq/L\n 29.3 %\n 21.5 K/uL\n [image002.jpg]\n 04:16 AM\n 04:22 AM\n 05:09 PM\n 05:22 PM\n 10:16 PM\n 03:59 AM\n 04:03 AM\n 12:58 AM\n 03:59 AM\n 10:04 AM\n WBC\n 24.5\n 24.7\n 21.5\n Hct\n 30.5\n 29.6\n 29.3\n Plt\n \n Cr\n 0.8\n 0.9\n 0.9\n 0.8\n TCO2\n 43\n 48\n 48\n 47\n 49\n 47\n Glucose\n 132\n 185\n 114\n 107\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Day 9 of intubation today for multilobar\n pneumonia & COPD c/b ARDS. Difficult to oxygenate without high\n PEEP/FIO2. I/O neg 1.6 L yesterday on furosemide gtt. Bedside u/s\n showed no tappable effusion.\n - continue lasix gtt, plan for goal I/O negative 1 liter-2liter\n - PM lytes\n - continue acetazolamide\n - continue prednisone to 30mg daily for 2 more days\n .\n # PNA: sputum cx unrevealing so far. GPC from sputum still not\n speciated. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime; azithromycin for 8-day course to end\n \n .\n # Alkalosis: secondary to aggressive diuresis\n - continue acetazolamide as above\n .\n # Hx of hypertension: now normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds (will concentrate\n to assist with tube feeds)\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:20 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 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": "2192-04-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728026,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Rec\nd pt intubated. Vent settings CMV 50% 350/18/10 PEEP. Fentanyl @\n 200mcg/hr & Versed @ 5mg/hr. Pt is awake/alert & following simple\n commands. Pt often gestures to communicate needs but also responds well\n to yes/no questions. PERRL. O2 sat 92-98%. Lasix gtt @ 2mg/hr (resumed\n PM after Aline placement) TF @ goal.\n Action:\n ABG drawn after peep was decreased to 10. Please see Metavision for\n specifics. Restarted lasix gtt around 1530 after A-line was placed.\n pt is maintaing good urine out put on her own we are still\n trying to get her peep to 8 for trach placement. On diamox due to\n metabolic alkalosis from diuresis. MDI\ns. Steroids.\n Response:\n Pt has remained calm throughout the day. Pt suctioned for minimal to no\n secretions. Aline placed around 1400. Pt was able to have her peep\n weaned to 10 today. Pt\ns cxray is improved and her edema has decreased.\n Plan:\n Cont to diurese with Lasix gtt. Wean vent as tolerated. Goal is to\n decrease PEEP to < 8 for trach placement.\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-08 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 728732,
"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 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with ARDS / respiratory failure who was admitted on .\n 24 Hour Events:\n On and off BiPAP overnight.\n Anxious this morning; repeat ABG (off BiPAP) reveals respiratory\n alkalosis:\n 7.51 / 47 / 124\n Allergies:\n Penicillins\n Unknown\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Prophylaxis - 12:00 AM\n Other medications:\n Heparin 5K TID\n Colace \n Atrovent 6 puffs q6\n Protonix 40mg IV q24h\n Peridex \n RSSI\n Prednisone 30mg q24h\n Fluticasone 220mcg 4 puffs \n Free H2O 250mg \n Narcan 1mg PO q6h\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 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.1\nC (97\n HR: 89 (73 - 89) bpm\n BP: 160/88 {109/66 - 178/96} mmHg\n RR: 16 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt current: 90.1 kg admi): 100.9 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 154 mL\n PO:\n 350 mL\n 50 mL\n TF:\n 140 mL\n IVF:\n 340 mL\n 104 mL\n Blood products:\n Total out:\n 3,065 mL\n 400 mL\n Urine:\n 3,065 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,935 mL\n -246 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (400 - 540) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 18 cmH2O\n SpO2: 93%\n ABG: 7.44/61/147/37/14\n Ve: 9.6 L/min\n PaO2 / FiO2: 294\n Physical Examination\n Gen: Very uncomfortable .\n HEENT: OP clear.\n CV: S1S2 RRR w/o m/r/g\ns appreciated.\n Lungs: CTA anteriorly without significant crackles / wheezing.\n Ab: Positive BS\ns. Obese. NT/ND.\n Ext: No significant edema.\n Neuro: Alert, appropriate, anxious, no gross focal deficits.\n Labs / Radiology\n 10.7 g/dL\n 465 K/uL\n 93 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 100 mEq/L\n 148 mEq/L\n 32.9 %\n 22.7 K/uL\n [image002.jpg]\n Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %, Mono:3.0 %, Eos:0.0\n %,\n pCXR (): Overall much improved right-sided opacity from .\n Similar film to exam. Bibasilar atelectasis without significant\n infiltrate or edema.\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n 10:27 AM\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n WBC\n 20.8\n 22.7\n Hct\n 31.3\n 32.9\n Plt\n 435\n 465\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 42\n 40\n 40\n 38\n 39\n 43\n Glucose\n 143\n 93\n 121\n 93\n Other labs:\n PT / PTT / INR:10.8/28.4/0.9,\n ALT / AST:29/13, Alk Phos / T Bili:103/0.2,\n Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.6 mg/dL, Mg++:2.5 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with right-sided pneumonia and ARDS / respiratory failure who was\n admitted on ; extubated yesterday with increasing\n respiratory distress.\n HYPERNATREMIA (HIGH SODIUM)\n Continue free water boluses when enteral access established; will\n increase to q6h.\n CONSTIPATION (OBSTIPATION, FOS)\n Rectal tube. Follow.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n Extubated yesterday, did relatively well overnight but more anxious /\n agitated this morning and clinically has obvious respiratory distress\n with tachypnea and accessory muscle use. She is at high risk for\n re-intubation and very well may need to be re-intubated today. Will\n focus on optimizing her hemodynamics, volume status, anxiety and COPD:\n 1) Hemodyanics: Increase captopril to 25mg TID; may need to add a\n second . Goal SBP < 140mm Hg today.\n 2) Volume status: She has been net negative, anticipate titrating\n Lasix off today as SBP improves. Ideally will keep her net negative and\n may need intermittent boluses for this.\n 3) Anxiety: Providing benzos today, titrate as needed. Will try\n Ativan 1mg IV now. Would consider adjuvant morphine as well if no\n improvement over 15-30 minutes.\n 4) COPD: decreased Prednisone to 20mg q24h today; continue\n bronchodilators.\n VOLUME OVERLOAD\n Anticipate d/c\ning Lasix gtt today. Goal net negative today.\n HYPERTENSION\n Increasing captopril as above. Follow, goal SBP < 140mm Hg.\n LEUKOCYTOSIS\n Overall, her impressive leukocytosis is improving from admission.\n Source unclear. Follow closely.\n ICU Care\n Nutrition: NPO for now\n advance pending stability of respiratory\n distress\n Glycemic Control:\n Lines: Multi Lumen - 04:24 AM and Arterial Line - \n 02:41 PM\n Prophylaxis:\n DVT: Heparin subQ / SCDs\n Stress ulcer: PPI\n VAP: N/A for now\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : MICU for now.\n Total time spent:\n ------ Protected Section ------\n 67 yo with FEV1 at 23% predicted and admitted with hypercapnic\n respiratory failure with new right sided pneumonia. She has had\n prolonged ventilator weaning across this admission and was extubated\n yesterday. Through today patient has had persistent issues of hypoxia\n and hypercarbia.\n On exam\n SBP-146\n P-100\n SaO2-96% on 80% through high flow O2\n Patient comfortable and responding to questions appropriately\n She is able to take deep breaths and cough on command.\n A/P-\n 1)Respiratory Failure-Secondary to severe COPD and volume overload and\n pneumonia\n -Continue negative fluid balance\n -Continue with Captopril\n -Continue prednisone qd and bronchodilators\n -Will look to continue to mobilize patient as tolerated\n -BIPAP intermittently and will titrate o2 down with time.\n -Will check ABG this evening\n Critical Care Time-35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 15:32 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-04-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 728733,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 14\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\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:\n Sputum source/amount:\n Comments: Pt data as above/ per Meta-V. Pt on and off NIV over night\n and then again this\n AM due to had a severe period of anxiety. Pt was given Ativan and\n Valium by RN for her anxiety. Placed on HI- Aerosol .80 when off\n NIV. Will taper FIO2 as tolerated and use NIV as needed. Will also c/w\n MDI\ns : Albuterol/ Atrovent/ Flovent and monitor closely.\n"
},
{
"category": "General",
"chartdate": "2192-04-09 00:00:00.000",
"description": "Generic Note",
"row_id": 728822,
"text": "TITLE: Respiratory Care\n Pt able to tol off NIV all shift. SpO2 high 90\ns on 50% hi flow\n nebulizer. Tol MDIs well. Fair productive cough able to raise and\n clear, unable to expectorate.\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727866,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:18 AM\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.6\nC (97.8\n HR: 71 (60 - 79) bpm\n BP: 90/42(54) {90/42(54) - 90/42(54)} mmHg\n RR: 18 (17 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,325 mL\n 313 mL\n PO:\n TF:\n 840 mL\n 189 mL\n IVF:\n 865 mL\n 124 mL\n Blood products:\n Total out:\n 3,620 mL\n 800 mL\n Urine:\n 3,620 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,295 mL\n -487 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n Plateau: 11 cmH2O\n Compliance: 350 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/73./105/45/16\n Ve: 6.9 L/min\n PaO2 / FiO2: 210\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 478 K/uL\n 9.7 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 45 mEq/L\n 5.1 mEq/L\n 61 mg/dL\n 95 mEq/L\n 143 mEq/L\n 31.0 %\n 21.0 K/uL\n [image002.jpg]\n 03:59 AM\n 04:03 AM\n 12:58 AM\n 03:59 AM\n 10:04 AM\n 12:37 PM\n 02:56 PM\n 11:01 PM\n 02:46 AM\n 03:07 AM\n WBC\n 24.7\n 21.5\n 21.0\n Hct\n 29.6\n 29.3\n 31.0\n Plt\n \n Cr\n 0.9\n 0.8\n 0.9\n TCO2\n 47\n 49\n 47\n 41\n 46\n 46\n 47\n Glucose\n 114\n 107\n 137\n 115\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 10:30 PM 35 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 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": "2192-04-07 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 728459,
"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 note above, including assessment and plan.\n HPI:\n 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with ARDS / respiratory failure who was admitted on .\n 24 Hour Events:\n Lasix gtt shut off briefly yesterday for hypotension. Now lasix gtt\n back on.\n PEEP titrated down to 5.\n Tube feeds off in anticipation of possible extubation today.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Heparin 5K TID\n Colace \n Atrovent 6 puffs q6\n Protonix 40mg IV q24h\n Peridex \n RSSI\n Prednisone 30mg q24h\n Fluticasone 220mcg 4 puffs \n Free H2O 250mg \n Narcan 1mg PO q6h\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 at this time.\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: 37\nC (98.6\n Tcurrent: 36.7\nC (98\n HR: 79 (72 - 82) bpm\n BP: 129/67 {89/45 - 143/76} mmHg\n RR: 19 (17 - 28) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt current: 92.4 kg admit: 100.9 kg\n Height: 67 Inch\n Total In:\n 1,851 mL\n 267 mL\n PO:\n TF:\n 1,137 mL\n 140 mL\n IVF:\n 574 mL\n 127 mL\n Blood products:\n Total out:\n 3,840 mL\n 680 mL\n Urine:\n 3,840 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,989 mL\n -413 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 356 (320 - 424) mL\n PS : 8 cmH2O\n RR (Set): 20\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 97\n PIP: 14 cmH2O\n Plateau: 17 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 90%\n ABG: 7.39 / 63 / 73 / 38 / 9 on 50%\n Ve: 8.8 L/min\n PaO2 / FiO2: 146\n Physical Examination\n Gen: Looks comfortable on vent, answering yes / no questions\n appropriately.\n HEENT: ETT in place.\n CV: S1S2 RRR w/o m/r/g\ns appreciated.\n Lungs: CTA anteriorly without significant crackles / wheezing.\n Ab: Positive BS\ns. Obese. NT/ND.\n Ext: No significant edema.\n Neuro: Alert, appropriate\n Labs / Radiology\n 10.0 g/dL\n 435 K/uL\n 93 mg/dL\n 0.8 mg/dL\n 38 mEq/L\n 4.4 mEq/L\n 63 mg/dL\n 101 mEq/L\n 148 mEq/L\n 31.3 %\n 20.8 K/uL\n [image002.jpg]\n Differential - Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %, Mono:3.0 %,\n Eos:0.0 %\n No chest x-ray this AM.\n 03:41 PM\n 08:24 PM\n 03:24 AM\n 03:40 AM\n 05:03 AM\n 06:16 AM\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n WBC\n 19.9\n 20.8\n Hct\n 30.2\n 31.3\n Plt\n 425\n 435\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n TCO2\n 44\n 43\n 42\n 41\n 42\n 40\n Glucose\n 136\n 112\n 143\n 93\n Other labs:\n PT / PTT / INR:10.8/28.4/0.9,\n ALT / AST:29/13, Alk Phos / T Bili:103/0.2,\n Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.0 mg/dL, Mg++:2.7 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with right-sided pneumonia and ARDS / respiratory failure who was\n admitted on .\n HYPERNATREMIA (HIGH SODIUM)\n Continue free water boluses for now; if no improvement by tomorrow will\n increase to q6h.\n CONSTIPATION (OBSTIPATION, FOS)\n D/c Narcan PO. Has rectal tube in and is having adequate stool out-put.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n Will try with 0/0 trial this morning. If she passes the with\n normal hemodynamics, RSBI < 105, and an acceptable ABG she could be\n extubatable. Continue Lasix gtt / consider bolus immediately prior to\n extubation. If passes , extubate to NIPPV given she has chronic\n respiratory disease and is high-risk for extubation failure.\n Plan to titrate Prednisone to 20mg q24h tomorrow. Continue inhalers.\n If she fails extubation, she would be a candidate for trach.\n VOLUME OVERLOAD\n Remains on Lasix gtt with a goal of continued diuresis as tolerated.\n She had been on acetazolamide for metabolic alkalosis related to\n aggressive diuresis, currently off. Follow bicarb. Anticipate getting\n intermittent ABGs with and possible extubation today.\n HYPERTENSION\n Off antihypertensives now, anticipate reintroducing meds\n peri-extubation as sedation comes off. Goal to optimize BP to minimize\n risk of peri-extubation pulmonary edema.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM and Arterial Line - 02:41\n PM\n Prophylaxis:\n DVT: Heparin subQ / SCDs\n Stress ulcer: PPI\n VAP: Peridex / elevate HOB\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : MICU for now\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727868,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:18 AM\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.6\nC (97.8\n HR: 71 (60 - 79) bpm\n BP: 90/42(54) {90/42(54) - 90/42(54)} mmHg\n RR: 18 (17 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,325 mL\n 313 mL\n PO:\n TF:\n 840 mL\n 189 mL\n IVF:\n 865 mL\n 124 mL\n Blood products:\n Total out:\n 3,620 mL\n 800 mL\n Urine:\n 3,620 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,295 mL\n -487 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n Plateau: 11 cmH2O\n Compliance: 350 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/73./105/45/16\n Ve: 6.9 L/min\n PaO2 / FiO2: 210\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: trace bilaterally pitting edema, improving\n Labs / Radiology\n 478 K/uL\n 9.7 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 45 mEq/L\n 5.1 mEq/L\n 61 mg/dL\n 95 mEq/L\n 143 mEq/L\n 31.0 %\n 21.0 K/uL\n [image002.jpg]\n 03:59 AM\n 04:03 AM\n 12:58 AM\n 03:59 AM\n 10:04 AM\n 12:37 PM\n 02:56 PM\n 11:01 PM\n 02:46 AM\n 03:07 AM\n WBC\n 24.7\n 21.5\n 21.0\n Hct\n 29.6\n 29.3\n 31.0\n Plt\n \n Cr\n 0.9\n 0.8\n 0.9\n TCO2\n 47\n 49\n 47\n 41\n 46\n 46\n 47\n Glucose\n 114\n 107\n 137\n 115\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Day 9 of intubation today for multilobar\n pneumonia & COPD c/b ARDS. Difficult to oxygenate without high\n PEEP/FIO2. I/O neg 1.6 L yesterday on furosemide gtt. Bedside u/s\n showed no tappable effusion.\n - continue lasix gtt, plan for goal I/O negative 1 liter-2liter\n - PM lytes\n - continue acetazolamide\n - continue prednisone to 30mg daily for 2 more days\n .\n # PNA: sputum cx unrevealing so far. GPC from sputum still not\n speciated. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime; azithromycin for 8-day course to end\n \n .\n # Alkalosis: secondary to aggressive diuresis\n - continue acetazolamide as above\n .\n # Hx of hypertension: now normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds (will concentrate\n to assist with tube feeds)\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 10:30 PM 35 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 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": "2192-04-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727872,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:18 AM\n -decreasing PEEP down to 10, PaO2 OK but CO2 rising-->increased rate\n but gas not improved-->going back up on PEEP\n -BP borderline, 1.5 L negative but had to go down on the lasix gtt\n because of borderline BP\n -lost arterial line\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.6\nC (97.8\n HR: 71 (60 - 79) bpm\n BP: 90/42(54) {90/42(54) - 90/42(54)} mmHg\n RR: 18 (17 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,325 mL\n 313 mL\n PO:\n TF:\n 840 mL\n 189 mL\n IVF:\n 865 mL\n 124 mL\n Blood products:\n Total out:\n 3,620 mL\n 800 mL\n Urine:\n 3,620 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,295 mL\n -487 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n Plateau: 11 cmH2O\n Compliance: 350 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/73./105/45/16\n Ve: 6.9 L/min\n PaO2 / FiO2: 210\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: trace bilaterally pitting edema, improving\n Labs / Radiology\n 478 K/uL\n 9.7 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 45 mEq/L\n 5.1 mEq/L\n 61 mg/dL\n 95 mEq/L\n 143 mEq/L\n 31.0 %\n 21.0 K/uL\n [image002.jpg]\n 03:59 AM\n 04:03 AM\n 12:58 AM\n 03:59 AM\n 10:04 AM\n 12:37 PM\n 02:56 PM\n 11:01 PM\n 02:46 AM\n 03:07 AM\n WBC\n 24.7\n 21.5\n 21.0\n Hct\n 29.6\n 29.3\n 31.0\n Plt\n \n Cr\n 0.9\n 0.8\n 0.9\n TCO2\n 47\n 49\n 47\n 41\n 46\n 46\n 47\n Glucose\n 114\n 107\n 137\n 115\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Day 9 of intubation today for multilobar\n pneumonia & COPD c/b ARDS. Difficult to oxygenate without high\n PEEP/FIO2. I/O neg 1.6 L yesterday on furosemide gtt. Bedside u/s\n showed no tappable effusion.\n - continue lasix gtt, plan for goal I/O negative 1 liter-2liter\n - PM lytes\n - continue acetazolamide\n - continue prednisone to 30mg daily for 2 more days\n .\n # PNA: sputum cx unrevealing so far. GPC from sputum still not\n speciated. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime; azithromycin for 8-day course to end\n \n .\n # Alkalosis: secondary to aggressive diuresis\n - continue acetazolamide as above\n .\n # Hx of hypertension: now normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds (will concentrate\n to assist with tube feeds)\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 10:30 PM 35 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 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": "2192-04-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 727972,
"text": "Demographics\n Day of intubation: 11\n Day of mechanical ventilation: 11\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 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: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency\n Sputum source/amount: Suctioned / None\n Comments: Pt data as above/ per Meta-V. PEEP tapered today to 10 cm\n H2O. ABG stable. Will keep SPO2 88-92 % as per MICU-Team.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 729012,
"text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received the pt on 50% high flow aerosol mask, sats in low 90\nlungs\n clear occ non productive cough\nanxious at baseline\n.pt was very\n reluctuant to egt oob, was limitedly interactive,\n with motor\n restlessness\n Action:\n Received MDI\ns,contd on prednisone,on sliding scale, o2 weaned to 4L\n nc,received valium for anxiety/restlessness\n Response:\n Satting 92-94%on 4l...much more interactive and co operative with\n care\nwas OOB to the chair ~4 hrs,\n Plan:\n Wean o2 as tolerated,cont prednisone taper,valium for anxiety,OOB\n daily,PT consult on board.\n Hypernatremia (high sodium) with low urine output.\n Assessment:\n Am labs with Na 147, with poor po intake,UOP dropped to this noon,(was\n on lasix drip till yesterday)\n Action:\n Started n NS @125cc/hr x1L,started on regular diet, encouraged PO\n intake\n Response:\n Pt had excellent PO intake,no signs of asipartion,,,feeling thirsty and\n requesting water,uop slowly rising\n Plan:\n Will follow the Na level daily,encourage PO intake,follow I/O,\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728012,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Rec\nd pt intubated. Vent settings CMV 50% 350/16/12 PEEP. Fentanyl @\n 200mcg/hr & Versed @ 5mg/hr. Pt is awake/alert & following simple\n commands. Pt often gestures to communicate needs but also responds well\n to yes/no questions. PERRL. O2 sat 92-98%. Lasix gtt off low NBP\n readings. TF @ goal.\n Action:\n ABG drawn after peep was decreased to 10. Please see Metavision for\n specifics. Restarted lasix gtt around 1530 after A-line was placed.\n pt is maintaing good urine out put on her own we are still\n trying to get her peep to 8 for trach placement. On diamox due to\n metabolic alkalosis from diuresis. MDI\ns. Steroids.\n Response:\n Pt has remained calm throughout the day. Pt suctioned for minimal to no\n secretions. Aline placed around 1400. Pt was able to have her peep\n weaned to 10 today. Pt\ns cxray is improved and her edema has decreased.\n Plan:\n Cont to diurese with Lasix gtt. Wean vent as tolerated. Goal is to\n decrease PEEP to < 8 for trach placement.\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-07 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 728502,
"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 note above, including assessment and plan.\n HPI:\n 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with ARDS / respiratory failure who was admitted on .\n 24 Hour Events:\n Lasix gtt shut off briefly yesterday for hypotension. Now lasix gtt\n back on.\n PEEP titrated down to 5.\n Tube feeds off in anticipation of possible extubation today.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Heparin 5K TID\n Colace \n Atrovent 6 puffs q6\n Protonix 40mg IV q24h\n Peridex \n RSSI\n Prednisone 30mg q24h\n Fluticasone 220mcg 4 puffs \n Free H2O 250mg \n Narcan 1mg PO q6h\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 at this time.\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: 37\nC (98.6\n Tcurrent: 36.7\nC (98\n HR: 79 (72 - 82) bpm\n BP: 129/67 {89/45 - 143/76} mmHg\n RR: 19 (17 - 28) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt current: 92.4 kg admit: 100.9 kg\n Height: 67 Inch\n Total In:\n 1,851 mL\n 267 mL\n PO:\n TF:\n 1,137 mL\n 140 mL\n IVF:\n 574 mL\n 127 mL\n Blood products:\n Total out:\n 3,840 mL\n 680 mL\n Urine:\n 3,840 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,989 mL\n -413 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 356 (320 - 424) mL\n PS : 8 cmH2O\n RR (Set): 20\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 97\n PIP: 14 cmH2O\n Plateau: 17 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 90%\n ABG: 7.39 / 63 / 73 / 38 / 9 on 50%\n Ve: 8.8 L/min\n PaO2 / FiO2: 146\n Physical Examination\n Gen: Looks comfortable on vent, answering yes / no questions\n appropriately.\n HEENT: ETT in place.\n CV: S1S2 RRR w/o m/r/g\ns appreciated.\n Lungs: CTA anteriorly without significant crackles / wheezing.\n Ab: Positive BS\ns. Obese. NT/ND.\n Ext: No significant edema.\n Neuro: Alert, appropriate\n Labs / Radiology\n 10.0 g/dL\n 435 K/uL\n 93 mg/dL\n 0.8 mg/dL\n 38 mEq/L\n 4.4 mEq/L\n 63 mg/dL\n 101 mEq/L\n 148 mEq/L\n 31.3 %\n 20.8 K/uL\n [image002.jpg]\n Differential - Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %, Mono:3.0 %,\n Eos:0.0 %\n No chest x-ray this AM.\n 03:41 PM\n 08:24 PM\n 03:24 AM\n 03:40 AM\n 05:03 AM\n 06:16 AM\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n WBC\n 19.9\n 20.8\n Hct\n 30.2\n 31.3\n Plt\n 425\n 435\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n TCO2\n 44\n 43\n 42\n 41\n 42\n 40\n Glucose\n 136\n 112\n 143\n 93\n Other labs:\n PT / PTT / INR:10.8/28.4/0.9,\n ALT / AST:29/13, Alk Phos / T Bili:103/0.2,\n Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.0 mg/dL, Mg++:2.7 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with right-sided pneumonia and ARDS / respiratory failure who was\n admitted on .\n HYPERNATREMIA (HIGH SODIUM)\n Continue free water boluses for now; if no improvement by tomorrow will\n increase to q6h.\n CONSTIPATION (OBSTIPATION, FOS)\n D/c Narcan PO. Has rectal tube in and is having adequate stool out-put.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n Will try with 0/0 trial this morning. If she passes the with\n normal hemodynamics, RSBI < 105, and an acceptable ABG she could be\n extubatable. Continue Lasix gtt / consider bolus immediately prior to\n extubation. If passes , extubate to NIPPV given she has chronic\n respiratory disease and is high-risk for extubation failure.\n Plan to titrate Prednisone to 20mg q24h tomorrow. Continue inhalers.\n If she fails extubation, she would be a candidate for trach.\n VOLUME OVERLOAD\n Remains on Lasix gtt with a goal of continued diuresis as tolerated.\n She had been on acetazolamide for metabolic alkalosis related to\n aggressive diuresis, currently off. Follow bicarb. Anticipate getting\n intermittent ABGs with and possible extubation today.\n HYPERTENSION\n Off antihypertensives now, anticipate reintroducing meds\n peri-extubation as sedation comes off. Goal to optimize BP to minimize\n risk of peri-extubation pulmonary edema.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM and Arterial Line - 02:41\n PM\n Prophylaxis:\n DVT: Heparin subQ / SCDs\n Stress ulcer: PPI\n VAP: Peridex / elevate HOB\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : MICU for now\n Total time spent:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n fellow for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n CC: resp failure\n 67 yo woman with severe COPD (FEV1 23%), constipation here with right\n PNA, ARDS / respiratory failure who was admitted on .\n Extubated today at 12:30, doing well on BiPAP 12/5 for 4 hours, now\n doing well on 80% aerosol high flow face tent and doing well. Will go\n back on BiPAP after 1 hour off.\n Tapering prednisone.\n Off antibiotics.\n Continuing diuresis.\n Critically ill.\n 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 17:52 ------\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728513,
"text": "Hypernatremia (high sodium)\n Assessment:\n Please see labs this am. Continues on lasix drip at 3 mgs/hr,. no\n peripheral edema noted. Has had an excellent urinary output.. receiving\n free water boluses of 250 ccs q 12 hrs.\n Action:\n Tx with extra 10 mgs ivp lasix prior to extubation. Sent repeat labs at\n 1730\n Response:\n Good response\n Plan:\n Will follow I\ns and o\ns, labs\n Respiratory failure, chronic\n Assessment:\n Repeated SBT and pt looked comfortable- and ABG was acceptable.\n Action:\n Extubated pt and placed on bipap 12/5. did well. After a few hours was\n switched to a cool neb at 80%- o2 sats are 96% and rr 22.\n Response:\n Continued to look comfortable. Took pills without signs aspiration.\n Plan:\n Will go with cool neb for now- can replace bipap prn\n Brief review of systems- CV- continues with some hypertension- was\n started on captopril 12.5 mgs. Hr has been stable. ID- afebrile. Wbc\n elevated pred tx. GI- NGT out. Needs diet order. abd is soft with\n positive bowel sounds. Has a flexiseal in place draining small amts\n liquid brown stool. NEURO- is alert and oriented x 3, cooperative and\n interactive. All sedatives off prior to extubation, IV ACCESS- has an\n a-line R wrist, triple lumen R IJ. Social- no phone calls or visitors\n today.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 729009,
"text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received the pt on 50% high flow aerosol mask, sats in low 90\nlungs\n clear occ non productive cough\nanxious at baseline\n.pt was very\n reluctuant to egt oob, was limitedly interactive,\n with motor\n restlessness\n Action:\n Received MDI\ns,contd on prednisone,on sliding scale, o2 weaned to 4L\n nc,received valium for anxiety/restlessness\n Response:\n Satting 92-94%on 4l...much more interactive and co operative with\n care\nwas OOB to the chair ~4 hrs,\n Plan:\n Wean o2 as tolerated,cont prednisone taper,valium for anxiety,OOB\n daily,PT consult on board.\n Hypernatremia (high sodium) with low urine output.\n Assessment:\n Am labs with Na 147, with poor po intake,UOP dropped to this noon,(was\n on lasix drip till yesterday)\n Action:\n Started n NS @125cc/hr x1L,started on regular diet,\n Response:\n Pt had excellent PO intake,no signs of asipartion,,,feeling thirsty and\n requesting water,uop slowly rising\n Plan:\n Will follow the Na level daily,encourage PO intake,follow I/O,\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728075,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Rec\nd pt intubated. Vent settings CMV 50% 350/18/10 PEEP. Fentanyl @\n 200mcg/hr & Versed @ 5mg/hr. Pt is awake/alert & following simple\n commands. Pt often gestures to communicate needs but also responds well\n to yes/no questions. PERRL. O2 sat 92-98%. Lasix gtt @ 2mg/hr (resumed\n in PM after Aline placement) Pt suctioned Q2-4 hrs for\n thick/yellow secretions. TF @ goal.\n Action:\n Multiple ABG\ns drawn in attempt to decrease vent settings for trach\n placement. Please see Metavision for specifics. Lasix gtt increased to\n 6mg O/N. SBP 100\ns. MAPs 70\ns. Remains on Diamox due to intial\n metabolic alkalosis from diuresis. MDI\ns. Steroids.\n Response:\n Pt has remained calm throughout the night. Occasional biting of ETT\n noted. CXR showing much improved edema.\n Plan:\n Cont to diurese with Lasix gtt. Wean vent as tolerated. Goal is to\n decrease PEEP to < 8 for trach placement. Pt does need reminders to not\n bite ETT.\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-08 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 728726,
"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 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with ARDS / respiratory failure who was admitted on .\n 24 Hour Events:\n On and off BiPAP overnight.\n Anxious this morning; repeat ABG (off BiPAP) reveals respiratory\n alkalosis:\n 7.51 / 47 / 124\n Allergies:\n Penicillins\n Unknown\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Prophylaxis - 12:00 AM\n Other medications:\n Heparin 5K TID\n Colace \n Atrovent 6 puffs q6\n Protonix 40mg IV q24h\n Peridex \n RSSI\n Prednisone 30mg q24h\n Fluticasone 220mcg 4 puffs \n Free H2O 250mg \n Narcan 1mg PO q6h\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 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.1\nC (97\n HR: 89 (73 - 89) bpm\n BP: 160/88 {109/66 - 178/96} mmHg\n RR: 16 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt current: 90.1 kg admi): 100.9 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 154 mL\n PO:\n 350 mL\n 50 mL\n TF:\n 140 mL\n IVF:\n 340 mL\n 104 mL\n Blood products:\n Total out:\n 3,065 mL\n 400 mL\n Urine:\n 3,065 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,935 mL\n -246 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (400 - 540) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 18 cmH2O\n SpO2: 93%\n ABG: 7.44/61/147/37/14\n Ve: 9.6 L/min\n PaO2 / FiO2: 294\n Physical Examination\n Gen: Very uncomfortable .\n HEENT: OP clear.\n CV: S1S2 RRR w/o m/r/g\ns appreciated.\n Lungs: CTA anteriorly without significant crackles / wheezing.\n Ab: Positive BS\ns. Obese. NT/ND.\n Ext: No significant edema.\n Neuro: Alert, appropriate, anxious, no gross focal deficits.\n Labs / Radiology\n 10.7 g/dL\n 465 K/uL\n 93 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 100 mEq/L\n 148 mEq/L\n 32.9 %\n 22.7 K/uL\n [image002.jpg]\n Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %, Mono:3.0 %, Eos:0.0\n %,\n pCXR (): Overall much improved right-sided opacity from .\n Similar film to exam. Bibasilar atelectasis without significant\n infiltrate or edema.\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n 10:27 AM\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n WBC\n 20.8\n 22.7\n Hct\n 31.3\n 32.9\n Plt\n 435\n 465\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 42\n 40\n 40\n 38\n 39\n 43\n Glucose\n 143\n 93\n 121\n 93\n Other labs:\n PT / PTT / INR:10.8/28.4/0.9,\n ALT / AST:29/13, Alk Phos / T Bili:103/0.2,\n Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.6 mg/dL, Mg++:2.5 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with right-sided pneumonia and ARDS / respiratory failure who was\n admitted on ; extubated yesterday with increasing\n respiratory distress.\n HYPERNATREMIA (HIGH SODIUM)\n Continue free water boluses when enteral access established; will\n increase to q6h.\n CONSTIPATION (OBSTIPATION, FOS)\n Rectal tube. Follow.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n Extubated yesterday, did relatively well overnight but more anxious /\n agitated this morning and clinically has obvious respiratory distress\n with tachypnea and accessory muscle use. She is at high risk for\n re-intubation and very well may need to be re-intubated today. Will\n focus on optimizing her hemodynamics, volume status, anxiety and COPD:\n 1) Hemodyanics: Increase captopril to 25mg TID; may need to add a\n second . Goal SBP < 140mm Hg today.\n 2) Volume status: She has been net negative, anticipate titrating\n Lasix off today as SBP improves. Ideally will keep her net negative and\n may need intermittent boluses for this.\n 3) Anxiety: Providing benzos today, titrate as needed. Will try\n Ativan 1mg IV now. Would consider adjuvant morphine as well if no\n improvement over 15-30 minutes.\n 4) COPD: decreased Prednisone to 20mg q24h today; continue\n bronchodilators.\n VOLUME OVERLOAD\n Anticipate d/c\ning Lasix gtt today. Goal net negative today.\n HYPERTENSION\n Increasing captopril as above. Follow, goal SBP < 140mm Hg.\n LEUKOCYTOSIS\n Overall, her impressive leukocytosis is improving from admission.\n Source unclear. Follow closely.\n ICU Care\n Nutrition: NPO for now\n advance pending stability of respiratory\n distress\n Glycemic Control:\n Lines: Multi Lumen - 04:24 AM and Arterial Line - \n 02:41 PM\n Prophylaxis:\n DVT: Heparin subQ / SCDs\n Stress ulcer: PPI\n VAP: N/A for now\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : MICU for now.\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 728932,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 01:33 PM\n INVASIVE VENTILATION - STOP 04:00 AM\n - was agitated, restless during the day with stable vitals and ABGs\n - received diazepam PO and IV and restlessness resolved; concerning for\n benzo withdrawal\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:33 AM\n Lorazepam (Ativan) - 12:14 PM\n Diazepam (Valium) - 07:30 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:10 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: 37\nC (98.6\n HR: 82 (75 - 109) bpm\n BP: 152/80(105) {114/64(83) - 174/96(191)} mmHg\n RR: 22 (16 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 838 mL\n 380 mL\n PO:\n 550 mL\n 380 mL\n TF:\n IVF:\n 288 mL\n Blood products:\n Total out:\n 1,335 mL\n 380 mL\n Urine:\n 1,335 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -497 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n PS : 12 cmH2O\n PEEP: 5 cmH2O\n FiO2: 50%\n SpO2: 95%\n ABG: 7.46/54/131/35/13\n PaO2 / FiO2: 262\n Physical Examination\n GEN: on face mask, appears comfortable, awake, alert, answering\n questions appropriately\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes improved\n CARDIAC: distant, regular, no murmurs audible\n ABDOMEN: obese, soft, nontender; prominent bowel sounds\n EXTREMITIES: no edema, no sacral edema, 2+ distal pulses\n Labs / Radiology\n 446 K/uL\n 10.6 g/dL\n 90 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 50 mg/dL\n 101 mEq/L\n 147 mEq/L\n 33.4 %\n 19.2 K/uL\n [image002.jpg]\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n 09:57 AM\n 12:26 PM\n 12:51 PM\n 05:36 PM\n 04:49 AM\n WBC\n 22.7\n 19.2\n Hct\n 32.9\n 33.4\n Plt\n 465\n 446\n Cr\n 0.9\n 0.9\n 1.0\n 0.9\n TCO2\n 38\n 39\n 43\n 39\n 39\n 40\n Glucose\n 121\n 93\n 127\n 90\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS, now\n extubated after prolonged intubation.\n # Respiratory failure: now extubated. Now tachypneic. Most recent\n ABG 7.51/47/124/39 suggesting respiratory alkalosis on top of ongoing\n metabolic alkalosis from hyperventilation.\n - benzo prn for anxiety and possible benzo withdrawal given long term\n - BiPAP prn\n - continue supplemental oxygen for goal SpO2 88-92%\n - allow her to autodiuresis for goal of net negative daily\n - continue prednisone taper at 20mg daily x 3 days\n - incentive spirometry\n # Pneumonia: s/p course of broad-spectrum abx.\n # Metabolic alkalosis: secondary to aggressive diuresis, improving\n # Hx of hypertension:\n - continue captopril 25 tid with plan to convert to lisinopril in am\n .\n # Hypernatremia:\n - Encourage po water intake\n - continue to monitor\n # FEN: IVF boluses / replete lytes prn / advance diet as tolerated\n # PPX: PPI per home regimen, heparin SQ, bowel regimen\n # ACCESS: RIJ if PIV placed will d/c RIJ and art line\n # CODE: Full\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 728933,
"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 67yo woman with severe COPD (FEV1 23%, on 4L home O2), constipation,\n and other issues here with right-sided pneumonia and ARDS / respiratory\n failure who was admitted on ; extubated \n 24 Hour Events:\n no sob, no chest pain, no complaints\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 12:14 PM\n Diazepam (Valium) - 07:30 PM\n Pantoprazole (Protonix) - 08:22 AM\n Heparin Sodium (Prophylaxis) - 09:00 AM\n Other medications:\n RISS, Albuterol, Atrovent, Flovent, Colace, Prednisone 20, Captopril,\n amlodipine, Valium prn, heparin sc\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:03 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.7\nC (96.3\n HR: 95 (75 - 99) bpm\n BP: 127/79(95) {105/64(77) - 169/96(191)} mmHg\n RR: 26 (16 - 26) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 838 mL\n 510 mL\n PO:\n 550 mL\n 500 mL\n TF:\n IVF:\n 288 mL\n 10 mL\n Blood products:\n Total out:\n 1,335 mL\n 645 mL\n Urine:\n 1,335 mL\n 645 mL\n NG:\n Stool:\n Drains:\n Balance:\n -497 mL\n -135 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 93%\n ABG: 7.46/54/131/35/13\n PaO2 / FiO2: 262\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R basilar)\n Abdominal: Soft, Non-tender, abd hernia fully reducible\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.6 g/dL\n 446 K/uL\n 90 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 50 mg/dL\n 101 mEq/L\n 147 mEq/L\n 33.4 %\n 19.2 K/uL\n [image002.jpg]\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n 09:57 AM\n 12:26 PM\n 12:51 PM\n 05:36 PM\n 04:49 AM\n WBC\n 22.7\n 19.2\n Hct\n 32.9\n 33.4\n Plt\n 465\n 446\n Cr\n 0.9\n 0.9\n 1.0\n 0.9\n TCO2\n 38\n 39\n 43\n 39\n 39\n 40\n Glucose\n 121\n 93\n 127\n 90\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Imaging: CXR- resovling RLL infiltrate\n Assessment and Plan\n 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with right-sided pneumonia and ARDS / respiratory failure who was\n admitted on ; extubated \n 1. Resp failure- resolving ARDS and COPD exac, pna; distress yest\n likely related to benzo withdrawal (prolonged ICU course of gtt)\n -prednisone 20 qd; slow taper\n -pulmonary toilet\n -OOB, incentive spirometry\n -monitor autodiuresis; strive for neg TBB\n 2. Benzo withdrawal- Ativan prn and PO Valium but will increase\n interval or decrease dose\n 3. Hypernatremia- encourage po\n 4. HTN- monitor creat on ACE, cont CCB\n 5. Gen Care-\n -PT/OT\n -advance diet\n ICU Care\n Nutrition:\n Comments: po diet- advance today\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-04-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 727855,
"text": "Demographics\n Day of mechanical ventilation: 11\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: /\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 claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728373,
"text": "Respiratory failure, chronic\n Assessment:\n Pt cont to do well on PSV of , with no c/o SOB\n Action:\n Sedation weaned down to Fentanyl 50mcg/hr and Versed 1mg/hr, Checked\n ABG and Sx only ever 6hrs. TF turned of at 4am in anticipation of\n ?extubation. Lasix drip cont at 3mg and she was 2l Neg at mn She cont\n on her inhalers\n Response:\n She has had no c/o SOB through the night, O2 sats 90-94% with min\n secretions and a good ABG for her.. She has not been increasingly\n agitated as sedation is weaned down . Attempt at SBT and PEEP at 0\n Brought on an O2 sat of 85% so she is back to PSV of . u/o\n 60-120cc/hr . No changes with VS as yet\n Plan:\n Will eval for extubation, cont inhalers\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728375,
"text": "Respiratory failure, chronic\n Assessment:\n Pt cont to do well on PSV of , with no c/o SOB\n Action:\n Sedation weaned down to Fentanyl 50mcg/hr and Versed 1mg/hr, Checked\n ABG and Sx only ever 6hrs. TF turned of at 4am in anticipation of\n ?extubation. Lasix drip cont at 3mg and she was 2l Neg at mn She cont\n on her inhalers\n Response:\n She has had no c/o SOB through the night, O2 sats 90-94% with min\n secretions and a good ABG for her.. She has not been increasingly\n agitated as sedation is weaned down . Attempt at SBT and PEEP at 0\n Brought on an O2 sat of 85% so she is back to PSV of . u/o\n 60-120cc/hr . No changes with VS as yet\n Plan:\n Will eval for extubation, cont inhalers\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 729065,
"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 67yo woman with severe COPD (FEV1 23%, on 4L home O2), constipation,\n and other issues here with right-sided pneumonia and ARDS / respiratory\n failure who was admitted on ; extubated \n 24 Hour Events:\n no sob, no chest pain, no complaints\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 12:14 PM\n Diazepam (Valium) - 07:30 PM\n Pantoprazole (Protonix) - 08:22 AM\n Heparin Sodium (Prophylaxis) - 09:00 AM\n Other medications:\n RISS, Albuterol, Atrovent, Flovent, Colace, Prednisone 20, Captopril,\n amlodipine, Valium prn, heparin sc\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:03 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.7\nC (96.3\n HR: 95 (75 - 99) bpm\n BP: 127/79(95) {105/64(77) - 169/96(191)} mmHg\n RR: 26 (16 - 26) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 838 mL\n 510 mL\n PO:\n 550 mL\n 500 mL\n TF:\n IVF:\n 288 mL\n 10 mL\n Blood products:\n Total out:\n 1,335 mL\n 645 mL\n Urine:\n 1,335 mL\n 645 mL\n NG:\n Stool:\n Drains:\n Balance:\n -497 mL\n -135 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 93%\n ABG: 7.46/54/131/35/13\n PaO2 / FiO2: 262\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : R basilar)\n Abdominal: Soft, Non-tender, abd hernia fully reducible\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.6 g/dL\n 446 K/uL\n 90 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 50 mg/dL\n 101 mEq/L\n 147 mEq/L\n 33.4 %\n 19.2 K/uL\n [image002.jpg]\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n 09:57 AM\n 12:26 PM\n 12:51 PM\n 05:36 PM\n 04:49 AM\n WBC\n 22.7\n 19.2\n Hct\n 32.9\n 33.4\n Plt\n 465\n 446\n Cr\n 0.9\n 0.9\n 1.0\n 0.9\n TCO2\n 38\n 39\n 43\n 39\n 39\n 40\n Glucose\n 121\n 93\n 127\n 90\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Imaging: CXR- resovling RLL infiltrate\n Assessment and Plan\n 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with right-sided pneumonia and ARDS / respiratory failure who was\n admitted on ; extubated \n 1. Resp failure- resolving ARDS and COPD exac, pna; distress yest\n likely related to benzo withdrawal (prolonged ICU course of gtt)\n -prednisone 20 qd; slow taper\n -pulmonary toilet\n -OOB, incentive spirometry\n -monitor autodiuresis; strive for neg TBB\n 2. Benzo withdrawal- Ativan prn and PO Valium but will increase\n interval or decrease dose\n 3. Hypernatremia- encourage po\n 4. HTN- monitor creat on ACE, cont CCB\n 5. Gen Care-\n -PT/OT\n -advance diet\n ICU Care\n Nutrition:\n Comments: po diet- advance today\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n ------ Protected Section ------\n I have seen and examined the patient with the fellow and agree\n substantially with the assessment and plan as above with the following\n modifications/emphasis:\n Overnight, has remained extubated without any new problems\n Tm: 98.6 Tc: 96.5 P: 80 BP: 139/80 RR: 18 Oxygen\n Saturation: 94-5% on Fio2 of 0.5\n General: Awake, alert NAD\n Chest: Clear to auscultation\n Heart: S1 S2 reg\n Abd: Soft NT ND\n Ext: warm, vendynes in place\n Labs: reviewed and as above\n Assessment:\n 1) Pneumonia\n resolving/resolved\n 2) COPD Exacerbation\n improving and oxygen saturation approaching\n baseline leves (on outpatient 2 -4 liters per nasal cannula)\n 3) Hypernatremia\n Plan:\n 1) Continue albuterol and atrovent therapy; continue to wean\n prednisone\n 2) Continue wean oxygen as tolerated\n 3) Discontinue right arterial line and attempt peripheral access\n in order to discontinue central line as well\n 4) Physical therapy consult but maintain limited exertion\n 5) Advance diet but observe for aspiration and advance only as\n tolerated\n 6) Monitor sodium\n appears to be auto-correcting after holding\n diuretics and liberalizing PO/free water\n Time Spent: 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 19:17 ------\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-08 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 728656,
"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 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with ARDS / respiratory failure who was admitted on .\n 24 Hour Events:\n On and off BiPAP overnight.\n Anxious this morning; repeat ABG (off BiPAP) reveals respiratory\n alkalosis:\n 7.51 / 47 / 124\n Allergies:\n Penicillins\n Unknown\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Prophylaxis - 12:00 AM\n Other medications:\n Heparin 5K TID\n Colace \n Atrovent 6 puffs q6\n Protonix 40mg IV q24h\n Peridex \n RSSI\n Prednisone 30mg q24h\n Fluticasone 220mcg 4 puffs \n Free H2O 250mg \n Narcan 1mg PO q6h\n Changes to medical 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: 36.6\nC (97.8\n Tcurrent: 36.1\nC (97\n HR: 89 (73 - 89) bpm\n BP: 160/88 {109/66 - 178/96} mmHg\n RR: 16 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt current: 90.1 kg admi): 100.9 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 154 mL\n PO:\n 350 mL\n 50 mL\n TF:\n 140 mL\n IVF:\n 340 mL\n 104 mL\n Blood products:\n Total out:\n 3,065 mL\n 400 mL\n Urine:\n 3,065 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,935 mL\n -246 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (400 - 540) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 18 cmH2O\n SpO2: 93%\n ABG: 7.44/61/147/37/14\n Ve: 9.6 L/min\n PaO2 / FiO2: 294\n Physical Examination\n Gen: Looks comfortable on vent, answering yes / no questions\n appropriately.\n HEENT: OP clear.\n CV: S1S2 RRR w/o m/r/g\ns appreciated.\n Lungs: CTA anteriorly without significant crackles / wheezing.\n Ab: Positive BS\ns. Obese. NT/ND.\n Ext: No significant edema.\n Neuro: Alert, appropriate\n Labs / Radiology\n 10.7 g/dL\n 465 K/uL\n 93 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 100 mEq/L\n 148 mEq/L\n 32.9 %\n 22.7 K/uL\n [image002.jpg]\n Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %, Mono:3.0 %, Eos:0.0\n %,\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n 10:27 AM\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n WBC\n 20.8\n 22.7\n Hct\n 31.3\n 32.9\n Plt\n 435\n 465\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 42\n 40\n 40\n 38\n 39\n 43\n Glucose\n 143\n 93\n 121\n 93\n Other labs:\n PT / PTT / INR:10.8/28.4/0.9,\n ALT / AST:29/13, Alk Phos / T Bili:103/0.2,\n Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.6 mg/dL, Mg++:2.5 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with right-sided pneumonia and ARDS / respiratory failure who was\n admitted on .\n HYPERNATREMIA (HIGH SODIUM)\n Continue free water boluses for now; if no improvement by tomorrow will\n increase to q6h.\n CONSTIPATION (OBSTIPATION, FOS)\n D/c Narcan PO. Has rectal tube in and is having adequate stool out-put.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n Will try with 0/0 trial this morning. If she passes the with\n normal hemodynamics, RSBI < 105, and an acceptable ABG she could be\n extubatable. Continue Lasix gtt / consider bolus immediately prior to\n extubation. If passes , extubate to NIPPV given she has chronic\n respiratory disease and is high-risk for extubation failure.\n Plan to titrate Prednisone to 20mg q24h tomorrow. Continue inhalers.\n If she fails extubation, she would be a candidate for trach.\n VOLUME OVERLOAD\n Remains on Lasix gtt with a goal of continued diuresis as tolerated.\n She had been on acetazolamide for metabolic alkalosis related to\n aggressive diuresis, currently off. Follow bicarb. Anticipate getting\n intermittent ABGs with and possible extubation today.\n HYPERTENSION\n Off antihypertensives now, anticipate reintroducing meds\n peri-extubation as sedation comes off. Goal to optimize BP to minimize\n risk of peri-extubation pulmonary edema.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 PM\n Prophylaxis:\n DVT: Heparin subQ / SCDs\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": "2192-04-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728864,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, Now\n extubated () and improving\n constipation (Constipation, FOS)\n Assessment:\n Pt with no abd c/o pain but with min stool output in last 24hrs. No\n trouble with swallowing or\n Action:\n Given senecot and colace\n Response:\n +bowel sounds, sm amt of stool in flexiseal\n Plan:\n Cont to follow stool amts, Encourage eating today\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n She cont to do well on 50% high flow neb , Much less cont of SOB and\n anxiety after given valium\n Action:\n Nebs and steroids cont , Following I&O , given 10mg po valium at 8pm\n for agitation\n Response:\n Much less restlessness, O2 sats of 92-96%, Pt still neg I&O and u/o\n 50-60cc/hr\n Plan:\n Cont to wean Fio2 as able, cont nebs an steroids taper, Asses for need\n for more valium with increased agitation/restlessness/anxiety\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728866,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, Now\n extubated () and improving\n constipation (Constipation, FOS)\n Assessment:\n Pt with no abd c/o pain but with min stool output in last 24hrs. No\n trouble with swallowing or\n Action:\n Given senecot and colace\n Response:\n +bowel sounds, sm amt of stool in flexiseal\n Plan:\n Cont to follow stool amts, Encourage eating today\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n She cont to do well on 50% high flow neb , Much less cont of SOB and\n anxiety after given valium\n Action:\n Nebs and steroids cont , Following I&O , given 10mg po valium at 8pm\n for agitation\n Response:\n Much less restlessness, O2 sats of 92-96%, Pt still neg I&O and u/o\n 50-60cc/hr\n Plan:\n Cont to wean Fio2 as able, cont nebs an steroids taper, Asses for need\n for more valium with increased agitation/restlessness/anxiety\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 728661,
"text": "Chief Complaint:\n 24 Hour Events:\n - extubated to bipap - 7.43/58/61 after ~1 hour on %\n - bipap off for 6 hours - pt stated uncomfortable although O2 Sat OK\n and RR 15 (ABG 7.43/53/108, same as on bipap and as when intubated) -\n back to bipap for a bit just for her comfort but quickly back to face\n tent.\n - lasix gtt @ 3, making ~150cc/h urine\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.1\nC (97\n HR: 89 (73 - 89) bpm\n BP: 160/88(113) {109/66(84) - 178/96(128)} mmHg\n RR: 16 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 155 mL\n PO:\n 350 mL\n 50 mL\n TF:\n 140 mL\n IVF:\n 340 mL\n 105 mL\n Blood products:\n Total out:\n 3,065 mL\n 400 mL\n Urine:\n 3,065 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,935 mL\n -245 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (400 - 540) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 18 cmH2O\n SpO2: 93%\n ABG: 7.44/61/147/37/14\n Ve: 9.6 L/min\n PaO2 / FiO2: 294\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: no edema, no sacral edema\n Labs / Radiology\n 465 K/uL\n 10.7 g/dL\n 93 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 100 mEq/L\n 148 mEq/L\n 32.9 %\n 22.7 K/uL\n [image002.jpg]\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n 10:27 AM\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n WBC\n 20.8\n 22.7\n Hct\n 31.3\n 32.9\n Plt\n 435\n 465\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 42\n 40\n 40\n 38\n 39\n 43\n Glucose\n 143\n 93\n 121\n 93\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.6 mg/dL, Mg++:2.5 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS, now\n extubated after prolonged intubation.\n # Respiratory failure: now extubated. Now tachypneic, anxious. ABG\n 7.51/47/124/39, suggesting respiratory alkalosis on top of ongoing\n metabolic alkalosis from hyperventilation.\n - benzo for anxiety\n - monitor closely\n - BiPAP prn\n - continue gentle furosemide gtt for pulm edema\n # Pneumonia: s/p course of broad-spectrum abx.\n # Metabolic alkalosis: secondary to aggressive diuresis, improving\n # Hx of hypertension:\n - increase captopril to 25 tid\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ\n # CODE: Full\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 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": "2192-04-08 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 728663,
"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 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with ARDS / respiratory failure who was admitted on .\n 24 Hour Events:\n On and off BiPAP overnight.\n Anxious this morning; repeat ABG (off BiPAP) reveals respiratory\n alkalosis:\n 7.51 / 47 / 124\n Allergies:\n Penicillins\n Unknown\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Prophylaxis - 12:00 AM\n Other medications:\n Heparin 5K TID\n Colace \n Atrovent 6 puffs q6\n Protonix 40mg IV q24h\n Peridex \n RSSI\n Prednisone 30mg q24h\n Fluticasone 220mcg 4 puffs \n Free H2O 250mg \n Narcan 1mg PO q6h\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 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.1\nC (97\n HR: 89 (73 - 89) bpm\n BP: 160/88 {109/66 - 178/96} mmHg\n RR: 16 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt current: 90.1 kg admi): 100.9 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 154 mL\n PO:\n 350 mL\n 50 mL\n TF:\n 140 mL\n IVF:\n 340 mL\n 104 mL\n Blood products:\n Total out:\n 3,065 mL\n 400 mL\n Urine:\n 3,065 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,935 mL\n -246 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (400 - 540) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 18 cmH2O\n SpO2: 93%\n ABG: 7.44/61/147/37/14\n Ve: 9.6 L/min\n PaO2 / FiO2: 294\n Physical Examination\n Gen: Very uncomfortable .\n HEENT: OP clear.\n CV: S1S2 RRR w/o m/r/g\ns appreciated.\n Lungs: CTA anteriorly without significant crackles / wheezing.\n Ab: Positive BS\ns. Obese. NT/ND.\n Ext: No significant edema.\n Neuro: Alert, appropriate, anxious, no gross focal deficits.\n Labs / Radiology\n 10.7 g/dL\n 465 K/uL\n 93 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 100 mEq/L\n 148 mEq/L\n 32.9 %\n 22.7 K/uL\n [image002.jpg]\n Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %, Mono:3.0 %, Eos:0.0\n %,\n pCXR (): Overall much improved right-sided opacity from .\n Similar film to exam. Bibasilar atelectasis without significant\n infiltrate or edema.\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n 10:27 AM\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n WBC\n 20.8\n 22.7\n Hct\n 31.3\n 32.9\n Plt\n 435\n 465\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 42\n 40\n 40\n 38\n 39\n 43\n Glucose\n 143\n 93\n 121\n 93\n Other labs:\n PT / PTT / INR:10.8/28.4/0.9,\n ALT / AST:29/13, Alk Phos / T Bili:103/0.2,\n Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.6 mg/dL, Mg++:2.5 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with right-sided pneumonia and ARDS / respiratory failure who was\n admitted on ; extubated yesterday with increasing\n respiratory distress.\n HYPERNATREMIA (HIGH SODIUM)\n Continue free water boluses when enteral access established; will\n increase to q6h.\n CONSTIPATION (OBSTIPATION, FOS)\n Rectal tube. Follow.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n Extubated yesterday, did relatively well overnight but more anxious /\n agitated this morning and clinically has obvious respiratory distress\n with tachypnea and accessory muscle use. She is at high risk for\n re-intubation and very well may need to be re-intubated today. Will\n focus on optimizing her hemodynamics, volume status, anxiety and COPD:\n 1) Hemodyanics: Increase captopril to 25mg TID; may need to add a\n second . Goal SBP < 140mm Hg today.\n 2) Volume status: She has been net negative, anticipate titrating\n Lasix off today as SBP improves. Ideally will keep her net negative and\n may need intermittent boluses for this.\n 3) Anxiety: Providing benzos today, titrate as needed. Will try\n Ativan 1mg IV now. Would consider adjuvant morphine as well if no\n improvement over 15-30 minutes.\n 4) COPD: decreased Prednisone to 20mg q24h today; continue\n bronchodilators.\n VOLUME OVERLOAD\n Anticipate d/c\ning Lasix gtt today. Goal net negative today.\n HYPERTENSION\n Increasing captopril as above. Follow, goal SBP < 140mm Hg.\n LEUKOCYTOSIS\n Overall, her impressive leukocytosis is improving from admission.\n Source unclear. Follow closely.\n ICU Care\n Nutrition: NPO for now\n advance pending stability of respiratory\n distress\n Glycemic Control:\n Lines: Multi Lumen - 04:24 AM and Arterial Line - \n 02:41 PM\n Prophylaxis:\n DVT: Heparin subQ / SCDs\n Stress ulcer: PPI\n VAP: N/A for now\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : MICU for now.\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-04-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 728477,
"text": "Demographics\n Day of intubation: 13\n Day of mechanical ventilation: 13\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments: Pt data as above/ per Meta-V. RSBI 97 this AM and MIP -34 cm\n H2O. Pt placed on PSV 0/0 PEEP for about one hour. ABG w/out CO2\n retention although marginal oxygenation w/ a PaO2 of 61 mmHg. Decision\n was made to extubate w/ bridge on BIPAP or NIV 12/5 PEEP FIO2 .50.\n Tolerating mask very well now for about 3 hours. Will c/w NIV and give\n a break and a trial off of NIV in another hour. Will c/w this regimen\n as long as there is no significant CO2 retention for up to 24 hours.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728766,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt conts to do well on high flow nebs , Is intermittently having some\n c/o SOB and DOE with high anxiety. Pt unable to get comfortable,\n unable to tolerate BIPAP, positive HTN.\n Action:\n Pt cont on her inhalers, Encouraged to C&DB-clr throat, restarted on\n her antihypertensives, started on an anit anxiety regimen. Multiple\n abg\ns drawn with her sereve anxiety. EKG done.\n Response:\n Pt is now more calm after 2mg of ativan ivp, .5mg of ativan po, 10 mg\n valium po and 10mg valium ivp. Team believes this is benzo\n withdrawal. Able to wean high neb to 50% from 80%.\n Plan:\n Cont with inhalers and address her needs as able, give antianxities as\n needed. Pt Is very fragile When it comes to excursion pt takes awhile\n to recover. Labs pending from 1800.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727771,
"text": "Respiratory failure, chronic\n Assessment:\n Pt. with PNA/COPD exacerbation day 9 intubated/sedated. LS\n clear/distant. VSS. Skin warm, dry, well-perfused. Receieved on\n lasix gtt at 2mg/hr.\n Action:\n ABG\ns drawn, PEEP changes made as documented (initially increased due\n to PO2 of 57, then weaned.)\n Lasix gtt increased this a.m. as BP allowed, then decreased as BP\n dipping into 80\ns systolic. Diamox increased. Pt. continues on\n prednisone.\n Response:\n Latest ABG stable for patient. No secretions noted. Pt. negative >1L\n thus far today. Sedation level between -1 and -2.\n Plan:\n Continue to monitor and treat as indicated. ?Continue to wean peep\n this evening. Continue lasix gtt for goal of negative 2L today. Pt.\n to be trached when abg\ns stable with peep <8.\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-05 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727951,
"text": "Chief Complaint:\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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 24 Hour Events:\n a line out this am.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:01 AM\n Other medications:\n Atrovent, Pantoprazole, Peridex, RISS, PO Narcan, Diamox 500 q6\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.6\nC (97.8\n HR: 69 (62 - 79) bpm\n BP: 88/50(60) {86/42(54) - 100/57(67)} mmHg\n RR: 19 (17 - 22) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,326 mL\n 830 mL\n PO:\n TF:\n 841 mL\n 362 mL\n IVF:\n 865 mL\n 218 mL\n Blood products:\n Total out:\n 3,620 mL\n 1,400 mL\n Urine:\n 3,620 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,294 mL\n -570 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 20 cmH2O\n Compliance: 47.3 cmH2O/mL\n SpO2: 92%\n Ve: 6.2 L/min\n PaO2 / FiO2: 156\n Physical Examination\n General Appearance: No acute distress\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 : ant, No(t) Crackles : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.7 g/dL\n 478 K/uL\n 115 mg/dL\n 0.9 mg/dL\n 45 mEq/L\n 5.1 mEq/L\n 61 mg/dL\n 95 mEq/L\n 143 mEq/L\n 31.0 %\n 21.0 K/uL\n [image002.jpg]\n 04:03 AM\n 12:58 AM\n 03:59 AM\n 10:04 AM\n 12:37 PM\n 02:56 PM\n 11:01 PM\n 02:46 AM\n 03:07 AM\n 05:31 AM\n WBC\n 21.5\n 21.0\n Hct\n 29.3\n 31.0\n Plt\n 432\n 478\n Cr\n 0.8\n 0.9\n TCO2\n 47\n 49\n 47\n 41\n 46\n 46\n 47\n 48\n Glucose\n 107\n 137\n 115\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR- decreased effusions\n Microbiology: Sputum - yeast\n All blood cx neg to date\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS. Slow and\n steady decrease in PEEP req't.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -cont ARDSnet ventilation --> A/CV w/ 6cc/kg Vt and permissive\n hypercapnia, tolerating pH down to 7.20\n -wean FiO2 and PEEP to maintain PaO2 > 60\n -day 10 intubation at this point, if PEEP <8 tomorrow will assess for\n spont breathing\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n increase azetazolamide to help w/ HCO3 wasting in the setting of\n contraction alkalosis\n -will concentrate IVF and tube feeds\n -steroids weaning to 20 qd tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:33 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Comments: attempt to replace aline\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n ------ Protected Section ------\n Patient seen and examined with Dr. , and house staff team.\n I have reviewed his note and agree with assessment and plan. Would\n add/emphasize.\n 67 yo women with severe PNA, COPD, and respiratory failure. Slowly\n weaning down on Peep.\n Exam: patient arousable, moves all extremities. Lungs diminished BS\n CV: reg Abd: soft\n A/P\n - Respiratory failure: will with significant Peep requirement.\n Continue diuresis and weaning of the Peep.\n - Has completed antibiotics course. Continue to wean steroids.\n - Consider changing out central like to a PIC.\n CC 30 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:29 ------\n"
},
{
"category": "General",
"chartdate": "2192-04-05 00:00:00.000",
"description": "Generic Note",
"row_id": 727954,
"text": "TITLE: Updating family over the phone\n Talked to patient\ns sister over the phone to update her on patient\n progress. Told sister that Ms. was still very sick but making\n slow progress. Discussed possibility of tracheostomy in the next few\n days. Sister understood and had no question.\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-08 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 728624,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.1\nC (97\n HR: 89 (73 - 89) bpm\n BP: 160/88(113) {109/66(84) - 178/96(128)} mmHg\n RR: 16 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 154 mL\n PO:\n 350 mL\n 50 mL\n TF:\n 140 mL\n IVF:\n 340 mL\n 104 mL\n Blood products:\n Total out:\n 3,065 mL\n 400 mL\n Urine:\n 3,065 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,935 mL\n -246 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (400 - 540) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 18 cmH2O\n SpO2: 93%\n ABG: 7.44/61/147/37/14\n Ve: 9.6 L/min\n PaO2 / FiO2: 294\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 10.7 g/dL\n 465 K/uL\n 93 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 100 mEq/L\n 148 mEq/L\n 32.9 %\n 22.7 K/uL\n [image002.jpg]\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n 10:27 AM\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n WBC\n 20.8\n 22.7\n Hct\n 31.3\n 32.9\n Plt\n 435\n 465\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 42\n 40\n 40\n 38\n 39\n 43\n Glucose\n 143\n 93\n 121\n 93\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.6 mg/dL, Mg++:2.5 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 728629,
"text": "Chief Complaint:\n 24 Hour Events:\n - extubated to bipap - 7.43/58/61 after ~1 hour on %\n - bipap off for 6 hours - pt stated uncomfortable although O2 Sat OK\n and RR 15 (ABG 7.43/53/108, same as on bipap and as when intubated) -\n back to bipap for a bit just for her comfort but quickly back to face\n tent.\n - lasix gtt @ 3, making ~150cc/h urine\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.1\nC (97\n HR: 89 (73 - 89) bpm\n BP: 160/88(113) {109/66(84) - 178/96(128)} mmHg\n RR: 16 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 155 mL\n PO:\n 350 mL\n 50 mL\n TF:\n 140 mL\n IVF:\n 340 mL\n 105 mL\n Blood products:\n Total out:\n 3,065 mL\n 400 mL\n Urine:\n 3,065 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,935 mL\n -245 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (400 - 540) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 18 cmH2O\n SpO2: 93%\n ABG: 7.44/61/147/37/14\n Ve: 9.6 L/min\n PaO2 / FiO2: 294\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 465 K/uL\n 10.7 g/dL\n 93 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 100 mEq/L\n 148 mEq/L\n 32.9 %\n 22.7 K/uL\n [image002.jpg]\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n 10:27 AM\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n WBC\n 20.8\n 22.7\n Hct\n 31.3\n 32.9\n Plt\n 435\n 465\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 42\n 40\n 40\n 38\n 39\n 43\n Glucose\n 143\n 93\n 121\n 93\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.6 mg/dL, Mg++:2.5 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 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": "2192-04-08 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 728632,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Prophylaxis - 12:00 AM\n Other medications:\n Heparin 5K TID\n Colace \n Atrovent 6 puffs q6\n Protonix 40mg IV q24h\n Peridex \n RSSI\n Prednisone 30mg q24h\n Fluticasone 220mcg 4 puffs \n Free H2O 250mg \n Narcan 1mg PO q6h\n Changes to medical 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: 36.6\nC (97.8\n Tcurrent: 36.1\nC (97\n HR: 89 (73 - 89) bpm\n BP: 160/88(113) {109/66(84) - 178/96(128)} mmHg\n RR: 16 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 154 mL\n PO:\n 350 mL\n 50 mL\n TF:\n 140 mL\n IVF:\n 340 mL\n 104 mL\n Blood products:\n Total out:\n 3,065 mL\n 400 mL\n Urine:\n 3,065 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,935 mL\n -246 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (400 - 540) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 18 cmH2O\n SpO2: 93%\n ABG: 7.44/61/147/37/14\n Ve: 9.6 L/min\n PaO2 / FiO2: 294\n Physical Examination\n Gen: Looks comfortable on vent, answering yes / no questions\n appropriately.\n HEENT: ETT in place.\n CV: S1S2 RRR w/o m/r/g\ns appreciated.\n Lungs: CTA anteriorly without significant crackles / wheezing.\n Ab: Positive BS\ns. Obese. NT/ND.\n Ext: No significant edema.\n Neuro: Alert, appropriate\n Labs / Radiology\n 10.7 g/dL\n 465 K/uL\n 93 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 100 mEq/L\n 148 mEq/L\n 32.9 %\n 22.7 K/uL\n [image002.jpg]\n Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %, Mono:3.0 %, Eos:0.0\n %,\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n 10:27 AM\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n WBC\n 20.8\n 22.7\n Hct\n 31.3\n 32.9\n Plt\n 435\n 465\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 42\n 40\n 40\n 38\n 39\n 43\n Glucose\n 143\n 93\n 121\n 93\n Other labs:\n PT / PTT / INR:10.8/28.4/0.9,\n ALT / AST:29/13, Alk Phos / T Bili:103/0.2,\n Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.6 mg/dL, Mg++:2.5 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with right-sided pneumonia and ARDS / respiratory failure who was\n admitted on .\n HYPERNATREMIA (HIGH SODIUM)\n Continue free water boluses for now; if no improvement by tomorrow will\n increase to q6h.\n CONSTIPATION (OBSTIPATION, FOS)\n D/c Narcan PO. Has rectal tube in and is having adequate stool out-put.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n Will try with 0/0 trial this morning. If she passes the with\n normal hemodynamics, RSBI < 105, and an acceptable ABG she could be\n extubatable. Continue Lasix gtt / consider bolus immediately prior to\n extubation. If passes , extubate to NIPPV given she has chronic\n respiratory disease and is high-risk for extubation failure.\n Plan to titrate Prednisone to 20mg q24h tomorrow. Continue inhalers.\n If she fails extubation, she would be a candidate for trach.\n VOLUME OVERLOAD\n Remains on Lasix gtt with a goal of continued diuresis as tolerated.\n She had been on acetazolamide for metabolic alkalosis related to\n aggressive diuresis, currently off. Follow bicarb. Anticipate getting\n intermittent ABGs with and possible extubation today.\n HYPERTENSION\n Off antihypertensives now, anticipate reintroducing meds\n peri-extubation as sedation comes off. Goal to optimize BP to minimize\n risk of peri-extubation pulmonary edema.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 PM\n Prophylaxis:\n DVT: Heparin subQ / SCDs\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": "2192-04-08 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 728633,
"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 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with ARDS / respiratory failure who was admitted on .\n 24 Hour Events:\n Allergies:\n Penicillins\n Unknown\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Heparin Prophylaxis - 12:00 AM\n Other medications:\n Heparin 5K TID\n Colace \n Atrovent 6 puffs q6\n Protonix 40mg IV q24h\n Peridex \n RSSI\n Prednisone 30mg q24h\n Fluticasone 220mcg 4 puffs \n Free H2O 250mg \n Narcan 1mg PO q6h\n Changes to medical 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: 36.6\nC (97.8\n Tcurrent: 36.1\nC (97\n HR: 89 (73 - 89) bpm\n BP: 160/88(113) {109/66(84) - 178/96(128)} mmHg\n RR: 16 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 1,130 mL\n 154 mL\n PO:\n 350 mL\n 50 mL\n TF:\n 140 mL\n IVF:\n 340 mL\n 104 mL\n Blood products:\n Total out:\n 3,065 mL\n 400 mL\n Urine:\n 3,065 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,935 mL\n -246 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (400 - 540) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 80%\n PIP: 18 cmH2O\n SpO2: 93%\n ABG: 7.44/61/147/37/14\n Ve: 9.6 L/min\n PaO2 / FiO2: 294\n Physical Examination\n Gen: Looks comfortable on vent, answering yes / no questions\n appropriately.\n HEENT: ETT in place.\n CV: S1S2 RRR w/o m/r/g\ns appreciated.\n Lungs: CTA anteriorly without significant crackles / wheezing.\n Ab: Positive BS\ns. Obese. NT/ND.\n Ext: No significant edema.\n Neuro: Alert, appropriate\n Labs / Radiology\n 10.7 g/dL\n 465 K/uL\n 93 mg/dL\n 0.9 mg/dL\n 37 mEq/L\n 4.1 mEq/L\n 58 mg/dL\n 100 mEq/L\n 148 mEq/L\n 32.9 %\n 22.7 K/uL\n [image002.jpg]\n Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %, Mono:3.0 %, Eos:0.0\n %,\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n 10:27 AM\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n WBC\n 20.8\n 22.7\n Hct\n 31.3\n 32.9\n Plt\n 435\n 465\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 42\n 40\n 40\n 38\n 39\n 43\n Glucose\n 143\n 93\n 121\n 93\n Other labs:\n PT / PTT / INR:10.8/28.4/0.9,\n ALT / AST:29/13, Alk Phos / T Bili:103/0.2,\n Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.6 mg/dL, Mg++:2.5 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with right-sided pneumonia and ARDS / respiratory failure who was\n admitted on .\n HYPERNATREMIA (HIGH SODIUM)\n Continue free water boluses for now; if no improvement by tomorrow will\n increase to q6h.\n CONSTIPATION (OBSTIPATION, FOS)\n D/c Narcan PO. Has rectal tube in and is having adequate stool out-put.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n Will try with 0/0 trial this morning. If she passes the with\n normal hemodynamics, RSBI < 105, and an acceptable ABG she could be\n extubatable. Continue Lasix gtt / consider bolus immediately prior to\n extubation. If passes , extubate to NIPPV given she has chronic\n respiratory disease and is high-risk for extubation failure.\n Plan to titrate Prednisone to 20mg q24h tomorrow. Continue inhalers.\n If she fails extubation, she would be a candidate for trach.\n VOLUME OVERLOAD\n Remains on Lasix gtt with a goal of continued diuresis as tolerated.\n She had been on acetazolamide for metabolic alkalosis related to\n aggressive diuresis, currently off. Follow bicarb. Anticipate getting\n intermittent ABGs with and possible extubation today.\n HYPERTENSION\n Off antihypertensives now, anticipate reintroducing meds\n peri-extubation as sedation comes off. Goal to optimize BP to minimize\n risk of peri-extubation pulmonary edema.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 PM\n Prophylaxis:\n DVT: Heparin subQ / SCDs\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": "2192-04-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728835,
"text": "Constipation (Constipation, FOS)\n Assessment:\n Pt with no abd c/o pain but with min stool output in last 24hrs. No\n trouble with swallowing or\n Action:\n Given senecot and colace\n Response:\n +bowel sounds, sm amt of stool in flexiseal\n Plan:\n Cont to follow stool amts, Encourage eating today\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n She cont to do well on 50% high flow neb , Much less cont of SOB after\n given valium\n Action:\n Nebs and steroids cont , Following I&O , given 10mg po valium at 8pm\n for agitation\n Response:\n Much less restlessness, O2 sats of 92-96%\n Plan:\n Cont to wean Fio2 as able, cont nebs an steroids taper, Asses for need\n for more valium with increased agitation/restlessness\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728836,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, Now\n extubated () and improving\n constipation (Constipation, FOS)\n Assessment:\n Pt with no abd c/o pain but with min stool output in last 24hrs. No\n trouble with swallowing or\n Action:\n Given senecot and colace\n Response:\n +bowel sounds, sm amt of stool in flexiseal\n Plan:\n Cont to follow stool amts, Encourage eating today\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n She cont to do well on 50% high flow neb , Much less cont of SOB and\n anxiety after given valium\n Action:\n Nebs and steroids cont , Following I&O , given 10mg po valium at 8pm\n for agitation\n Response:\n Much less restlessness, O2 sats of 92-96%, Pt still neg I&O and u/o\n 50-60cc/hr\n Plan:\n Cont to wean Fio2 as able, cont nebs an steroids taper, Asses for need\n for more valium with increased agitation/restlessness/anxiety\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727768,
"text": "Respiratory failure, chronic\n Assessment:\n Pt. with PNA/COPD exacerbation day 13 intubated/sedated. LS\n clear/distant.\n Action:\n ABG\ns drawn, PEEP changes made as documented.\n Lasix gtt increased for continued diuresis. Diamox increased.\n Cont. cef\n Response:\n Latest ABG stable for patient.\n Plan:\n Continue to monitor and treat as indicated. Goal is trach when vent\n settings stabilize.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727769,
"text": "Respiratory failure, chronic\n Assessment:\n Pt. with PNA/COPD exacerbation day 9 intubated/sedated. LS\n clear/distant. VSS. Skin warm, dry, well-perfused. Receieved on\n lasix gtt at 2mg/hr.\n Action:\n ABG\ns drawn, PEEP changes made as documented.\n Lasix gtt increased this a.m. as BP allowed. Diamox increased.\n Cont. cef\n Response:\n Latest ABG stable for patient.\n Plan:\n Continue to monitor and treat as indicated. Goal is trach when vent\n settings stabilize.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728257,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Rec\nd pt intubated. Vent settings CMV 50% 350/18/10 PEEP. Fentanyl @\n 200mcg/hr & Versed @ 5mg/hr. Pt is awake/alert & following simple\n commands. Pt often gestures to communicate needs but also responds well\n to yes/no questions. PERRL. O2 sat 92-98%. Lasix gtt @ 6mg/hr (resumed\n in PM after Aline placement) Pt suctioned Q2-4 hrs for\n thick/yellow secretions. TF @ goal.\n Action:\n Multiple ABG\ns drawn in attempt to decrease vent settings for trach\n placement. Lasix gtt decreased to 3mg O/D, slight drop in BP. MAPs\n 60\ns. Finished Diamox today. MDI\ns. Steroids. Pt was switch to\n 50%/, decreased sedation.\n Response:\n Pt has remained calm throughout shift. Occasional biting of ETT noted.\n CXR showing much improved edema. Please see metavision for last\n abg, no changes made still resting comfortably.\n Plan:\n Cont to diurese with Lasix gtt. Wean vent as tolerated. Pt will need\n to maintain PEEP <10 for trach placement. attempt to extubate if pt\n keeps improving.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728602,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Pt cont to do well on high flow nebs , Is intermittently having some\n c/o SOB but it looks more like a anxiety attach as she calms down when\n you ask her to do some C&DB and clr her throat\n Action:\n Pt cont on her inhalers, Encouraged to C&DB-clr throat, Cont on lasix\n drip\n Response:\n Has cont to have good ABG for her, Diuresed 2.5l of fluid\n Plan:\n Cont with inhalers and address her needs as able\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727748,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 24 Hour Events:\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 09:03 AM\n Other medications:\n Atrovent, Peridex, RISS, Albuterol prn, Narcan PO, Flovent, Lasix gtt,\n Diamox, Prednisone 30 qd\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.6\nC (97.8\n HR: 76 (60 - 79) bpm\n BP: 101/53(67) {91/48(63) - 108/75(83)} mmHg\n RR: 21 (16 - 22) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,898 mL\n 953 mL\n PO:\n TF:\n 1,168 mL\n 369 mL\n IVF:\n 1,050 mL\n 304 mL\n Blood products:\n Total out:\n 4,550 mL\n 1,330 mL\n Urine:\n 4,450 mL\n 1,330 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -1,652 mL\n -377 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 91%\n ABG: 7.43/68/57/49/16\n Ve: 7.8 L/min\n PaO2 / FiO2: 114\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ant)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 9.2 g/dL\n 432 K/uL\n 107 mg/dL\n 0.8 mg/dL\n 49 mEq/L\n 3.9 mEq/L\n 55 mg/dL\n 91 mEq/L\n 143 mEq/L\n 29.3 %\n 21.5 K/uL\n [image002.jpg]\n 04:16 AM\n 04:22 AM\n 05:09 PM\n 05:22 PM\n 10:16 PM\n 03:59 AM\n 04:03 AM\n 12:58 AM\n 03:59 AM\n 10:04 AM\n WBC\n 24.5\n 24.7\n 21.5\n Hct\n 30.5\n 29.6\n 29.3\n Plt\n \n Cr\n 0.8\n 0.9\n 0.9\n 0.8\n TCO2\n 43\n 48\n 48\n 47\n 49\n 47\n Glucose\n 132\n 185\n 114\n 107\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Imaging: CXR- no sig change, bibasilr dz\n Microbiology: Sputum- GPCs, yeast\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -cont ARDSnet ventilation --> A/CV w/ 6cc/kg Vt and permissive\n hypercapnia, tolerating pH down to 7.20\n -wean FiO2 and PEEP to maintain PaO2 > 60\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n increase azetazolamide to help w/ HCO3 wasting in the setting of\n contraction alkalosis\n -will concentrate IVF and tube feeds\n -off ABX yesterday\n -steroids weaning to 20 qd tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:20 AM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\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: 30 minutes\n Patient is critically ill\n ------ Protected Section ------\n Patient seen and examined with Dr. , and house staff team.\n I have reviewed his note and agree with assessment and plan. Would\n add/emphasize.\n 67 yo women with severe COPD, PNA, respiratory failure. Slow weaning\n of PEEP - was down to 10 last night and then back up to 12.\n Exam: clear lungs: patient arousable. CV: reg. Abd; Soft, ext trace\n edema.\n A/P.\n Respiratory failue: COPD, PNA. Wean Peep, steroids, continue\n antibiotics.\n need trach at some point.\n Contineu diuresis, diamox for alkalosis.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:57 ------\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727760,
"text": "Respiratory failure, chronic\n Assessment:\n Pt. with PNA/COPD exacerbation day 13 intubated/sedated. LS\n clear/distant.\n Action:\n ABG\ns drawn, PEEP changes made as documented.\n Lasix gtt increased for continued diuresis. Diamox increased.\n Cont. cef\n Response:\n Latest ABG stable for patient.\n Plan:\n Continue to monitor and treat as indicated. Goal is trach when vent\n settings stabilize.\n"
},
{
"category": "Nutrition",
"chartdate": "2192-04-05 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 727936,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 100.9 kg\n 92.4 kg ( 08:00 AM)\n 34.8\n Pertinent medications: Fentanyl drip, normal saline @ 10ml/hr, lasix,\n heparin, colace, pantoprazole, naloxone, prednisone, humalog insulin\n sliding scale\n Labs:\n Value\n Date\n Glucose\n 115 mg/dL\n 02:46 AM\n Glucose Finger Stick\n 182\n 12:00 PM\n BUN\n 61 mg/dL\n 02:46 AM\n Creatinine\n 0.9 mg/dL\n 02:46 AM\n Sodium\n 143 mEq/L\n 02:46 AM\n Potassium\n 5.1 mEq/L\n 02:46 AM\n Chloride\n 95 mEq/L\n 02:46 AM\n TCO2\n 45 mEq/L\n 02:46 AM\n PO2 (arterial)\n 77. mm Hg\n 05:31 AM\n PO2 (venous)\n 42 mm Hg\n 09:59 AM\n PCO2 (arterial)\n 75 mm Hg\n 05:31 AM\n PCO2 (venous)\n 65 mm Hg\n 04:39 AM\n pH (arterial)\n 7.40 units\n 05:31 AM\n pH (venous)\n 7.16 units\n 04:39 AM\n pH (urine)\n 6.0 units\n 07:39 PM\n CO2 (Calc) arterial\n 48 mEq/L\n 05:31 AM\n CO2 (Calc) venous\n 24 mEq/L\n 04:39 AM\n Albumin\n 3.0 g/dL\n 03:58 AM\n Calcium non-ionized\n 9.3 mg/dL\n 02:46 AM\n Phosphorus\n 3.7 mg/dL\n 02:46 AM\n Ionized Calcium\n 1.13 mmol/L\n 03:14 AM\n Magnesium\n 2.5 mg/dL\n 02:46 AM\n ALT\n 29 IU/L\n 03:58 AM\n Alkaline Phosphate\n 103 IU/L\n 03:58 AM\n AST\n 13 IU/L\n 03:58 AM\n Total Bilirubin\n 0.2 mg/dL\n 03:58 AM\n WBC\n 21.0 K/uL\n 02:46 AM\n Hgb\n 9.7 g/dL\n 02:46 AM\n Hematocrit\n 31.0 %\n 02:46 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Nutren 2.0 @ 35ml/hr + 21g Beneprotein\n GI: soft, positive bowel sounds, loose stool\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Patient w/ severe COPD admitted w/ respiratory failure due to pneumonia\n and COPD exacerbation. Remains intubated/sedated. Tube feed formula\n changed to minimize free water. Tolerating tube feed at goal via\n OGT to provide 1755 calories and 85g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Continue\n tube feed at goal\n o Monitor residuals, hold tube feed if greater than 200ml\n Check chemistry 10 panel daily\n BS management\n Will follow, page if questions *\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-04-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 728062,
"text": "Demographics\n Day of mechanical ventilation: 12\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 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 / 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 Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727749,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 24 Hour Events:\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 09:03 AM\n Other medications:\n Atrovent, Peridex, RISS, Albuterol prn, Narcan PO, Flovent, Lasix gtt,\n Diamox, Prednisone 30 qd\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.6\nC (97.8\n HR: 76 (60 - 79) bpm\n BP: 101/53(67) {91/48(63) - 108/75(83)} mmHg\n RR: 21 (16 - 22) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,898 mL\n 953 mL\n PO:\n TF:\n 1,168 mL\n 369 mL\n IVF:\n 1,050 mL\n 304 mL\n Blood products:\n Total out:\n 4,550 mL\n 1,330 mL\n Urine:\n 4,450 mL\n 1,330 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -1,652 mL\n -377 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 91%\n ABG: 7.43/68/57/49/16\n Ve: 7.8 L/min\n PaO2 / FiO2: 114\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ant)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 9.2 g/dL\n 432 K/uL\n 107 mg/dL\n 0.8 mg/dL\n 49 mEq/L\n 3.9 mEq/L\n 55 mg/dL\n 91 mEq/L\n 143 mEq/L\n 29.3 %\n 21.5 K/uL\n [image002.jpg]\n 04:16 AM\n 04:22 AM\n 05:09 PM\n 05:22 PM\n 10:16 PM\n 03:59 AM\n 04:03 AM\n 12:58 AM\n 03:59 AM\n 10:04 AM\n WBC\n 24.5\n 24.7\n 21.5\n Hct\n 30.5\n 29.6\n 29.3\n Plt\n \n Cr\n 0.8\n 0.9\n 0.9\n 0.8\n TCO2\n 43\n 48\n 48\n 47\n 49\n 47\n Glucose\n 132\n 185\n 114\n 107\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.4 mg/dL, PO4:4.0 mg/dL\n Imaging: CXR- no sig change, bibasilr dz\n Microbiology: Sputum- GPCs, yeast\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -cont ARDSnet ventilation --> A/CV w/ 6cc/kg Vt and permissive\n hypercapnia, tolerating pH down to 7.20\n -wean FiO2 and PEEP to maintain PaO2 > 60\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n increase azetazolamide to help w/ HCO3 wasting in the setting of\n contraction alkalosis\n -will concentrate IVF and tube feeds\n -off ABX yesterday\n -steroids weaning to 20 qd tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:20 AM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\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: 30 minutes\n Patient is critically ill\n ------ Protected Section ------\n Patient seen and examined with Dr. , and house staff team.\n I have reviewed his note and agree with assessment and plan. Would\n add/emphasize.\n 67 yo women with severe COPD, PNA, respiratory failure. Slow weaning\n of PEEP - was down to 10 last night and then back up to 12.\n Exam: clear lungs: patient arousable. CV: reg. Abd; Soft, ext trace\n edema.\n A/P.\n Respiratory failue: COPD, PNA. Wean Peep, steroids, continue\n antibiotics.\n need trach at some point.\n Contineu diuresis, diamox for alkalosis.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:57 ------\n CC: 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 13:57 ------\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727822,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Rec\nd pt intubated, on vent settings CMV 50% 350/16/14 PEEP. Rec\nd pt\n sedated on 200mcg/kg/min fentanyl, and 6mg/hr versed. Obv 1-4 bpm,\n easily awakens to vioce, consitently following commands. Sats low\n 90s. TF at goal. Rec\nd pt on lasix gtt at 8mg/hr.\n Action:\n Cont to diurese with lasix drip titrating to UO goal -1.5-2L neg.\n Decreasing lasix gtt to 3mg/hr t/o shift systolics < 90s. On\n diamox due to metabolic alkalosis from diurese. On standing dose PO\n prednisone. On standing mdi\ns. Able to wean PEEP to 12.\n Response:\n Negative 1.6L at midnight. UO > 100cc/hr. ABG unchanged, please see\n metavision for specifics. Bilte block remains in to prevent patient\n from biting on tube as she bit through her pilot on Friday. Lips look\n ok with bit block in. position of bite block and ett slightly changed\n today to prevent pressure ulcers.\n Plan:\n Cont to diurese with lasix. Cont mdi\ns. Wean vent as tolerated. ?\n plan with bite block as this is high potential for patient to break\n down, Dr. aware, will address in AM.\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-04-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 728352,
"text": "Demographics\n Day of mechanical ventilation: 13\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n 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 Comments: MDIs given as documented\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt remains orally intubated on PSV; no changes made overnoc;\n pt desat to high 80s when placed on +0PEEP for RSBI this AM, placed\n back to previous settings of +8PSV/+5PEEP w/ Vt ~300s RR 20s\n maintaining Ve ~8L/M. RSBI = 97\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts; Comments: desat when positive pressure is taken away\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728472,
"text": "Hypernatremia (high sodium)\n Assessment:\n Please see labs this am. Continues on lasix drip at 3 mgs/hr,. no\n peripheral edema noted. Has had an excellent urinary output.. receiving\n free water boluses of 250 ccs q 12 hrs.\n Action:\n Tx with extra 10 mgs ivp lasix prior to extubation. Also increased drip\n to 10 mgs/hr as bp was on high side.\n Response:\n Good response\n Plan:\n Will follow I\ns and o\ns, labs\n Respiratory failure, chronic\n Assessment:\n Repeated SBT and pt looked comfortable- and ABG was acceptable.\n Action:\n Extubated pt and placed on bipap 12/5.\n Response:\n Continued to look comfortable and tolerate bipap.\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 728947,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 01:33 PM\n INVASIVE VENTILATION - STOP 04:00 AM\n - was agitated, restless during the day with stable vitals and ABGs\n - received diazepam PO and IV and restlessness resolved; concerning for\n benzo withdrawal\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:33 AM\n Lorazepam (Ativan) - 12:14 PM\n Diazepam (Valium) - 07:30 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:10 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: 37\nC (98.6\n HR: 82 (75 - 109) bpm\n BP: 152/80(105) {114/64(83) - 174/96(191)} mmHg\n RR: 22 (16 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 838 mL\n 380 mL\n PO:\n 550 mL\n 380 mL\n TF:\n IVF:\n 288 mL\n Blood products:\n Total out:\n 1,335 mL\n 380 mL\n Urine:\n 1,335 mL\n 380 mL\n NG:\n Stool:\n Drains:\n Balance:\n -497 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n Ventilator mode: CPAP/PSV\n PS : 12 cmH2O\n PEEP: 5 cmH2O\n FiO2: 50%\n SpO2: 95%\n ABG: 7.46/54/131/35/13\n PaO2 / FiO2: 262\n Physical Examination\n GEN: on face mask, appears comfortable, awake, alert, answering\n questions appropriately\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes improved\n CARDIAC: distant, regular, no murmurs audible\n ABDOMEN: obese, soft, nontender; prominent bowel sounds\n EXTREMITIES: no edema, no sacral edema, 2+ distal pulses\n Labs / Radiology\n 446 K/uL\n 10.6 g/dL\n 90 mg/dL\n 0.9 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 50 mg/dL\n 101 mEq/L\n 147 mEq/L\n 33.4 %\n 19.2 K/uL\n [image002.jpg]\n 03:35 PM\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n 09:57 AM\n 12:26 PM\n 12:51 PM\n 05:36 PM\n 04:49 AM\n WBC\n 22.7\n 19.2\n Hct\n 32.9\n 33.4\n Plt\n 465\n 446\n Cr\n 0.9\n 0.9\n 1.0\n 0.9\n TCO2\n 38\n 39\n 43\n 39\n 39\n 40\n Glucose\n 121\n 93\n 127\n 90\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.3 mg/dL, Mg++:2.5 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS, now\n extubated after prolonged intubation.\n # Respiratory failure: now extubated.. Most recent () ABG\n 7.51/47/124/39 suggesting respiratory alkalosis on top of ongoing\n metabolic alkalosis from hyperventilation.\n - benzo prn for anxiety and possible benzo withdrawal given long term\n - BiPAP prn\n - continue supplemental oxygen for goal SpO2 88-92%\n - allow her to autodiuresis for goal of net negative daily\n - continue prednisone taper at 20mg daily x 3 days\n - encourage incentive spirometry\n # Pneumonia: s/p course of broad-spectrum abx.\n # Metabolic alkalosis: secondary to aggressive diuresis, improving\n # Hx of hypertension:\n - continue captopril 25 tid with plan to convert to lisinopril in am\n .\n # Hypernatremia:\n - Encourage po water intake\n - continue to monitor\n # FEN: IVF boluses / replete lytes prn / advance diet as tolerated\n # PPX: PPI per home regimen, heparin SQ, bowel regimen\n # ACCESS: RIJ if PIV placed will d/c RIJ and art line\n # CODE: Full\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-04-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 728248,
"text": "Demographics\n Day of intubation: 12\n Day of mechanical ventilation: 12\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments: Pt data as above and per Meta-V. RSBI 80 this AM but a bit\n labored on PSV 5/ 0 PEEP w/ marginal oxygenation on 200 Fentanyl.\n Changed to PSV 8/8 PEEP FIO2 .50 as tolerated and appears comfortable\n w/ VT\ns 350-400 cc. ABG pending. Will c/w PSV as tolerated while\n Fentanyl being tapered and reevaluate in the AM.\n"
},
{
"category": "ECG",
"chartdate": "2192-04-08 00:00:00.000",
"description": "Report",
"row_id": 240256,
"text": "Sinus rhythm. Tracing may be within normal limits but baseline artifact in\nleads V2-V6 makes assessment difficult. Since the previous tracing of \nthere may be no significant change but baseline artifact in the precordial\nleads makes comparison difficult.\n\n"
},
{
"category": "ECG",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Report",
"row_id": 240257,
"text": "Sinus rhythm. Tracing is without diagnostic abnormality. Compared to the\nprevious tracing of there is no diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2192-03-26 00:00:00.000",
"description": "Report",
"row_id": 240258,
"text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727134,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Hypernatremia (high sodium)\n Assessment:\n Na 145. TF infusing at goal of 65cc/hr.\n Action:\n Continue with free water flushes of 250cc every 4 hours.\n Response:\n Morning sodium 143.\n Plan:\n Continue to monitor.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. On CPAP w/PS\n 12/+14 50%. RR 18-20 with sats 94%. LS clear with diminished bases.\n Hemodynamically stable. On lasix gtt at 4mg/hr but urine output\n dropping.\n Action:\n No vent changes. Increased Lasix to 10mg/hr. No change in sedation.\n Continue vanco, cefepime and azithromycin for PNA.\n Response:\n +332cc at midnight, currently with negative fluid balance. Decreasing\n sats this morning to 88-90%. RR 17-23 with TV\ns 300-400cc. Suctioned\n for nothing.\n Plan:\n Wean vent as tolerated. back off on lasix gtt if BP on the low\n side. Goal sats 88-92% with Pao2 >60\n v Positive bowel sounds, abdomen soft and obese. Brown, loose\n stool via flexiseal.\n v Full code.\n v On sedation patient will open eyes, follow commands and MAE.\n Denies pain. Restrained for safety of lines and tubes.\n v HR 60-70\ns SR with frequent ectopy. SBP 90-131. Hct stable @32.\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-02 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727333,
"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 67 yo women with severe PNA, respiratory failure: has been getting\n diuresed for fluid overload in order to optimize ventilation.\n 24 Hour Events:\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 10:18 PM\n Vancomycin - 08:02 AM\n Azithromycin - 08:39 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:08 AM\n Heparin Sodium (Prophylaxis) - 08:02 AM\n Other medications:\n atrovent\n chlorhex\n azithro\n SSI\n albuterol\n narcan PO\n prednisone 40mg qd\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:29 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: 37.1\nC (98.7\n HR: 74 (67 - 79) bpm\n BP: 97/53(68) {90/48(63) - 129/94(108)} mmHg\n RR: 21 (15 - 21) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 4,212 mL\n 1,348 mL\n PO:\n TF:\n 1,599 mL\n 657 mL\n IVF:\n 1,493 mL\n 652 mL\n Blood products:\n Total out:\n 5,900 mL\n 585 mL\n Urine:\n 5,900 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,688 mL\n 763 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 343 (323 - 431) mL\n PS : 12 cmH2O\n RR (Spontaneous): 16\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 27 cmH2O\n SpO2: 90%\n ABG: 7.41/66/84./45/13\n Ve: 6.1 L/min\n PaO2 / FiO2: 168\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.7 g/dL\n 557 K/uL\n 132 mg/dL\n 0.8 mg/dL\n 45 mEq/L\n 4.1 mEq/L\n 47 mg/dL\n 93 mEq/L\n 142 mEq/L\n 30.5 %\n 24.5 K/uL\n [image002.jpg]\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n 02:09 PM\n 06:04 PM\n 08:49 PM\n 04:16 AM\n 04:22 AM\n WBC\n 26.2\n 23.1\n 24.5\n Hct\n 30.6\n 32.0\n 30.5\n Plt\n 535\n 537\n 557\n Cr\n 0.8\n 0.8\n 0.7\n 0.8\n 0.8\n 0.8\n TCO2\n 40\n 40\n 45\n 43\n Glucose\n 168\n 150\n 171\n 133\n 176\n 132\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n Respiratory failure: still requiring high PEEP. continue diuresis.\n Will switch over to AC to control Vt in setting of ARDS.\n COPD: wean prednisone.\n Fluid overload: continue to diurese. Aim net 1L negative today. can\n treat alkalosis with diamox\n PNA: continue current antibiotics. final day is tomorrow.\n hypernatremia: improved\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:02 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727334,
"text": "Chief Complaint:\n 24 Hour Events:\n - more difficulty with oxygenation in the afternoon, CXR unchanged, up\n from 50% to 70% FiO2 all afternoon\n - decreased FW boluses to attempt to get net negative, still on lasix\n gtt at 10\n - stopped lasix gtt for hypotension (90/60) ~ 1700, still net negative\n ~1.5L/24h\n - able to go back to 60% FiO2 early AM\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 09:02 AM\n Vancomycin - 08:02 PM\n Cefipime - 10:18 PM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 08:05 AM\n Pantoprazole (Protonix) - 10:08 AM\n Heparin Sodium (Prophylaxis) - 12:19 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 07:34 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: 36.9\nC (98.4\n HR: 69 (67 - 79) bpm\n BP: 92/49(63) {90/48(63) - 129/94(108)} mmHg\n RR: 18 (15 - 21) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 4,212 mL\n 643 mL\n PO:\n TF:\n 1,599 mL\n 492 mL\n IVF:\n 1,493 mL\n 151 mL\n Blood products:\n Total out:\n 5,900 mL\n 410 mL\n Urine:\n 5,900 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,688 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 412 (323 - 442) mL\n PS : 12 cmH2O\n RR (Spontaneous): 13\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 26 cmH2O\n SpO2: 90%\n ABG: 7.41/66/84./45/13\n Ve: 5.1 L/min\n PaO2 / FiO2: 168\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: trace bilaterally pitting edema, improving\n Labs / Radiology\n 557 K/uL\n 9.7 g/dL\n 132 mg/dL\n 0.8 mg/dL\n 45 mEq/L\n 4.1 mEq/L\n 47 mg/dL\n 93 mEq/L\n 142 mEq/L\n 30.5 %\n 24.5 K/uL\n [image002.jpg]\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n 02:09 PM\n 06:04 PM\n 08:49 PM\n 04:16 AM\n 04:22 AM\n WBC\n 26.2\n 23.1\n 24.5\n Hct\n 30.6\n 32.0\n 30.5\n Plt\n 535\n 537\n 557\n Cr\n 0.8\n 0.8\n 0.7\n 0.8\n 0.8\n 0.8\n TCO2\n 40\n 40\n 45\n 43\n Glucose\n 168\n 150\n 171\n 133\n 176\n 132\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Multilobar pneumonia & COPD c/b ARDS.\n Difficult to oxygenate without high PEEP/FIO2. Requiring high PEEP and\n PSV. Still significantly positive for the stay- LOS 4.5 liters.\n Continue lasix gtt, plan for goal I/O negative 1 liter.\n -repeat ABG and lytes, if pH increasing or bicarb increasing may start\n diamox\n -taper prednisone to 30mg daily today\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, d/c azithromycin for 8-day course to\n end \n - change IV meds to PO if possible\n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-04-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 727407,
"text": "Demographics\n Day of mechanical ventilation: 8\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 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: 26 cmH2O\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 Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt placed on ARDSNET/? may need esoph ballooon if Pa02 trends\n down. require more sedation\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment: Tolerated well\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Rehab Services",
"chartdate": "2192-04-10 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 729238,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: COPD / 493.20\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 67 yo F with severe\n COPD, admitted with 1 week h/o SOB, EMS found patient at 70% O2 on\n RA and tachypneic. CXR revealed large R-sided pneumonia, patient was\n intubated and sedated for ARDS. Extubated .\n Past Medical / Surgical History: COPD on home O2, HTN, ICH due to\n hypertensive crisis requiring craniotomy and VP shunt, GERD, stab wound\n ' leading to splenectomy and partial pancreatectomy, L THR, LE edema,\n partial RUL collapse \n Medications: heparin, lactulose, amlodipine, albuterol, diazepam,\n prednisone\n Radiology: CXR - Improving chest x-ray with diminished effusions\n and better lung aeration.\n Labs:\n 28.4\n 9.3\n 415\n 16.9\n [image002.jpg]\n Other labs:\n Activity Orders: OK for OOB per micu team\n Social / Occupational History: lives alone in \n Living Environment: accessible\n Prior Functional Status / Activity Level: uses SC at baseline,\n independent with adl's but has assistance \"when needed\"\n Objective Test\n Arousal / Attention / Cognition / Communication: A&O x3, pleasant and\n cooperative.\n Aerobic Capacity\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 80\n 116/71\n 22\n 94% on 3L NC\n Activity\n 94\n 101/85\n 35\n 91% on 3L\n Recovery\n 80\n 130/78\n 20\n 93% on 3L\n Total distance walked: 0\n Minutes:\n Pulmonary Status: markedly increased WOB with minimal activity,\n inspiratory wheezes, no cough noted.\n Integumentary / Vascular: 3+ peripheral edema, R PIV, foley, tele\n Sensory Integrity: B LE's grossly intact to light touch\n Pain / Limiting Symptoms: denies pain\n Posture: obese\n Range of Motion\n Muscle Performance\n B LE's WNL\n moves all extremities against gravity\n Motor Function: mildly impulsive, no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: able to stand and take several small steps from chair\n to edge of bed. Assist to return to supine and positioning in bed.\n Rolling:\n\n\n\n T\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\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: CG sitting at edge of bed, Min A static standing, min-mod A x2\n dynamic standing activities. No gross LOB with mobility.\n Education / Communication: Reviewed PT , safety and use of call\n light, d/c planning.\n Intervention:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired balance\n 3.\n Impaired endurance\n 4.\n Impaired pulmonary hygiene\n 5.\n Impaired strength\n Clinical impression / Prognosis: 67 yo F with severe COPD c/b ARDS p/w\n above impairments a/w ventilatory pump dysfunction. She is most\n limited by severe SOB with minimal activity due to poor respiratory\n reserve at this time, as well as general weakness a/w prolonged\n hospitalization. She is well below her baseline level, and given her\n complicated medical course and minimal home support, would recommend\n rehab when medically stable. Anticipate good rehab potential given her\n prior level of function. PT to continue to follow to progress as able.\n Goals\n Time frame: 1 week\n 1.\n Min A bed mobility and transfers, assess gait\n 2.\n No LOB with mobility\n 3.\n Ambulate >/= 30' with stable HDR\n 4.\n Maintains O2 >/= 94% on minimal O2 with mobility\n 5.\n Tolerate daily strengthening\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-3x\n bed mobility, transfers, ambulation, balance, endurance, education,\n strengthening, pulmonary hygiene, d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727121,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Hypernatremia (high sodium)\n Assessment:\n Na 145. TF infusing at goal of 65cc/hr.\n Action:\n Continue with free water flushes of 250cc every 4 hours.\n Response:\n Morning sodium 143.\n Plan:\n Continue to monitor.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. On CPAP w/PS\n 12/+14 50%. RR 18-20 with sats 94%. LS clear with diminished bases.\n Hemodynamically stable. On lasix gtt at 4mg/hr but urine output\n dropping.\n Action:\n No vent changes. Increased Lasix to 10mg/hr. No change in sedation.\n Continue vanco, cefepime and azithromycin for PNA.\n Response:\n +332cc at midnight, currently with negative fluid balance. Decreasing\n sats this morning to 88-90%. RR 17-23 with TV\ns 300-400cc. Suctioned\n for nothing.\n Plan:\n Wean vent as tolerated. back off on lasix gtt if BP on the low\n side.\n v Positive bowel sounds, abdomen soft and obese. Brown, loose\n stool via flexiseal.\n v Full code.\n v On sedation patient will open eyes, follow commands and MAE.\n Denies pain. Restrained for safety of lines and tubes.\n * HR 60-70\ns SR with frequent ectopy. SBP 90-131. Hct stable @32.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727404,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. On CPAP w/PS\n 12/+14 50%. RR 18-20 with sats 90-92%. LS clear with diminished bases.\n Hemodynamically stable.\n Action:\n No change in sedation. Continue vanco, cefepime and azithromycin for\n PNA. Lasix gtt restarted for goal -1L . MDI\ns and steroids as ordered.\n Vent settings changed to CMV 350x 16 PEEP 14 and FiO2 50% for ARDS.\n Response:\n O2 sat 88-92% this shift. PM lytes done and ABG: 7.45/67/62. Peep\n increased to 16 at 1800. HCO3 44.\n Plan:\n Wean vent as tolerated.\n Check ABG\ns. Goal sats 88-92% with Pao2 >60\n v Positive bowel sounds, abdomen soft and obese. Brown, loose\n stool via flexiseal.\n v On sedation patient will open eyes, follow commands and MAE.\n Denies pain. Restrained for safety of lines and tubes.\n v HR 60-70\ns SR with frequent ectopy. SBP 90-129. Hct stable\n @30.5.\n v Full code. No contact from family this shift.\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 729206,
"text": "Chief Complaint:\n 24 Hour Events:\n - decreased urine output 10cc/hr--> gave NS 125cc/hr total 1L (later\n found on that foley was leaking)\n - 95% on 4L NC\n - Central line and A-line removed, Single PIV placed\n - Na 142 on recheck\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:22 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 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: 36.3\nC (97.3\n HR: 70 (59 - 99) bpm\n BP: 91/54(79) {89/50(60) - 118/77(87)} mmHg\n RR: 20 (17 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,389 mL\n 77 mL\n PO:\n 1,360 mL\n TF:\n IVF:\n 1,029 mL\n 77 mL\n Blood products:\n Total out:\n 937 mL\n 350 mL\n Urine:\n 937 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,452 mL\n -273 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///33/\n Physical Examination\n Labs / Radiology\n 415 K/uL\n 9.3 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 52 mg/dL\n 101 mEq/L\n 141 mEq/L\n 28.4 %\n 16.9 K/uL\n [image002.jpg]\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n 09:57 AM\n 12:26 PM\n 12:51 PM\n 05:36 PM\n 04:49 AM\n 03:27 AM\n WBC\n 22.7\n 19.2\n 16.9\n Hct\n 32.9\n 33.4\n 28.4\n Plt\n 465\n 446\n 415\n Cr\n 0.9\n 0.9\n 1.0\n 0.9\n 1.0\n TCO2\n 39\n 43\n 39\n 39\n 40\n Glucose\n 121\n 93\n 127\n 90\n 96\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n A 67 yo woman with a history of very severe COPD with PNA/ARDS, now\n extubated after prolonged intubation.\n .\n # Respiratory failure: Extubated. Resp status remains stable on 4L\n NC.\n --cont O2 to keep sats 88-92%\n --BIPAP overnight\n - continue prednisone taper\n reduce to 10mg daily today () x 3\n days then taper\n - cont albuterol,fluticasone\n - encourage incentive spirometry\n - prior to discharged should be switched to spiriva (and off of\n atrovent)\n .\n # Pneumonia: s/p course of broad-spectrum abx.\n .\n # Hx of hypertension: BP running low normal\n -discontinue antihypertensives (only getting doses of captopril due\n to low normal BPs)\n # Hypernatremia: Resolved with IVF and free water intake\n # Anemia: Hct drop 33 to 28 today (). No source of bleeding.\n Continue home PPI and trend for now.\n ICU Care\n Nutrition: HH/Diabetic\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 03:12 PM\n Prophylaxis:\n DVT: Hep SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727119,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Hypernatremia (high sodium)\n Assessment:\n Na 145. TF infusing at goal of 65cc/hr.\n Action:\n Continue with free water flushes of 250cc every 4 hours.\n Response:\n Morning sodium 143.\n Plan:\n Continue to monitor.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. On CPAP w/PS\n 12/+14 50%. RR 18-20 with sats 94%. LS clear with diminished bases.\n Hemodynamically stable. On lasix gtt at 4mg/hr but urine output\n dropping.\n Action:\n No vent changes. Increased Lasix to 10mg/hr. No change in sedation.\n Response:\n +332cc at midnight, currently with negative fluid balance. Decreasing\n sats this morning to 88-90%. RR 17-23 with TV\ns 300-400cc. Suctioned\n for nothing.\n Plan:\n Wean vent as tolerated. back off on lasix gtt if BP on the low\n side.\n *On sedation patient will open eyes, and follow commands. MAE. Denies\n pain. Restrained for safety of lines and tubes.\n * HR 60\ns Sr with frequent ectopy. SBP 90-131. HCT stable @32.\n * Abdomen soft and obese with positive bowel sounds. OGT in place.\n Receiving Naloxone. Brown, loose stool via flexiseal.\n * Afebrile with WBC 23 (down from 26). Continues on vanco,\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727234,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation. Intubated 5 days ago.\n Hypernatremia (high sodium)\n Assessment:\n Na 143. TF at goal of 65cc/hr. No residuals noted.\n Action:\n Free water flushes decreased to 250cc .\n Response:\n Will check pm lytes to assess Na.\n Plan:\n Continue to monitor. Adjust free water flushes as necessary\n Respiratory failure, chronic\n Assessment:\n Pt remains vented on PSV 12/14 5 70%. ABG: 7.45/56/63/40. Pt had\n episode after turning on left side of decreased O2 sats to 87-88%. LS\n diminished at bases otherwise CTA. Pt receiving antibx for PNA. Lasix\n drip remains at 10mg/hr for goal of liters negative today.\n Action:\n FIo2 increased to 70% with Saturation drop. CXR obtained. 1 time 40mg\n lasix dose given .\n Response:\n CXR showed improving PNA but continues to have fluid. ABG unchanged.\n Pt is currently approx. neg. 1.9 liters negative today thus far so\n lasix drip d/ced at this time.\n Plan:\n Continue to wean vent settings as able. Diuresis as necessary.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727571,
"text": "A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated\n Events- team assessed with u/s if there were any effusions to tap.\n There was not.\n Tf changed to nutren 2.0 with 21gms beneprotein per day at\n 35cc/hr to cut down on fluid in.\n Lytes checked at 1500 k 4.6 mg 2.1.\n Respiratory failure, chronic\n Assessment:\n Remains intubated and sedated this am. Cont on 6mg/hr versed and\n 200mcgs/hr fentanyl with easily ability to waken to voice. On 50% fio2\n tv 350/ a/c rate of 16 overbreathing by a few breast and 16 peep. Sats\n low 90\ns. suctioned for min secretions.\n Action:\n Cont to diurese with lasix drip at 10mg/hr and on diamox due to\n metabolic alkalosis from diurese. Goal for diuresis is 1-2l neg.\n Prednisone being tapered down to 30mg qd now. Cont on mdi\ns. finished 8\n day course of antibiodics today so vanco and cefipime dc\n Response:\n At 1600 neg by 1500. per dr lasix decreased to 8mg/hr and peep\n decreased to 14 from 6. Sats remain in the low 90\ns. Bilte block\n remains in to prevent patient from biting on tube as she bit through\n her pilot on Friday. Lips look ok with bit block in. position of bite\n block and ett slightly changed today to prevent pressure ulcers.\n Plan:\n Cont to diurese with lasix. Cont mdi\ns. wean vent as able\n Social- team to touch base with patient\ns family.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727643,
"text": "A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated\n Respiratory failure, chronic\n Assessment:\n Rec\nd pt intubated, on vent settings CMV 50% 350/16/14 PEEP. Rec\nd pt\n sedated on 200mcg/kg/min fentanyl, and 6mg/hr versed. Obv 1-4 bpm,\n easily awakens to vioce, consitently following commands. Sats low\n 90s. TF at goal. Rec\nd pt on lasix gtt at 8mg/hr.\n Action:\n Cont to diurese with lasix drip titrating to UO goal -1.5-2L neg.\n Decreasing lasix gtt to 3mg/hr t/o shift systolics < 90s. On\n diamox due to metabolic alkalosis from diurese. On standing dose PO\n prednisone. On standing mdi\ns. Able to wean PEEP to 12.\n Response:\n Negative 1.6L at midnight. UO > 100cc/hr. ABG unchanged, please see\n metavision for specifics. Bilte block remains in to prevent patient\n from biting on tube as she bit through her pilot on Friday. Lips look\n ok with bit block in. position of bite block and ett slightly changed\n today to prevent pressure ulcers.\n Plan:\n Cont to diurese with lasix. Cont mdi\ns. Wean vent as tolerated. ?\n plan with bite block as this is high potential for patient to break\n down, Dr. aware, will address in AM.\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 727115,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions, Underlying illness not\n resolved\n Pt remains on , unable to wean peep overnight (sats 88-80%) Will\n continue to follow and wean as tolerated.\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 727227,
"text": "Demographics:\n Day of mechanical ventilation: 7\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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 / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Frequent desaturation episodes; Comments: After being turned patient\n desated to 86% required increase in FiO2.ABG showed PaO2 in the 60s\n from 70s on 50%. CXR showed no acute changes.\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: wean PEEP and FiO2 as\n tolerated.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727310,
"text": "Chief Complaint:\n 24 Hour Events:\n - more difficulty with oxygenation in the afternoon, CXR unchanged, up\n from 50% to 70% FiO2 all afternoon\n - decreased FW boluses to attempt to get net negative, still on lasix\n gtt at 10\n - stopped lasix gtt for hypotension (90/60) ~ 1700, still net negative\n ~1.5L/24h\n - able to go back to 60% FiO2 early AM\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 09:02 AM\n Vancomycin - 08:02 PM\n Cefipime - 10:18 PM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 08:05 AM\n Pantoprazole (Protonix) - 10:08 AM\n Heparin Sodium (Prophylaxis) - 12:19 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 07:34 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: 36.9\nC (98.4\n HR: 69 (67 - 79) bpm\n BP: 92/49(63) {90/48(63) - 129/94(108)} mmHg\n RR: 18 (15 - 21) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 4,212 mL\n 643 mL\n PO:\n TF:\n 1,599 mL\n 492 mL\n IVF:\n 1,493 mL\n 151 mL\n Blood products:\n Total out:\n 5,900 mL\n 410 mL\n Urine:\n 5,900 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,688 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 412 (323 - 442) mL\n PS : 12 cmH2O\n RR (Spontaneous): 13\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 26 cmH2O\n SpO2: 90%\n ABG: 7.41/66/84./45/13\n Ve: 5.1 L/min\n PaO2 / FiO2: 168\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 557 K/uL\n 9.7 g/dL\n 132 mg/dL\n 0.8 mg/dL\n 45 mEq/L\n 4.1 mEq/L\n 47 mg/dL\n 93 mEq/L\n 142 mEq/L\n 30.5 %\n 24.5 K/uL\n [image002.jpg]\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n 02:09 PM\n 06:04 PM\n 08:49 PM\n 04:16 AM\n 04:22 AM\n WBC\n 26.2\n 23.1\n 24.5\n Hct\n 30.6\n 32.0\n 30.5\n Plt\n 535\n 537\n 557\n Cr\n 0.8\n 0.8\n 0.7\n 0.8\n 0.8\n 0.8\n TCO2\n 40\n 40\n 45\n 43\n Glucose\n 168\n 150\n 171\n 133\n 176\n 132\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:02 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-04-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727311,
"text": "Chief Complaint:\n 24 Hour Events:\n - more difficulty with oxygenation in the afternoon, CXR unchanged, up\n from 50% to 70% FiO2 all afternoon\n - decreased FW boluses to attempt to get net negative, still on lasix\n gtt at 10\n - stopped lasix gtt for hypotension (90/60) ~ 1700, still net negative\n ~1.5L/24h\n - able to go back to 60% FiO2 early AM\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 09:02 AM\n Vancomycin - 08:02 PM\n Cefipime - 10:18 PM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 08:05 AM\n Pantoprazole (Protonix) - 10:08 AM\n Heparin Sodium (Prophylaxis) - 12:19 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 07:34 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: 36.9\nC (98.4\n HR: 69 (67 - 79) bpm\n BP: 92/49(63) {90/48(63) - 129/94(108)} mmHg\n RR: 18 (15 - 21) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 4,212 mL\n 643 mL\n PO:\n TF:\n 1,599 mL\n 492 mL\n IVF:\n 1,493 mL\n 151 mL\n Blood products:\n Total out:\n 5,900 mL\n 410 mL\n Urine:\n 5,900 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,688 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 412 (323 - 442) mL\n PS : 12 cmH2O\n RR (Spontaneous): 13\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 26 cmH2O\n SpO2: 90%\n ABG: 7.41/66/84./45/13\n Ve: 5.1 L/min\n PaO2 / FiO2: 168\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: trace bilaterally pitting edema, improving\n Labs / Radiology\n 557 K/uL\n 9.7 g/dL\n 132 mg/dL\n 0.8 mg/dL\n 45 mEq/L\n 4.1 mEq/L\n 47 mg/dL\n 93 mEq/L\n 142 mEq/L\n 30.5 %\n 24.5 K/uL\n [image002.jpg]\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n 02:09 PM\n 06:04 PM\n 08:49 PM\n 04:16 AM\n 04:22 AM\n WBC\n 26.2\n 23.1\n 24.5\n Hct\n 30.6\n 32.0\n 30.5\n Plt\n 535\n 537\n 557\n Cr\n 0.8\n 0.8\n 0.7\n 0.8\n 0.8\n 0.8\n TCO2\n 40\n 40\n 45\n 43\n Glucose\n 168\n 150\n 171\n 133\n 176\n 132\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Multilobar pneumonia & COPD c/b ARDS.\n Difficult to oxygenate without high PEEP/FIO2. Requiring PEEP 14.\n Still significantly positive for the stay. Lasix gtt started\n yesterday, but still net positive.\n - decrease FW flushes\n - continue Lasix gtt today\n - ABG today\n - continue prednisone 40 and plan to taper\n - Flovent 4 puffs \n - continue nebs\n - continue high PEEP\n - PM Lytes\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, and azithromycin for 8-day course to\n end \n - change IV meds to PO if possible\n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # Hypernatremia: free water deficit resolved\n - decrease FW flushes\n - pm lytes\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727564,
"text": "A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated\n Events- team assessed with u/s if there were any effusions to tap.\n There was not.\n Tf changed to nutren 2.0 with 21gms beneprotein per day at\n 35cc/hr to cut down on fluid in.\n Respiratory failure, chronic\n Assessment:\n Remains intubated and sedated this am. Cont on 6mg/hr versed and\n 200mcgs/hr fentanyl with easily ability to waken to voice. On 50% fio2\n tv 350/ a/c rate of 16 overbreathing by a few breast and 16 peep. Sats\n low 90\ns. suctioned for min secretions.\n Action:\n Cont to diurese with lasix drip at 10mg/hr and on diamox due to\n metabolic alkalosis from diurese. Goal for diuresis is 1-2l neg.\n Prednisone being tapered down to 30mg qd now. Cont on mdi\ns. finished 8\n day course of antibiodics today so vanco and cefipime dc\n Response:\n At 1600 neg by 1500. per dr lasix decreased to 8mg/hr and peep\n decreased to 14 from 6. Sats remain in the low 90\n Plan:\n Cont to diurese with lasix. Cont mdi\ns. wean vent as able\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726414,
"text": "A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n Respiratory failure\n Assessment:\n Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with\n O2 sats 90-92%, last ABG-\n L/S clear to diminished @ bases. CXR no improvement, has multiobar PNX\n with effusions, sputum spec has GPC\ns. Suctioning white thick\n secretions.\n Action:\n Changed vent mode from A/C to PS, suctioning q3-4hr\n Response:\n Remains acidotic, no improvement of PNX,\n Plan:\n Continue with pulmonary toilet, asses ABG\ns and O2 sats,\n Sepsis without organ dysfunction\n Assessment:\n Rec\nd on Levo Gtt @ .03mcq, with BP 98-114/50, HR 70-80\ns with APC\n CVP-. Temp 99.2 Po max. U/O 50-60cc/hr. BUN/CRe improved. WBC\n 35.6,\n Action:\n Levo Gtt stopped, IV antibx\ns were increased.\n Response:\n BP down to 85-94/50, with Levo off, MAP\ns60-63.\n Plan:\n Monitor U/O and BP off of Levo, tolerating MAP 60, continue with IV\n antibx\ns check results of cultures.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726417,
"text": "A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n Respiratory failure\n Assessment:\n Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with\n O2 sats 90-92%, last ABG- 7.27/53/70/-.\n L/S clear to diminished @ bases., sputum spec has GPC\ns. Suctioning\n white thick secretions CXR--. R-sided opacification, L hyperinflation;\n B effusions.\n Action:\n Changed vent mode from A/C to PS, suctioning q3-4hr .\n Response:\n Remains acidotic, no improvement of PNX,\n Plan:\n Continue with pulmonary toilet, asses ABG\ns and O2 sats,\n Sepsis without organ dysfunction\n Assessment:\n Rec\nd on Levo Gtt @ .03mcq, with BP 98-114/50, HR 70-80\ns with APC\n CVP-. Temp 99.2 Po max. U/O 50-60cc/hr. BUN/CRe improved. WBC\n 35.6,\n Action:\n Levo Gtt stopped, IV antibx\ns were increased.\n Response:\n BP down to 85-94/50, with Levo off, MAP\ns60-63.\n Plan:\n Monitor U/O and BP off of Levo, tolerating MAP 60, continue with IV\n antibx\ns check results of cultures.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726418,
"text": "A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n Respiratory failure\n Assessment:\n Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with\n O2 sats 90-92%, last ABG- 7.27/53/70/-.\n L/S clear to diminished @ bases., sputum spec has GPC\ns. Suctioning\n white thick secretions CXR--. R-sided opacification, L hyperinflation;\n B effusions. Desat\nd to 87%, on FIO2-60% Peep-10.\n Action:\n Changed vent mode from A/C to PS, suctioning q3-4hr . , and FIO2 was\n placed back up to 70%.\n Response:\n Remains acidotic, and hypoxic, no improvement of PNX,\n Plan:\n Continue with pulmonary toilet, asses ABG\ns and O2 sats, adjust vent\n setting as needed.\n Sepsis without organ dysfunction\n Assessment:\n Rec\nd on Levo Gtt @ .03mcq, with BP 98-114/50, HR 70-80\ns with APC\n CVP-. Temp 99.2 Po max. U/O 50-60cc/hr. BUN/CRe improved. WBC\n 35.6,\n Action:\n Levo Gtt stopped, IV antibx\ns were increased.\n Response:\n BP down to 85-94/50, with Levo off, MAP\ns60-63.\n Plan:\n Monitor U/O and BP off of Levo, tolerating MAP 60, continue with IV\n antibx\ns check results of cultures.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-10 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 729294,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS\n ROS:Neuro:alert and oriented x3(know the month/date,unsure yr),moves\n all extremities,flat affect,restless ++,.no head ache.CVS:sinus in\n 70-90\ns sbp 100-130, Resp\nocc insp/sxp wheeze,cough+,GI:abd soft\n ,BS+ve,BM yes,h yellow urine(foley was leaking changed to\n 20FR.SKIN;intact except minimal excoriation.\n IV access:PIV X1(20g).\n Allergies:PCN.\n Precuations:Contact\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received the pt on NC 4L with sat 94,occ insp/exp wheeze on exam RR\n 15-30,no c/o sob,uses 02 2-4 L at home\n Action:\n Received MDI\ns/nebs,contd prednisone taper, contd 02 4l via the NC,was\n OOb to chair today,worked with PT today,\n Response:\n Satting 92-94%on 4l...no episode of desaturation,\n Plan:\n Cont o2,cont MDI/nebs,prednisone taper,follow resp status.\n Fall(s)\n Assessment:\n This PM pt was found in the floor in her knees with head and back\n resting on the side of the bed,didn\nt hit the bed,denied any pain in\n the knee ,non tender to touch,moves all extremities,pt does moves side\n to side in bed,doesn\nt call for any help,flat affect,restless in the\n bed intermittently.\n Action:\n MD evaluated the pt,fall precaution instituted,\n Response:\n Comfortable in bed,no s/s of distress\n Plan:\n Will con the fall precautions(side rails,bed alarm,bed low and locked.\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n PNEUMONIA;CHRONIC PULM DISEASE\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 100.9 kg\n Daily weight:\n 90.1 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions: Contact\n PMH: Asthma, COPD\n CV-PMH:\n Additional history: Emphysema, normally on 4L 02 at home during\n activity and 2L during rest\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:57\n Temperature:\n 98.8\n Arterial BP:\n S:188\n D:181\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 74 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula..4l\n O2 saturation:\n 98% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 784 mL\n 24h total out:\n 970 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 03:27 AM\n Potassium:\n 3.9 mEq/L\n 03:27 AM\n Chloride:\n 101 mEq/L\n 03:27 AM\n CO2:\n 33 mEq/L\n 03:27 AM\n BUN:\n 52 mg/dL\n 03:27 AM\n Creatinine:\n 1.0 mg/dL\n 03:27 AM\n Glucose:\n 96 mg/dL\n 03:27 AM\n Hematocrit:\n 28.4 %\n 03:27 AM\n Finger Stick Glucose:\n 171\n 12:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: micu 786\n Transferred to: cc 608\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 729297,
"text": "Chief Complaint:\n 24 Hour Events:\n - decreased urine output 10cc/hr--> gave NS 125cc/hr total 1L (later\n found on that foley was leaking)\n - 95% on 4L NC\n - Central line and A-line removed, Single PIV placed\n - Na 142 on recheck\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:22 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 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: 36.3\nC (97.3\n HR: 70 (59 - 99) bpm\n BP: 91/54(79) {89/50(60) - 118/77(87)} mmHg\n RR: 20 (17 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.1 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,389 mL\n 77 mL\n PO:\n 1,360 mL\n TF:\n IVF:\n 1,029 mL\n 77 mL\n Blood products:\n Total out:\n 937 mL\n 350 mL\n Urine:\n 937 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,452 mL\n -273 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///33/\n Physical Examination\n Labs / Radiology\n 415 K/uL\n 9.3 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 52 mg/dL\n 101 mEq/L\n 141 mEq/L\n 28.4 %\n 16.9 K/uL\n [image002.jpg]\n 05:23 PM\n 09:19 PM\n 04:59 AM\n 05:21 AM\n 09:57 AM\n 12:26 PM\n 12:51 PM\n 05:36 PM\n 04:49 AM\n 03:27 AM\n WBC\n 22.7\n 19.2\n 16.9\n Hct\n 32.9\n 33.4\n 28.4\n Plt\n 465\n 446\n 415\n Cr\n 0.9\n 0.9\n 1.0\n 0.9\n 1.0\n TCO2\n 39\n 43\n 39\n 39\n 40\n Glucose\n 121\n 93\n 127\n 90\n 96\n Other labs: PT / PTT / INR:10.8/28.4/0.9, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n A 67 yo woman with a history of very severe COPD with PNA/ARDS, now\n extubated after prolonged intubation.\n .\n # Respiratory failure: Extubated. Resp status remains stable on 4L\n NC.\n --cont O2 to keep sats 88-92%\n --BIPAP overnight\n - continue prednisone taper\n reduce to 10mg daily today () x 3\n days then taper\n - cont albuterol,fluticasone\n - encourage incentive spirometry\n - prior to discharged should be switched to spiriva (and off of\n atrovent)\n .\n # Pneumonia: s/p course of broad-spectrum abx.\n .\n # Hx of hypertension: BP running low normal\n -discontinue antihypertensives (only getting doses of captopril due\n to low normal BPs)\n # Hypernatremia: Resolved with IVF and free water intake\n # Anemia: Hct drop 33 to 28 today (). No source of bleeding.\n Continue home PPI and trend for now.\n ICU Care\n Nutrition: HH/Diabetic\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 03:12 PM\n Prophylaxis:\n DVT: Hep SC\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n ------ Protected Section ------\n PHYSICAL EXAM FROM \n GEN: on nasal cannula, appears very comfortable.\n HEENT:JVP not elevated\n CHEST: good air movement, no wheezes\n CARDIAC: distant, regular, no murmurs audible\n ABDOMEN: obese, soft, nontender; prominent bowel sounds\n EXTREMITIES: no edema, no sacral edema, 2+ distal pulses\n ------ Protected Section Addendum Entered By: , MD\n on: 10:42 ------\n I have seen and examined the patient with the fellow and agree\n substantially with the assessment and plan as above with the following\n modifications/emphasis:\n Overnight, no new events\n Tm: 97 P: 70 BP: 90/64 RR: 20 Oxygen Saturation: 94-5%\n on nasal cannula\n General: Awake, alert NAD\n Chest: Clear to auscultation\n Heart: S1 S2 reg\n Abd: Soft NT ND\n Ext: warm, vendynes in place\n Labs: reviewed and as above\n WBC dropping\n Assessment:\n 1) Pneumonia\n resolving/resolved\n 2) COPD Exacerbation\n improving and oxygen saturation approaching\n baseline leves (on outpatient 2 -4 liters per nasal cannula)\n 3) Hypernatremia\n improving\n Plan:\n 1) Continue albuterol and atrovent therapy\n 2) Continue to wean prednisone\n 3) Continue wean oxygen as tolerated\n 4) Physical therapy consult but maintain limited exertion\n 5) Monitor sodium\n Addendum: Slipped of bed in the afternoon when trying to go to the\n bathroom. Did not hit head or neck and no obvious injuries as assessed\n on bedside examination.\n Time Spent: 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 05:44 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727547,
"text": "A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated\n Events- team assessed with u/s if there were any effusions to tap.\n There was not.\n Tf changed to nutren 2.0 with 21gms beneprotein per day at\n 35cc/hr to cut down on fluid in.\n Respiratory failure, chronic\n Assessment:\n Remains intubated and sedated this am. Cont on 6mg/hr versed and\n 200mcgs/hr fentanyl with easily ability to waken to voice. On 50% fio2\n tv 350/ a/c rate of 16 overbreathing by a few breast and 16 peep. Sats\n low 90\ns. suctioned for min secretions.\n Action:\n Cont to diurese with lasix drip at 10mg/hr and on diamox due to\n metabolic alkalosis from diurese. Goal for diuresis is 1-2l neg.\n Prednisone being tapered down to 30mg qd now. Cont on mdi\ns. finished 8\n day course of antibidics today so vanco and cefipime dc\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726406,
"text": "A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n Respiratory failure\n Assessment:\n Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with\n O2 sats 90-92%, last ABG-\n L/S clear to diminished @ bases. CXR no improvement, has multiobar PNX\n with effusions, sputum spec has GPC\ns. Suctioning thick yellow\n secretions.\n Action:\n Changed vent mode from A/C to PS, suctioning q3-4hr\n Response:\n Remains acidotic, no improvement of PNX,\n Plan:\n Continue with pulmonary toilet, asses ABG\ns and O2 sats,\n Sepsis without organ dysfunction\n Assessment:\n Rec\nd on Levo Gtt @ .03mcq, with BP 98-114/50, HR 70-80\ns with APC\n CVP-. Temp 99.2 Po max. U/O 50-60cc/hr. BUN/CRe improved.\n Action:\n Levo Gtt stopped, IV antibx\ns were increased.\n Response:\n BP down to 85-94/50, with Levo off, MAP\ns60-63.\n Plan:\n Monitor U/O and BP off of Levo, tolerating MAP 60, continue with IV\n antibx\ns check results of cultures.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726407,
"text": "A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n Respiratory failure\n Assessment:\n Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with\n O2 sats 90-92%, last ABG-\n L/S clear to diminished @ bases. CXR no improvement, has multiobar PNX\n with effusions, sputum spec has GPC\ns. Suctioning white thick\n secretions.\n Action:\n Changed vent mode from A/C to PS, suctioning q3-4hr\n Response:\n Remains acidotic, no improvement of PNX,\n Plan:\n Continue with pulmonary toilet, asses ABG\ns and O2 sats,\n Sepsis without organ dysfunction\n Assessment:\n Rec\nd on Levo Gtt @ .03mcq, with BP 98-114/50, HR 70-80\ns with APC\n CVP-. Temp 99.2 Po max. U/O 50-60cc/hr. BUN/CRe improved.\n Action:\n Levo Gtt stopped, IV antibx\ns were increased.\n Response:\n BP down to 85-94/50, with Levo off, MAP\ns60-63.\n Plan:\n Monitor U/O and BP off of Levo, tolerating MAP 60, continue with IV\n antibx\ns check results of cultures.\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 726411,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 24 Hour Events:\n persistent norepi req't for MAP <60.\n Allergies:\n Last dose of Antibiotics:\n Azithromycin - 10:37 AM\n Cefipime - 07:30 PM\n Vancomycin - 08:14 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 125 mcg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 11:52 AM\n Heparin Sodium (Prophylaxis) - 08:13 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 09:26 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 (97.8\n HR: 83 (71 - 84) bpm\n BP: 106/55(72) {89/47(61) - 112/64(79)} mmHg\n RR: 23 (9 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 2 (2 - 20)mmHg\n Total In:\n 6,768 mL\n 846 mL\n PO:\n TF:\n 208 mL\n 257 mL\n IVF:\n 6,391 mL\n 389 mL\n Blood products:\n Total out:\n 1,520 mL\n 560 mL\n Urine:\n 1,520 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,248 mL\n 286 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n PIP: 31 cmH2O\n Plateau: 25 cmH2O\n Compliance: 28 cmH2O/mL\n SpO2: 92%\n ABG: 7.28/52/68/23/-2\n Ve: 10.3 L/min\n PaO2 / FiO2: 113\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, reducible R ventral\n hernia\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Responds to: Tactile stimuli, Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 9.6 g/dL\n 375 K/uL\n 161 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 41 mg/dL\n 115 mEq/L\n 145 mEq/L\n 30.5 %\n 35.6 K/uL\n [image002.jpg]\n 10:01 AM\n 11:12 AM\n 01:11 PM\n 03:45 PM\n 04:04 PM\n 03:06 AM\n 03:14 AM\n 05:00 AM\n 05:57 AM\n 08:37 AM\n WBC\n 42.2\n 35.6\n Hct\n 31.7\n 30.5\n Plt\n 375\n Cr\n 1.1\n 1.0\n TCO2\n 24\n 23\n 25\n 25\n 25\n 26\n 26\n 25\n Glucose\n 139\n 161\n Other labs: PT / PTT / INR:11.6/27.4/1.0, Differential-Neuts:92.0 %,\n Band:5.0 %, Lymph:2.0 %, Mono:0.0 %, Eos:0.0 %, Lactic Acid:0.9 mmol/L,\n Ca++:7.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Imaging: CXR- ETT approx 6cm above carina; R-sided opacification, L\n hyperinflation; B effusions\n Microbiology: Sputum- GPCs\n Remainder of cx neg or pending\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia. Prior partial RUL\n collapse from will need further evaluation down the road and might\n have predisposed to current pna\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -wean FiO2 to maintain PaO2 > 60\n -tolerate autoPEEP for now as Pplat < 30 and hemodyn stable\n -assess spont breathing tolerance today but caution on weaning\n -will lighten sedation and assess breathing\n -vanco + cefepime + azithro (change to IV) for now --> narrow tommorrow\n based on cx data\n -tx COPD exac w/ Solu-Medrol --> cont 125 q8 today and scheduled nebs\n -will need CT scan at some point to re-evaluate, poss bronch\n 2. Shock- likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n -CVP goal, MAP goals reached; wean norepi gtt as tolerated\n -might become more conservative w/ fluids (will use LR given high Cl)\n given high FiO2 req't and little gross pulse pressure variation or CVP\n variation\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:42 PM 35 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 04:00 AM\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments: will touch base w/ pt's sister today\n status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n ------ Protected Section ------\n Patient seen and examined with Dr. , and house staff team.\n I have reviewed his note and agree with assessment and plan. Would\n add/emphasize.\n 67 yo women with severe COPD, admitted with respiratory failure and\n multifocal PNA. Slow improved, but has weaned off pressors. Still\n with significant oxygen requirement. Acting like he has a shunt may be\n intrapulmonary through lung or intracardiac. Had echo on with\n bubble study that showed no shunt.\n Exam: patient sedated, unresponsive. Lung exam with coarse rales\n throughout right lung.\n A/P\n Respiratory failure: Slow improvement, WBC coming down. Given\n severity of PNA and significant shunt, likely will have continued slow\n recovery.\n Septic shock: improved.\n Acute renal failure: improved.\n CC 35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 12:50 ------\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726487,
"text": "67 y/o pt with long standing history of severe COPD & chronic asthma.\n Pt lives in an facility and had been c/o SOB x 1 wk.\n EMS found pt to have a 70% O2 sat on RA. Placed on NRB and given\n nebs. Also found to be tachypneic to the 40's with obvious increased\n WOB. CXR significant for large right sided PNA. Given Azithromycin,\n Ceftriaxone, nebs and steroids in ED. Admitted to MICU for further\n observation.\n Sepsis without organ dysfunction\n Assessment:\n Received pt w/ WBC 59. Lactate flat. Levophed running @ 0.06mcgkg/min.\n SBP 90\ns-100\ns w/ MAPs 60\ns-70\ns. Of note, pt does have confirmed GPC\n in pairs within sputum. CVP ~ 16. CXR showing white out of right\n lung. Suctioning Q2-4hrs for thick, white/yellow sputum. Strong\n cough/impaired gag. O2 sats ranging 92-96%\n Action:\n Titrating Levophed gtt to MAPs > 60. Currently @ 0.03mcg/kg/min.\n Levophed turned off for ~ 1 hr. Pt initially did well, yet began to\n linger with MAPs in the 50\ns and SBP\ns in the 80\ns. Pt is on triple\n abx: Vanco, Cefepime & Azithromycin. Chest PT PRN. Q2hr turning.\n Elevate right lung as much as possible.\n Response:\n MAP\ns >/= 60 @ this time.\n Plan:\n Titrate Levophed as tolerated for goal MAP >60. Trend labs/culture\n data. ? bronch for clean out and additional spec.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Received pt vented on AC 70% x 450 x 24 w/ 10 PEEP. Versed @ 3mg/hr,\n Fentanyl @ 125mcg/kg/min. Pt is easily arousable & is able to respond\n to yes/no questions. Follows simple commands (great strengths in all\n extremeties) LS originally diminished w/ IW in BUL. O2 sat as noted\n above. ABG this AM on noted settings 7.31/47/98.\n Action:\n ABG much improved this AM (7.31/47/98). Pt originally presenting w/\n severe respiratory acidosis. Abx, stress dose steroids & inhalers via\n RT ATC. Attempt to wean vent settings to 60% FiO2 & 8 PEEP\n multiple\n ABG\ns (please see Metavision for results)\n Response:\n WBC improved 59\n 35.6. Tolerating TF\ns w/ minimal 5-10cc residuals.\n Electrolytes stable @ this time. Current settings 60% x 450 x 24 w/ 10\n PEEP.\n Plan:\n Trend ABG\ns & follow sats. ? Repeat CT chest to evaluate for malignant\n process on top of PNA given elevated WBC. Cont to titrate TF as\n tolerated with goal 65cc/hr. Wean vent settings as warranted.\n R IJ TLC\n L Radial ALINE\n PIV x 2\n Full Code\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727535,
"text": "A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated\n Respiratory failure, chronic\n Assessment:\n Remains intubated and sedated this am. Cont on 6mg/hr versed and\n 200mcgs/hr fentanyl with easily ability to waken to voice. On 50% fio2\n tv 350/ a/c rate of 16 overbreathing by a few breast and 16 peep. Sats\n low 90\ns. suctioned for min secretions.\n Action:\n Cont to diurese with lasix drip at 10mg/hr and on diamox due to\n metabolic alkalosis from diurese. Goal for diuresis is 1-2l neg.\n Prednisone being tapered down to 30mg qd now. Cont on mdi\ns. finished 8\n day course of antibidics today so vanco and cefipime dc\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-03 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727557,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to ARDS from pneumonia and COPD exacerbation.\n 24 Hour Events:\n Acetazolamide 250 q6 started overnight.\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Cefipime - 10:00 PM\n Vancomycin - 08:43 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:47 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 10:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.9\nC (98.5\n HR: 78 (67 - 93) bpm\n BP: 120/60(79) {87/47(61) - 124/70(89)} mmHg\n RR: 20 (19 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,608 mL\n 1,250 mL\n PO:\n TF:\n 1,560 mL\n 655 mL\n IVF:\n 1,448 mL\n 536 mL\n Blood products:\n Total out:\n 3,240 mL\n 1,680 mL\n Urine:\n 3,240 mL\n 1,680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 368 mL\n -430 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 25 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 96%\n ABG: 7.43/68/76./46/16\n Ve: 9.3 L/min\n PaO2 / FiO2: 152\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ant)\n Abdominal: Soft, Bowel sounds present, Obese\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: Purposeful, Tone: Not assessed\n Labs / Radiology\n 9.3 g/dL\n 475 K/uL\n 114 mg/dL\n 0.9 mg/dL\n 46 mEq/L\n 4.2 mEq/L\n 48 mg/dL\n 91 mEq/L\n 143 mEq/L\n 29.6 %\n 24.7 K/uL\n [image002.jpg]\n 02:09 PM\n 06:04 PM\n 08:49 PM\n 04:16 AM\n 04:22 AM\n 05:09 PM\n 05:22 PM\n 10:16 PM\n 03:59 AM\n 04:03 AM\n WBC\n 24.5\n 24.7\n Hct\n 30.5\n 29.6\n Plt\n 557\n 475\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 40\n 45\n 43\n 48\n 48\n 47\n Glucose\n 176\n 132\n 185\n 114\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:4.0 mg/dL\n Imaging: CXR- ? worsened RLL infiltrate\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -cont ARDSnet ventilation --> A/CV w/ 6cc/kg Vt and permissive\n hypercpania, tolerating pH down to 7.20\n -wean FiO2 and PEEP to maintain PaO2 > 60\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n have added azetazolamide to help w/ HCO3 wasting in the setting of\n contraction alkalosis\n -will concentrate IVF and tube feeds\n -complete 8d course of ABX today\n -steroids weaning to 30 qd tomorrow\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:43 AM 65 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\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: 30 minutes\n ------ Protected Section ------\n Patient seen and examined with Dr. , and house staff team.\n I have reviewed his note and agree with assessment and plan. Would\n add/emphasize.\n 67 yo women with severe COPD, admitted with respiratory failure, PNA,\n and sepsis. Continue high oxygen requirement and on high Peep.\n Exam notable for diminished BS b/l. Reg heart. Soft abdomen. 1+\n edema\n WBC 25.7\n A/P\n Respiratory failure: slow improvement. Wean Peep as tolerated.\n PNA: continue abtx.\n COPD: wean steroids.\n Fluid overload: continue diuresis.\n CC 35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 15:46 ------\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726404,
"text": "Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726405,
"text": "A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n Respiratory failure\n Assessment:\n Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with\n O2 sats 90-92%, last ABG-\n L/S clear to diminished @ bases. CXR no improvement, has\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726481,
"text": "A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n Respiratory failure\n Assessment:\n Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with\n O2 sats 90-92%, last ABG- 7.27/53/70/-.\n L/S clear to diminished @ bases., sputum spec has GPC\ns. Suctioning\n white thick secretions CXR--. R-sided opacification, L hyperinflation;\n B effusions. Desat\nd to 87%, on FIO2-60% Peep-10.\n Action:\n Changed vent mode from A/C to PS, suctioning q3-4hr . -- FIO2 was\n placed back up to 70%.\n Response:\n Remains acidotic, and hypoxic, no improvement of PNX, and COPD\n exacerbation.\n Plan:\n Continue with pulmonary toilet, asses ABG\ns and O2 sats, adjust vent\n setting as needed.\n Sepsis without organ dysfunction\n Assessment:\n Rec\nd on Levo Gtt @ .03mcq, with BP 98-114/50, HR 70-80\ns with APC\n CVP-. Temp 99.2 Po max. U/O 50-60cc/hr. BUN/CRe improved. WBC\n 35.6,\n Action:\n Levo Gtt stopped, IV antibx\ns were increased.\n Response:\n BP down to 85-100/50, with Levo off, MAP\ns60-63.\n Plan:\n Monitor U/O and BP off of Levo, tolerating MAP 60, continue with IV\n antibx\ns check results of cultures.\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726385,
"text": "Chief Complaint: intubated\n 24 Hour Events:\n - norepi weaned off; MAP drifted to 50s; norepi restarted at 0.03\n - required PEEP 10 for adequate oxygenation\n Allergies:\n Last dose of Antibiotics:\n Azithromycin - 10:37 AM\n Cefipime - 07:30 PM\n Vancomycin - 08:00 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 125 mcg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 11:52 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 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 (71 - 84) bpm\n BP: 108/60(77) {89/47(61) - 112/64(79)} mmHg\n RR: 24 (9 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 20 (11 - 20)mmHg\n Total In:\n 6,768 mL\n 425 mL\n PO:\n TF:\n 208 mL\n 178 mL\n IVF:\n 6,391 mL\n 147 mL\n Blood products:\n Total out:\n 1,520 mL\n 410 mL\n Urine:\n 1,520 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,248 mL\n 16 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n PIP: 28 cmH2O\n Plateau: 23 cmH2O\n Compliance: 31.9 cmH2O/mL\n SpO2: 93%\n ABG: 7.29/51/75/23/-2\n Ve: 10.4 L/min\n PaO2 / FiO2: 125\n Physical Examination\n GEN: intubated\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender\n EXTREMITIES: trace bilaterally pitting edema\n Labs / Radiology\n 375 K/uL\n 9.6 g/dL\n 161 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 41 mg/dL\n 115 mEq/L\n 145 mEq/L\n 30.5 %\n 35.6 K/uL\n [image002.jpg]\n 06:37 AM\n 10:01 AM\n 11:12 AM\n 01:11 PM\n 03:45 PM\n 04:04 PM\n 03:06 AM\n 03:14 AM\n 05:00 AM\n 05:57 AM\n WBC\n 42.2\n 35.6\n Hct\n 31.7\n 30.5\n Plt\n 375\n Cr\n 1.1\n 1.0\n TCO2\n 24\n 24\n 23\n 25\n 25\n 25\n 26\n 26\n Glucose\n 139\n 161\n Other labs: PT / PTT / INR:11.6/27.4/1.0, Differential-Neuts:92.0 %,\n Band:5.0 %, Lymph:2.0 %, Mono:0.0 %, Eos:0.0 %, Lactic Acid:0.9 mmol/L,\n Ca++:7.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n # Respiratory failure: Multilobar Pneumonia & COPD. Possible that she\n has some sort of endobronchial lesion (? malignancy given smoking hx)\n contributing. In any case, because of her very severe baseline\n obstructive disease, she remains a very tenuous respiratory place right\n now. She now requires PEEP of 10 for adequate O2. CXR unchanged. GPCs\n in pairs, Legionella (-)\n -\n - F/U blood cx\n - methylprednisolone to 125 mg q8h\n - fluticasone inh\n - albuterol nebs ,decrease to q4h\n - ipratropium nebs q6h\n -continue vent; trial of PSV\n - try to diurese if pressors are weaned\n .\n # PNA: GPCs in pairs, Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, and azithromycin for broad bacterial\n coverage including atypical pathogens.\n - redose abx renally per pharmacy\n - plan to reconsider abx tomorrow when sputum speciation returns\n - consider bronch prior to extubation if stabilizes tomorrow\n #. Shock: Pressor requirement lessening. Septic from PNA,\n leukocytosis, requiring pressors but is fluid responsive. No recent\n abx exposure.\n - Abx as above\n - Norepi as needed to keep MAP >60, allow for sedation\n - LOS 6 L positive; plan to avoid excessive IVF unless UOP falls (and\n diurese if off pressors)\n # kidney injury: improved with signficant fluid hydration.\n - F/U urine lytes\n - trend creatinine\n # hx hypertension: hypotensive on pressors\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , patient does not know #, SW is working on reaching family\n - d/w SW if family has been contact\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 726386,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 24 Hour Events:\n persistent norepi req't for MAP <60.\n Allergies:\n Last dose of Antibiotics:\n Azithromycin - 10:37 AM\n Cefipime - 07:30 PM\n Vancomycin - 08:14 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 125 mcg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 11:52 AM\n Heparin Sodium (Prophylaxis) - 08:13 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 09:26 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 (97.8\n HR: 83 (71 - 84) bpm\n BP: 106/55(72) {89/47(61) - 112/64(79)} mmHg\n RR: 23 (9 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 2 (2 - 20)mmHg\n Total In:\n 6,768 mL\n 846 mL\n PO:\n TF:\n 208 mL\n 257 mL\n IVF:\n 6,391 mL\n 389 mL\n Blood products:\n Total out:\n 1,520 mL\n 560 mL\n Urine:\n 1,520 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,248 mL\n 286 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n PIP: 31 cmH2O\n Plateau: 25 cmH2O\n Compliance: 28 cmH2O/mL\n SpO2: 92%\n ABG: 7.28/52/68/23/-2\n Ve: 10.3 L/min\n PaO2 / FiO2: 113\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Obese, reducible R ventral\n hernia\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Responds to: Tactile stimuli, Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 9.6 g/dL\n 375 K/uL\n 161 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 41 mg/dL\n 115 mEq/L\n 145 mEq/L\n 30.5 %\n 35.6 K/uL\n [image002.jpg]\n 10:01 AM\n 11:12 AM\n 01:11 PM\n 03:45 PM\n 04:04 PM\n 03:06 AM\n 03:14 AM\n 05:00 AM\n 05:57 AM\n 08:37 AM\n WBC\n 42.2\n 35.6\n Hct\n 31.7\n 30.5\n Plt\n 375\n Cr\n 1.1\n 1.0\n TCO2\n 24\n 23\n 25\n 25\n 25\n 26\n 26\n 25\n Glucose\n 139\n 161\n Other labs: PT / PTT / INR:11.6/27.4/1.0, Differential-Neuts:92.0 %,\n Band:5.0 %, Lymph:2.0 %, Mono:0.0 %, Eos:0.0 %, Lactic Acid:0.9 mmol/L,\n Ca++:7.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Imaging: CXR- ETT approx 6cm above carina; R-sided opacification, L\n hyperinflation; B effusions\n Microbiology: Sputum- GPCs\n Remainder of cx neg or pending\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia. Prior partial RUL\n collapse from will need further evaluation down the road and might\n have predisposed to current pna\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -wean FiO2 to maintain PaO2 > 60\n -tolerate autoPEEP for now as Pplat < 30 and hemodyn stable\n -assess spont breathing tolerance today but caution on weaning\n -will lighten sedation and assess breathing\n -vanco + cefepime + azithro (change to IV) for now --> narrow tommorrow\n based on cx data\n -tx COPD exac w/ Solu-Medrol --> cont 125 q8 today and scheduled nebs\n -will need CT scan at some point to re-evaluate, poss bronch\n 2. Shock- likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n -CVP goal, MAP goals reached; wean norepi gtt as tolerated\n -might become more conservative w/ fluids (will use LR given high Cl)\n given high FiO2 req't and little gross pulse pressure variation or CVP\n variation\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:42 PM 35 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 04:00 AM\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments: will touch base w/ pt's sister today\n status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726375,
"text": "Chief Complaint: intubated\n 24 Hour Events:\n - norepi weaned off; MAP drifted to 50s; norepi restarted at 0.03\n - required PEEP 10 for adequate oxygenation\n Allergies:\n Last dose of Antibiotics:\n Azithromycin - 10:37 AM\n Cefipime - 07:30 PM\n Vancomycin - 08:00 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 125 mcg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 11:52 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 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 (71 - 84) bpm\n BP: 108/60(77) {89/47(61) - 112/64(79)} mmHg\n RR: 24 (9 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 20 (11 - 20)mmHg\n Total In:\n 6,768 mL\n 425 mL\n PO:\n TF:\n 208 mL\n 178 mL\n IVF:\n 6,391 mL\n 147 mL\n Blood products:\n Total out:\n 1,520 mL\n 410 mL\n Urine:\n 1,520 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,248 mL\n 16 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n PIP: 28 cmH2O\n Plateau: 23 cmH2O\n Compliance: 31.9 cmH2O/mL\n SpO2: 93%\n ABG: 7.29/51/75/23/-2\n Ve: 10.4 L/min\n PaO2 / FiO2: 125\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 375 K/uL\n 9.6 g/dL\n 161 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 41 mg/dL\n 115 mEq/L\n 145 mEq/L\n 30.5 %\n 35.6 K/uL\n [image002.jpg]\n 06:37 AM\n 10:01 AM\n 11:12 AM\n 01:11 PM\n 03:45 PM\n 04:04 PM\n 03:06 AM\n 03:14 AM\n 05:00 AM\n 05:57 AM\n WBC\n 42.2\n 35.6\n Hct\n 31.7\n 30.5\n Plt\n 375\n Cr\n 1.1\n 1.0\n TCO2\n 24\n 24\n 23\n 25\n 25\n 25\n 26\n 26\n Glucose\n 139\n 161\n Other labs: PT / PTT / INR:11.6/27.4/1.0, Differential-Neuts:92.0 %,\n Band:5.0 %, Lymph:2.0 %, Mono:0.0 %, Eos:0.0 %, Lactic Acid:0.9 mmol/L,\n Ca++:7.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:42 PM 25 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 05:47 PM\n 18 Gauge - 04:00 AM\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 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": "2192-03-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726376,
"text": "Chief Complaint: intubated\n 24 Hour Events:\n - norepi weaned off; MAP drifted to 50s; norepi restarted at 0.03\n - required PEEP 10 for adequate oxygenation\n Allergies:\n Last dose of Antibiotics:\n Azithromycin - 10:37 AM\n Cefipime - 07:30 PM\n Vancomycin - 08:00 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 125 mcg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 11:52 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 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 (71 - 84) bpm\n BP: 108/60(77) {89/47(61) - 112/64(79)} mmHg\n RR: 24 (9 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 20 (11 - 20)mmHg\n Total In:\n 6,768 mL\n 425 mL\n PO:\n TF:\n 208 mL\n 178 mL\n IVF:\n 6,391 mL\n 147 mL\n Blood products:\n Total out:\n 1,520 mL\n 410 mL\n Urine:\n 1,520 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,248 mL\n 16 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n PIP: 28 cmH2O\n Plateau: 23 cmH2O\n Compliance: 31.9 cmH2O/mL\n SpO2: 93%\n ABG: 7.29/51/75/23/-2\n Ve: 10.4 L/min\n PaO2 / FiO2: 125\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 375 K/uL\n 9.6 g/dL\n 161 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 41 mg/dL\n 115 mEq/L\n 145 mEq/L\n 30.5 %\n 35.6 K/uL\n [image002.jpg]\n 06:37 AM\n 10:01 AM\n 11:12 AM\n 01:11 PM\n 03:45 PM\n 04:04 PM\n 03:06 AM\n 03:14 AM\n 05:00 AM\n 05:57 AM\n WBC\n 42.2\n 35.6\n Hct\n 31.7\n 30.5\n Plt\n 375\n Cr\n 1.1\n 1.0\n TCO2\n 24\n 24\n 23\n 25\n 25\n 25\n 26\n 26\n Glucose\n 139\n 161\n Other labs: PT / PTT / INR:11.6/27.4/1.0, Differential-Neuts:92.0 %,\n Band:5.0 %, Lymph:2.0 %, Mono:0.0 %, Eos:0.0 %, Lactic Acid:0.9 mmol/L,\n Ca++:7.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n # Respiratory failure: Multilobar Pneumonia & COPD. Possible that she\n has some sort of endobronchial lesion (? malignancy given smoking hx)\n contributing. In any case, because of her very severe baseline\n obstructive disease, she is in a very tenuous respiratory place right\n now. GPCs in pairs, Legionella (-)\n - vancomycin, cefepime, and azithromycin for broad bacterial coverage\n including atypical pathogens. (Lives in facility,\n chronic respiratory disease so will treat as if HCAP.)\n - F/U blood cx\n - ABG on current settings, tolerate large tidal volumes\n - Plateaus <30 as most ventilation is going to the L lung, maintain\n ARDSnet ventilation as pH tolerates\n - methylprednisolone to 125 mg q8h\n - fluticasone inh\n - albuterol nebs q1h for now, decrease to q6h as tolerated\n - ipratropium nebs q6h\n #. Shock: Septic from PNA, leukocytosis, requiring pressors but is\n fluid responsive. No recent abx exposure.\n - Abx as above\n - Norepi as needed to keep MAP >65, allow for sedation\n - trend WBC (will be complicated by steroids)\n - Send C. Diff\n - Measure SvO2 to r/o cardiogenic shock\n # kidney injury: Unclear if this is acute or chronic, but did improve\n with signficant fluid hydration.\n - F/U urine lytes\n - trend creatinine\n # hx hypertension: hypotensive on pressors\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , patient does not know # and none in chart; will consult social\n work\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:42 PM 25 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 05:47 PM\n 18 Gauge - 04:00 AM\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 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": "2192-03-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726378,
"text": "Chief Complaint: intubated\n 24 Hour Events:\n - norepi weaned off; MAP drifted to 50s; norepi restarted at 0.03\n - required PEEP 10 for adequate oxygenation\n Allergies:\n Last dose of Antibiotics:\n Azithromycin - 10:37 AM\n Cefipime - 07:30 PM\n Vancomycin - 08:00 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 125 mcg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 11:52 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 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 (71 - 84) bpm\n BP: 108/60(77) {89/47(61) - 112/64(79)} mmHg\n RR: 24 (9 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 20 (11 - 20)mmHg\n Total In:\n 6,768 mL\n 425 mL\n PO:\n TF:\n 208 mL\n 178 mL\n IVF:\n 6,391 mL\n 147 mL\n Blood products:\n Total out:\n 1,520 mL\n 410 mL\n Urine:\n 1,520 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,248 mL\n 16 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n PIP: 28 cmH2O\n Plateau: 23 cmH2O\n Compliance: 31.9 cmH2O/mL\n SpO2: 93%\n ABG: 7.29/51/75/23/-2\n Ve: 10.4 L/min\n PaO2 / FiO2: 125\n Physical Examination\n GEN: intubated\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender\n EXTREMITIES: trace bilaterally pitting edema\n Labs / Radiology\n 375 K/uL\n 9.6 g/dL\n 161 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 41 mg/dL\n 115 mEq/L\n 145 mEq/L\n 30.5 %\n 35.6 K/uL\n [image002.jpg]\n 06:37 AM\n 10:01 AM\n 11:12 AM\n 01:11 PM\n 03:45 PM\n 04:04 PM\n 03:06 AM\n 03:14 AM\n 05:00 AM\n 05:57 AM\n WBC\n 42.2\n 35.6\n Hct\n 31.7\n 30.5\n Plt\n 375\n Cr\n 1.1\n 1.0\n TCO2\n 24\n 24\n 23\n 25\n 25\n 25\n 26\n 26\n Glucose\n 139\n 161\n Other labs: PT / PTT / INR:11.6/27.4/1.0, Differential-Neuts:92.0 %,\n Band:5.0 %, Lymph:2.0 %, Mono:0.0 %, Eos:0.0 %, Lactic Acid:0.9 mmol/L,\n Ca++:7.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n # Respiratory failure: Multilobar Pneumonia & COPD. Possible that she\n has some sort of endobronchial lesion (? malignancy given smoking hx)\n contributing. In any case, because of her very severe baseline\n obstructive disease, she is in a very tenuous respiratory place right\n now. GPCs in pairs, Legionella (-)\n - vancomycin, cefepime, and azithromycin for broad bacterial coverage\n including atypical pathogens. (Lives in facility,\n chronic respiratory disease so will treat as if HCAP.)\n - F/U blood cx\n - ABG on current settings, tolerate large tidal volumes\n - Plateaus <30 as most ventilation is going to the L lung, maintain\n ARDSnet ventilation as pH tolerates\n - methylprednisolone to 125 mg q8h\n - fluticasone inh\n - albuterol nebs q1h for now, decrease to q6h as tolerated\n - ipratropium nebs q6h\n #. Shock: Septic from PNA, leukocytosis, requiring pressors but is\n fluid responsive. No recent abx exposure.\n - Abx as above\n - Norepi as needed to keep MAP >65, allow for sedation\n - trend WBC (will be complicated by steroids)\n - Send C. Diff\n - Measure SvO2 to r/o cardiogenic shock\n # kidney injury: Unclear if this is acute or chronic, but did improve\n with signficant fluid hydration.\n - F/U urine lytes\n - trend creatinine\n # hx hypertension: hypotensive on pressors\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , patient does not know # and none in chart; will consult social\n work\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:42 PM 25 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 05:47 PM\n 18 Gauge - 04:00 AM\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 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": "2192-03-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 726733,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation; Comments: Reintubated with same size ETT,\n after tube had migrated above vocal cords.\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments: Scant to small thick white/pale yellow 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 :\n Comments: Received vented on PSV/CPAP mode. Patient continues to have\n high FIO2 & PEEP requirement to prevent hypoxemia. Prior CXR showed no\n change in extensive right-sided opacification. Continues to require\n assistance to clear bronchopulmonary secretions, as well as diuresis.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726539,
"text": "67 y/o pt with long standing history of severe COPD & chronic asthma.\n Pt lives in an facility and had been c/o SOB x 1 wk.\n EMS found pt to have a 70% O2 sat on RA. Placed on NRB and given\n nebs. Also found to be tachypneic to the 40's with obvious increased\n WOB. CXR significant for large right sided PNA. Given Azithromycin,\n Ceftriaxone, nebs and steroids in ED. Admitted to MICU for further\n observation.\n Respiratory Failure\n Assessment:\n Received pt vented on PSV 70% 10/10. Versed @ 2mg/hr, Fentanyl @\n 125mcg/hr. Pt easily arousable & is able to respond to yes/no\n questions. Pt appearing uncomfortable @ change of shift, biting/nawing\n on EET and moving all extremeties. I/E wheezes noted in BUL, diminished\n @ bases. O2 sat 92-95%. Of note, pt does have confirmed GPC in pairs\n within sputum. Suctioning Q3-4hrs for thick, white/yellow sputum.\n Strong cough/gag noted.\n Action:\n Overnight pt did receive Lasix 20mg IV x 2 w/ great UOP (>100cc/hr)\n Upon entering room during AM assessment, pt noted to have what appeared\n like tubefeed oozing from corner of mouth. Tube feeds immediately shut\n off. Pt desatting slowly to 85%. RT @ bedside. Pt was suctioned via ETT\n & orally multiple times for white also appeared like tube feed &/or\n thick sputum. LS as noted above. <10cc residual noted in OGT &\n ausculation of placement heard without difficulty. CXR obtained to\n evaulate lung fields & OGT. Please see Metavision for ABG results. Dr.\n also @ bedside. This RN & MD did remove OGT for\n troubleshooting purposes. Pt is receiving triple abx, stress dose\n steroids & inhalers via RT ATC. Current vent settings after episode AC\n 70% x 450 x 24 w/ 10 PEEP.\n Response:\n WBC improving. Originally 59 on arrival to MICU , currently 27.2.\n Lactate this AM 1.3. K+ elevated this AM @ 5.4. EKG obtained. Per Dr.\n , redraw chem 7 @ 0630.\n Plan:\n Trend ABG\ns & follow O2 sats (goal O2 sat 88-94%). ? CT chest to\n evaluate for malignant process on top of PNA given elevated WBC. Wean\n vent settings as tolerated. Trend labs/culture data. ? bronch for clean\n out and additional spec.\n R IJ TLC\n L Radial ALINE\n PIV x 1\n Pt does not have OGT/NGT access @ this time.\n Full Code\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726738,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n Events- new ogt placed. Placement confirmed by xray per dr .\n Required reintubation as not getting volumes at 1700.\n Anesthesia called and up to see the patient. Tube pulled and\n reintubated after receiving 20mg etomidate and 100mg succinylcholine\n Respiratory failure, chronic\n Assessment:\n This am on 70% fio2 tv 450 a/c rate of 24 breathing 24 with peep of\n 10. sats low 90\ns. bs with upper insp wheeze and diminished at bases.\n Suctioned for minimal secretions. afebrile\n Action:\n Cont vancomycin, cefipime and azithromycin. Cont albuterol and\n atrovent mdi. Methylprednsionlone to end today. Changed to ps vent.\n Placed on 70% fio2 peep of 10 and ps of 12. 40 mg iv lasix ordered and\n given with goal of having patient neg 1-2l for today.\n Response:\n On above vent settings breathing low to mid 20\ns with tv of 350 or\n greater. Abg 7.35/54/60/31 when sat was 90%. Dr made aware and\n am leaving her on this setting as sat now 91-92%. Loosing volumes with\n obvious leak of air from mouth. Anesthesia called and old tube removed\n and patient reinutubated with # 7.5 tube. Placed on 80% fio2 tv 450 a/c\n rate of 16 and 10 peep. Xray pending. . abg sent.\n Plan:\n Check xray for tube placement and result of abg. Vanco random level to\n be checked at 1900.\n Constipation (Obstipation, FOS)\n Assessment:\n Pt received with no stool output since admission. Aggressive bowel\n regimen had been started on day shift. On assessment, pt with\n small amt liquid brown stool.\n Action:\n Pt cont on naloxone 2mg Q6. Also given colace, lactulose, senna. At MN,\n pt noted to be soiled in more stool so FMS placed. TF restarted @ 0230\n at starting rate 25cc/hr since pt had stooled.\n Response:\n Pt with small to moderate stool output, large amt of gas. FMS remains\n in place with stool leaking around device at times.\n Plan:\n Cont with bowel regimen.\n Hypernatremia (high sodium)\n Assessment:\n Na+ 148 on 1900 labs. Pt s/p 500cc IV D5W. Pt unable to receive free\n water constipation/high residuals and ? aspiration.\n Action:\n Pt given another 500cc D5W. Aggressive bowel regimen implemented in\n attempt to make pt stool.\n Response:\n Pt began stooling minimally. TF restarted\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 726799,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation; Comments: Reintubated with same size ETT,\n after tube had migrated above vocal cords.\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments: Scant to small thick white/pale yellow 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 :\n Comments: Received vented on PSV/CPAP mode. Patient continues to have\n high FIO2 & PEEP requirement to prevent hypoxemia. ABG slightly\n improved: 76/56/7.36. Prior CXR showed no change in extensive\n right-sided opacification. Continues to require assistance to clear\n bronchopulmonary secretions, as well as diuresis.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n 06:45\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726956,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation\n Events- sedation increased this am as attempting to push out ett with\n tongue this am.\n Switched to ards net vent.\n Bit through pilot of ett at 1700. reintubated with # 8 ett by\n anesthesia. Awaiting xray confirmation.\n Hypernatremia (high sodium)\n Assessment:\n Na this am 148.\n Action:\n Giving 500cc d5w at 200cc/hr this afternoon and then will hopefully\n change to free h20 boluses via ogt if cont to tolerate his tf as she\n has been. Check na at 1800/.\n Response:\n Able to tolerate 1400 free h20 bolus. No residuals at 1600. labs drawn\n at 1730. needs re confirmation of ogt now that he has been reintubated.\n Plan:\n Check result of 1730 na. restart free h20 boluses via ogt once\n confirmation of tube confirmed\n Constipation (Obstipation, FOS)\n Assessment:\n Passing malodorous stool via flexiseal today. Stool guiac neg brown\n loose.\n Action:\n Cont on bowel regimen. Able to start tf again.\n Response:\n Tolerating tf. Tf stopped at 170 when patient required reintubation.\n Cont to pass a lot of gas. Some stool.\n Plan:\n Cont bowel regimen. Restart tf once ogt placement reconfirmed by xray.\n Respiratory failure, chronic\n Assessment:\n This am on 80% fio2 peep of 10 and ps of 12 with resp rate high teens\n to low 20\ns. tv mid 300 or greater. Abg 7.36/56/76/33. sats in the mid\n 90\n Action:\n Weaned to 70% fio2. changed to ards net protocol due to infected right\n lung and emphysetic left lung. Cont on cefipime, vanco, and\n azithromycin. Cont on albuterol and atrovent mdi\ns. methylprednisolone\n weaned to 100mg iv q 12 hours today. Lasix 40mg given with goal 2.5 l\n neg for the day.\n Response:\n Abg 7.37/56/71/34 on 70% fio2 tv 340/ a/c rate of 16 breathing 19 and\n 10 peep. Neg 400cc at 1600. Dr. made aware. Wants to see 1800\n lytes prior to redosing lasix. Bit through pilot of ett at 1700.\n anesthesia here. Received 20 mg of etomidate and 100mg of\n succinylcholine 100mg iv for reintubation.\n Plan:\n Will accept ph of down to 7.20 on ards net vent. Check results of lytes\n at 1800 to see if we want to give more lasix. Needs xray confirmation\n of ett. This was ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726958,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation\n Events- sedation increased this am as attempting to push out ett with\n tongue this am.\n Switched to ards net vent.\n Bit through pilot of ett at 1700. reintubated with # 8 ett by\n anesthesia. Awaiting xray confirmation.\n Hypernatremia (high sodium)\n Assessment:\n Na this am 145.\n Action:\n Free water bolus 250ml q4h\n Response:\n Able to tolerate free h20 bolus. No residuals getting tube feeds @\n 45ml/hr\n Plan:\n Advance tube feed 10ml Q4h to reach goal 65ml/hr.\n Constipation (Obstipation, FOS)\n Assessment:\n Passing malodorous stool via flexiseal today. Stool guiac neg brown\n loose.\n Action:\n Cont on bowel regimen. Able to start tf again.\n Response:\n Tolerating tf. Cont to pass a lot of gas. Some stool.\n Plan:\n Cont bowel regimen.\n Respiratory failure, chronic\n Assessment:\n Sedated and vented lung fields diminished,\n Action:\n No vent changes overnight on ards net protocol due to infected right\n lung and emphysetic left lung. Cont on cefipime, vanco, and\n azithromycin. Cont on albuterol and atrovent mdi\ns. methylprednisolone\n weaned to 100mg iv q 12 hours today. Lasix 40mg given with goal 2.5 l\n neg for the day.\n Response:\n Sating low 90\n Plan:\n Will accept ph of down to 7.20 on ards net vent.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726783,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n Events- new ogt placed. Placement confirmed by xray per dr .\n Required reintubation as not getting volumes at 1700.\n Anesthesia called and up to see the patient. Tube pulled and\n reintubated after receiving 20mg etomidate and 100mg succinylcholine\n Respiratory failure, chronic\n Assessment:\n Received pt s/p reintubation for possible dislodging of ETT. Pt on PSV\n 80%/ with ABG 7.36/56/65. Pt with COPD, goal PO2 65, goal sats\n 88-93%. LS ronchorous/diminished. Pt suctioned for small amts tan thick\n secretions via ETT. Sats 92-94%. Pt afebrile. Lg amts CYU via foley s/p\n IV lasix.\n Action:\n Pt given last dose methylprednisolone @ MN. Cont on IV ABX for PNA.\n Pulmonary toilet.\n Response:\n No vent changes made this shift. ABG this AM slightly improved to\n 7.36/56/76. Sats remain 92-94% throughout shift. Pt cont to diurese.\n Plan:\n Attempt to wean vent as tolerated. No SBT this shift as it is\n contraindicated with current vent settings. Goal sats 88-93%, goal PO2\n 65, goal negative 1-2L to keep fluid out of lungs.\n Constipation (Obstipation, FOS)\n Assessment:\n Pt received with no stool output since admission. Aggressive bowel\n regimen had been started on day shift. On assessment, pt with\n small amt liquid brown stool.\n Action:\n Pt cont on naloxone 2mg Q6. Also given colace, lactulose, senna. At MN,\n pt noted to be soiled in more stool so FMS placed. TF restarted @ 0230\n at starting rate 25cc/hr since pt had stooled.\n Response:\n Pt with small to moderate stool output, large amt of gas. FMS remains\n in place with stool leaking around device at times. Pt with residual\n 60cc after 1.5hrs of intiation of tube feeds so feeding stopped.\n Plan:\n Cont with aggressive bowel regimen. Cont to reassess for proper time to\n restart TF.\n Hypernatremia (high sodium)\n Assessment:\n Na+ 148 on 1900 labs. Pt s/p 500cc IV D5W. Pt unable to receive free\n water via OGT constipation/high residuals and ? aspiration.\n Action:\n Pt given another 500cc D5W. Aggressive bowel regimen implemented in\n attempt to make pt stool so that free water boluses may be given via\n OGT in attempt to decrease sodium.\n Response:\n AM Na+ ____. Pt began stooling minimally but with initiation of TF,\n residuals high so unable to give free water.\n Plan:\n Cont to monitor sodium levels. Plan to give free water boluses once\n able to resume TF. While unable to give free water, may need to\n administer more D5W.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726787,
"text": "67 yo F prior smoker w/ severe COPD on home O2 admitted w/ resp failure\n due to pneumonia and COPD exacerbation.\n Respiratory failure, chronic\n Assessment:\n Received pt s/p reintubation after dislodging of ETT. Pt on PSV\n 80%/ with ABG 7.36/56/65. Pt with COPD, goal PO2 65, goal sats\n 88-93%. LS ronchorous/diminished. Pt suctioned for small amts tan thick\n secretions via ETT. Sats 92-94%. Pt afebrile. Lg amts CYU via foley s/p\n IV lasix.\n Action:\n Pt given last dose methylprednisolone @ MN. Cont on IV ABX for PNA.\n Pulmonary toilet.\n Response:\n No vent changes made this shift. ABG this AM slightly improved to\n 7.36/56/76. Sats remain 92-94% throughout shift. Pt cont to diurese\n well.\n Plan:\n Attempt to wean vent as tolerated. No SBT this shift as it is\n contraindicated with current vent settings. Goal sats 88-93%, goal PO2\n 65, goal negative 1-2L to keep fluid out of lungs.\n Constipation (Obstipation, FOS)\n Assessment:\n Pt received with no stool output since admission. Aggressive bowel\n regimen had been started on day shift. On assessment, pt with\n small amt liquid brown stool.\n Action:\n Pt cont on naloxone 2mg Q6. Also given colace, lactulose, senna. At MN,\n pt noted to be soiled in more stool so FMS placed. TF restarted @ 0230\n at starting rate 25cc/hr since pt had stooled and no residuals.\n Response:\n Pt with small to moderate stool output, large amt of gas. FMS remains\n in place with stool leaking around device at times. Pt with residual\n 60cc bilious contents after 1.5hrs of intiation of tube feeds so\n feeding stopped.\n Plan:\n Cont with aggressive bowel regimen. Cont to reassess for proper time to\n restart TF.\n Hypernatremia (high sodium)\n Assessment:\n Na+ 148 on 1900 labs. Pt s/p 500cc IV D5W. Pt unable to receive free\n water via OGT constipation/high residuals and ? aspiration.\n Action:\n Pt given another 500cc D5W. Aggressive bowel regimen implemented in\n attempt to make pt stool so that free water boluses may be given via\n OGT in attempt to decrease sodium.\n Response:\n AM Na+ remains 148. Pt began stooling minimally but with initiation of\n TF, residuals high so unable to cont TF and give free water.\n Plan:\n Cont to monitor sodium levels. Plan to give free water boluses once\n able to resume TF. While unable to give free water, may need to\n administer more D5W.\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-03-31 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 727071,
"text": "Demographics\n Day of mechanical ventilation: 6\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Patient weaned to PS, PEEP increased from 10 to 14, FiO2\n decreased to 50% Currently SpO2 90%.\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 Periodic SBT's for conditioning, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, underlying illness not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-03-31 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 726947,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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 Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated, Reduce PEEP as tolerated; Comments:\n unable to wean FIO2/PEEP this shift due to sats of only 88-90%, when\n decreased to 50% sats drop to low 80's. Will wean as tolerated.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions, Underlying illness not\n resolved\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726706,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n Events- new ogt placed. Placement confirmed by xray per dr .\n Required reintubation as not getting volumes at 1700.\n Anesthesia called and up to see the patient. Tube pulled and\n reintubated after receiving 20mg etomidate and 100mg succinylcholine\n R espiratory failure, chronic\n Assessment:\n This am on 70% fio2 tv 450 a/c rate of 24 breathing 24 with peep of\n 10. sats low 90\ns. bs with upper insp wheeze and diminished at bases.\n Suctioned for minimal secretions. afebrile\n Action:\n Cont vancomycin, cefipime and azithromycin. Cont albuterol and\n atrovent mdi. Methylprednsionlone to end today. Changed to ps vent.\n Placed on 70% fio2 peep of 10 and ps of 12. 40 mg iv lasix ordered and\n given with goal of having patient neg 1-2l for today.\n Response:\n On above vent settings breathing low to mid 20\ns with tv of 350 or\n greater. Abg 7.35/54/60/31 when sat was 90%. Dr made aware and\n am leaving her on this setting as sat now 91-92%. Loosing volumes with\n obvious leak of air from mouth. Anesthesia called and old tube removed\n and patient reinutubated with # 7.5 tube. Placed on 80% fio2 tv 450 a/c\n rate of 16 and 10 peep. Xray pending. . abg sent.\n Plan:\n Check xray for tube placement and result of abg. Vanco random level to\n be checked at 1900.\n Constipation (Obstipation, FOS)\n Assessment:\n Has had no stool since admission and episode of aspiration of tf this\n am.\n Action:\n Given 1 ducolax supp and 2mg naloxaone per ngt.\n Response:\n Had not stooled by 1300. Dr. made aware and lactulose 30cc q 6\n hours prn ordered. Dose given. Had only a smear of stool. Dr made\n aware. Was to get a dose of lactulsoe at 1700 when had issues with ett.\n Dose held as ogt placement needs to reconfirmed with xray.\n Plan:\n Check for placement of ogt by xray done. Readminister lactulose 30cc q\n 3 hours till stools.\n Hypernatremia (high sodium)\n Assessment:\n Na 149 this am.\n Action:\n Ordered for free h20 boluses 250cc q 4hours. This was not to start till\n she stooled as ? aspirated due to constipation.\n Response:\n Had not stooled despite intervention at 1400. Dr. made aware and\n d5w at 100cc/hr for 500cc ordered and hung.\n Plan:\n Lytes at 1900.\n Social- social services is working on contacting sister who is next of\n .\n ------ Protected Section ------\n Dr. looked at patient\ns cxr post intubation this evening. Ett\n position ok. She can not confirm ogt position. Will need to check with\n radiologist. Do not use ogt till placement confirmed. Of note Dr\n was able to contact and talk to patient\ns sister. She was\n updated on plan of care. Can switch back to ps per Dr .\n ------ Protected Section Addendum Entered By: , RN\n on: 18:23 ------\n ------ Protected Section Addendum Entered By: , RN\n on: 18:23 ------\n Dr spoke with radiologist. Tip of tube in stomach. Tube needed\n to be advanced 2 inches to make sure side posrts in stomach. Then tube\n ok to use. This was done and lactulsoe given.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:32 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 726712,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason: Elective\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Insp Wheeze\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 Comments: hypoxemic Pa02 in the 60s\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Plan to extubate in AM\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient switched from A/C to PSV with good tolerance. ETT migrated\n above vocal cord patient had to be re-intubated with # 7.5 @ 25 cm.ABG\n shows compensated resp acidosis. CXr improved from complete white out.\n (L) sided effusion will wean to extubated.\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 726909,
"text": "Demographics\n Day of mechanical ventilation: 5\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing, High\n flow demand; Comments: switch to AC for worsening oxygenation and CXR.\n At 1700 pt bit through the pilot balloon line and needed to be\n re-intubated.\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 Reduce PEEP as tolerated; Comments: and FIo2.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727489,
"text": "Chief Complaint:\n 24 Hour Events:\n - furosemide gtt restarted; MAP remains in mid 60s\n - trying to get IV meds and TF concentrated to reduce intake\n - back on AC with Tv in low 300s\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:47 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 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.5\n HR: 70 (67 - 93) bpm\n BP: 87/48(61) {87/47(61) - 124/70(89)} mmHg\n RR: 22 (16 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,608 mL\n 710 mL\n PO:\n TF:\n 1,560 mL\n 469 mL\n IVF:\n 1,448 mL\n 241 mL\n Blood products:\n Total out:\n 3,240 mL\n 920 mL\n Urine:\n 3,240 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n 368 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 0 (0 - 343) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 25 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 95%\n ABG: 7.43/68/76./46/16\n Ve: 6.9 L/min\n PaO2 / FiO2: 152\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 475 K/uL\n 9.3 g/dL\n 114 mg/dL\n 0.9 mg/dL\n 46 mEq/L\n 4.2 mEq/L\n 48 mg/dL\n 91 mEq/L\n 143 mEq/L\n 29.6 %\n 24.7 K/uL\n [image002.jpg]\n 02:09 PM\n 06:04 PM\n 08:49 PM\n 04:16 AM\n 04:22 AM\n 05:09 PM\n 05:22 PM\n 10:16 PM\n 03:59 AM\n 04:03 AM\n WBC\n 24.5\n 24.7\n Hct\n 30.5\n 29.6\n Plt\n 557\n 475\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 40\n 45\n 43\n 48\n 48\n 47\n Glucose\n 176\n 132\n 185\n 114\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:43 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-04-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727491,
"text": "Chief Complaint:\n 24 Hour Events:\n - furosemide gtt restarted; MAP remains in mid 60s\n - trying to get IV meds and TF concentrated to reduce intake\n - back on AC with Tv in low 300s\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:47 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 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.5\n HR: 70 (67 - 93) bpm\n BP: 87/48(61) {87/47(61) - 124/70(89)} mmHg\n RR: 22 (16 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,608 mL\n 710 mL\n PO:\n TF:\n 1,560 mL\n 469 mL\n IVF:\n 1,448 mL\n 241 mL\n Blood products:\n Total out:\n 3,240 mL\n 920 mL\n Urine:\n 3,240 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n 368 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 0 (0 - 343) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 25 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 95%\n ABG: 7.43/68/76./46/16\n Ve: 6.9 L/min\n PaO2 / FiO2: 152\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 475 K/uL\n 9.3 g/dL\n 114 mg/dL\n 0.9 mg/dL\n 46 mEq/L\n 4.2 mEq/L\n 48 mg/dL\n 91 mEq/L\n 143 mEq/L\n 29.6 %\n 24.7 K/uL\n [image002.jpg]\n 02:09 PM\n 06:04 PM\n 08:49 PM\n 04:16 AM\n 04:22 AM\n 05:09 PM\n 05:22 PM\n 10:16 PM\n 03:59 AM\n 04:03 AM\n WBC\n 24.5\n 24.7\n Hct\n 30.5\n 29.6\n Plt\n 557\n 475\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 40\n 45\n 43\n 48\n 48\n 47\n Glucose\n 176\n 132\n 185\n 114\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Multilobar pneumonia & COPD c/b ARDS.\n Difficult to oxygenate without high PEEP/FIO2. Requiring high PEEP and\n PSV. Still significantly positive for the stay- LOS 4.5 liters.\n Continue lasix gtt, plan for goal I/O negative 1 liter.\n -repeat ABG and lytes, if pH increasing or bicarb increasing may start\n diamox\n -taper prednisone to 30mg daily today\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, d/c azithromycin for 8-day course to\n end \n - change IV meds to PO if possible\n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:43 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-04-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727492,
"text": "Chief Complaint:\n 24 Hour Events:\n - furosemide gtt restarted; MAP remains in mid 60s\n - trying to get IV meds and TF concentrated to reduce intake\n - back on AC with Tv in low 300s\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:47 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 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.5\n HR: 70 (67 - 93) bpm\n BP: 87/48(61) {87/47(61) - 124/70(89)} mmHg\n RR: 22 (16 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,608 mL\n 710 mL\n PO:\n TF:\n 1,560 mL\n 469 mL\n IVF:\n 1,448 mL\n 241 mL\n Blood products:\n Total out:\n 3,240 mL\n 920 mL\n Urine:\n 3,240 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n 368 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 0 (0 - 343) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 25 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 95%\n ABG: 7.43/68/76./46/16\n Ve: 6.9 L/min\n PaO2 / FiO2: 152\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: trace bilaterally pitting edema, improving\n Labs / Radiology\n 475 K/uL\n 9.3 g/dL\n 114 mg/dL\n 0.9 mg/dL\n 46 mEq/L\n 4.2 mEq/L\n 48 mg/dL\n 91 mEq/L\n 143 mEq/L\n 29.6 %\n 24.7 K/uL\n [image002.jpg]\n 02:09 PM\n 06:04 PM\n 08:49 PM\n 04:16 AM\n 04:22 AM\n 05:09 PM\n 05:22 PM\n 10:16 PM\n 03:59 AM\n 04:03 AM\n WBC\n 24.5\n 24.7\n Hct\n 30.5\n 29.6\n Plt\n 557\n 475\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 40\n 45\n 43\n 48\n 48\n 47\n Glucose\n 176\n 132\n 185\n 114\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Multilobar pneumonia & COPD c/b ARDS.\n Difficult to oxygenate without high PEEP/FIO2. Requiring high PEEP and\n PSV. Still significantly positive for the stay- LOS 4.5 liters.\n Continue lasix gtt, plan for goal I/O negative 1 liter.\n -repeat ABG and lytes, if pH increasing or bicarb increasing may start\n diamox\n -taper prednisone to 30mg daily today\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, d/c azithromycin for 8-day course to\n end \n - change IV meds to PO if possible\n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:43 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726628,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n Events- new ogt placed. Placement confirmed by xray per dr .\n Respiratory failure, chronic\n Assessment:\n This am on 70% fio2 tv 450 a/c rate of 24 breathing 24 with peep of\n 10. sats low 90\ns. bs with upper insp wheeze and diminished at bases.\n Suctioned for minimal secretions. afebrile\n Action:\n Cont vancomycin, cefipime and azithromycin. Cont albuterol and\n atrovent mdi. Methylprednsionlone to end today. Changed to ps vent.\n Placed on 70% fio2 peep of 10 and ps of 12. 40 mg iv lasix ordered and\n given with goal of having patient neg 1-2l for today.\n Response:\n On above vent settings breathing low to mid 20\ns with tv of 350 or\n greater. Abg 7.35/54/60/31 when sat was 90%. Dr made aware and\n am leaving her on this setting as sat now 91-92%.\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Has had no stool since admission and episode of aspiration of tf this\n am.\n Action:\n Given 1 ducolax supp and 2mg naloxaone per ngt.\n Response:\n Had not stooled by 1300. Dr. made aware and lactulose 30cc q 6\n hours prn ordered. Dose given.\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n Na 149 this am.\n Action:\n Ordered for free h20 boluses 250cc q 4hours. This was not to start till\n she stooled as ? aspirated due to constipation.\n Response:\n Had not stooled despite intervention at 1400. Dr. made aware and\n d5w at 100cc/hr for 500cc ordered and hung.\n Plan:\n Lytes at 1800.\n Social- social services is working on contacting sister who is next of\n .\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727082,
"text": "A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n Hypernatremia (high sodium)\n Assessment:\n Na 145. TF infusing at goal of 65cc/hr.\n Action:\n Continue with free water flushes of 250cc every 4 hours.\n Response:\n Plan:\n Continue to monitor.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. LS\n diminished. Hemodynamically stable.\n Action:\n Vent settings changed to PSV 12/14 @ 50%. Pt started on lasix drip for\n goal removal of 1 liter today. Pt also given 1x 40mg lasix dose.\n Response:\n Pt is only netative 375cc thus far today.\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727180,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:30 AM\n Cefipime - 10:00 PM\n Vancomycin - 07:56 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:55 AM\n Furosemide (Lasix) - 08:05 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 08:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.8\nC (96.4\n HR: 75 (68 - 86) bpm\n BP: 103/54(69) {86/50(62) - 131/87(100)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,783 mL\n 1,518 mL\n PO:\n TF:\n 1,339 mL\n 546 mL\n IVF:\n 1,309 mL\n 447 mL\n Blood products:\n Total out:\n 3,450 mL\n 1,865 mL\n Urine:\n 3,450 mL\n 1,865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 333 mL\n -347 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 442 (389 - 442) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 14 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n SpO2: 91%\n ABG: 7.36/68/71/40/9\n Ve: 7.7 L/min\n PaO2 / FiO2: 142\n Physical Examination\n Gen:\n HEENT:\n CV:\n PULM:\n ABD:\n EXTREM:\n SKIN:\n NEURO:\n Labs / Radiology\n 10.0 g/dL\n 537 K/uL\n 133 mg/dL\n 0.8 mg/dL\n 40 mEq/L\n 4.1 mEq/L\n 40 mg/dL\n 97 mEq/L\n 143 mEq/L\n 32.0 %\n 23.1 K/uL\n [image002.jpg]\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n WBC\n 28.5\n 26.2\n 23.1\n Hct\n 30.2\n 30.6\n 32.0\n Plt\n 446\n 535\n 537\n Cr\n 0.9\n 0.8\n 0.8\n 0.8\n 0.7\n 0.8\n TCO2\n 33\n 33\n 34\n 40\n Glucose\n 194\n 166\n 168\n 150\n 171\n 133\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -wean FiO2 to maintain PaO2 > 60; increase PEEP to 12 since O2 sat on\n low side\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n Change to lasix gtt (low rate) for slow continuous diuresis\n -vanco + cefepime + azithro --> plan for empiric 8d course pending cx\n data\n -tx COPD exac w/ Solu-Medrol --> change to prednisone 40mg daily pNGT\n -will need CT scan at some point to re-evaluate, poss bronch given RUL\n collapse seen in , can be deferred til better on vent\n -flovent\n -will try to wean sedation and transition to PSV over the course of the\n day\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa- monitor w/ diuresis;\n -start free H20 boluses per NGT plus d5w IV and monitor. Na improved,\n continue free H20.\n 4. Constipation- resolving\n -cont aggressive regimen\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "Physician ",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727181,
"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: 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation. Intubated 5 days ago.\n 24 Hour Events:\n Excellent UOP on lasix, but only 500cc neg\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:30 AM\n Cefipime - 10:00 PM\n Vancomycin - 07:56 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:55 AM\n Furosemide (Lasix) - 08:05 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 08:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.8\nC (96.4\n HR: 75 (68 - 86) bpm\n BP: 103/54(69) {86/50(62) - 131/87(100)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,783 mL\n 1,518 mL\n PO:\n TF:\n 1,339 mL\n 546 mL\n IVF:\n 1,309 mL\n 447 mL\n Blood products:\n Total out:\n 3,450 mL\n 1,865 mL\n Urine:\n 3,450 mL\n 1,865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 333 mL\n -347 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 442 (389 - 442) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 14 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n SpO2: 91%\n ABG: 7.36/68/71/40/9\n Ve: 7.7 L/min\n PaO2 / FiO2: 142\n Physical Examination\n Gen:intubated, sedated\n HEENT:PERRL, anicteric\n CV:RRR, no m/r/g\n PULM:CTA bilat\n ABD:soft, NTND\n EXTREM:\n SKIN:no rashes\n NEURO:sedated\n Labs / Radiology\n 10.0 g/dL\n 537 K/uL\n 133 mg/dL\n 0.8 mg/dL\n 40 mEq/L\n 4.1 mEq/L\n 40 mg/dL\n 97 mEq/L\n 143 mEq/L\n 32.0 %\n 23.1 K/uL\n [image002.jpg]\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n WBC\n 28.5\n 26.2\n 23.1\n Hct\n 30.2\n 30.6\n 32.0\n Plt\n 446\n 535\n 537\n Cr\n 0.9\n 0.8\n 0.8\n 0.8\n 0.7\n 0.8\n TCO2\n 33\n 33\n 34\n 40\n Glucose\n 194\n 166\n 168\n 150\n 171\n 133\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -wean FiO2 to maintain PaO2 > 60; increase PEEP to 12 since O2 sat on\n low side\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n Change to lasix gtt (low rate) for slow continuous diuresis\n -vanco + cefepime + azithro --> plan for empiric 8d course pending cx\n data\n -tx COPD exac w/ Solu-Medrol --> change to prednisone 40mg daily pNGT\n -will need CT scan at some point to re-evaluate, poss bronch given RUL\n collapse seen in , can be deferred til better on vent\n -flovent\n -will try to wean sedation and transition to PSV over the course of the\n day\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa- monitor w/ diuresis;\n -start free H20 boluses per NGT plus d5w IV and monitor. Na improved,\n continue free H20.\n 4. Constipation- resolving\n -cont aggressive regimen\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "Physician ",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727182,
"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: 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation. Intubated 5 days ago.\n 24 Hour Events:\n Excellent UOP on lasix, but only 500cc neg\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:30 AM\n Cefipime - 10:00 PM\n Vancomycin - 07:56 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Lasix gtt at 10mg/hr\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:55 AM\n Furosemide (Lasix) - 08:05 AM\n Colace\n Protonix\n RISS\n Po narcan\n Prednisone 40mg daily\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 08:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.8\nC (96.4\n HR: 75 (68 - 86) bpm\n BP: 103/54(69) {86/50(62) - 131/87(100)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,783 mL\n 1,518 mL\n PO:\n TF:\n 1,339 mL\n 546 mL\n IVF:\n 1,309 mL\n 447 mL\n Blood products:\n Total out:\n 3,450 mL\n 1,865 mL\n Urine:\n 3,450 mL\n 1,865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 333 mL\n -347 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 442 (389 - 442) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 14 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n SpO2: 91%\n ABG: 7.36/68/71/40/9\n Ve: 7.7 L/min\n PaO2 / FiO2: 142\n Physical Examination\n Gen:intubated, sedated\n HEENT:PERRL, anicteric\n CV:RRR, no m/r/g\n PULM:CTA bilat\n ABD:soft, NTND\n EXTREM:\n SKIN:no rashes\n NEURO:sedated\n Labs / Radiology\n 10.0 g/dL\n 537 K/uL\n 133 mg/dL\n 0.8 mg/dL\n 40 mEq/L\n 4.1 mEq/L\n 40 mg/dL\n 97 mEq/L\n 143 mEq/L\n 32.0 %\n 23.1 K/uL\n [image002.jpg]\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n WBC\n 28.5\n 26.2\n 23.1\n Hct\n 30.2\n 30.6\n 32.0\n Plt\n 446\n 535\n 537\n Cr\n 0.9\n 0.8\n 0.8\n 0.8\n 0.7\n 0.8\n TCO2\n 33\n 33\n 34\n 40\n Glucose\n 194\n 166\n 168\n 150\n 171\n 133\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -wean FiO2 to maintain PaO2 > 60; increase PEEP to 12 since O2 sat on\n low side\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n Change to lasix gtt (low rate) for slow continuous diuresis\n -vanco + cefepime + azithro --> plan for empiric 8d course pending cx\n data\n -tx COPD exac w/ Solu-Medrol --> change to prednisone 40mg daily pNGT\n -will need CT scan at some point to re-evaluate, poss bronch given RUL\n collapse seen in , can be deferred til better on vent\n -flovent\n -will try to wean sedation and transition to PSV over the course of the\n day\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa- monitor w/ diuresis;\n -start free H20 boluses per NGT plus d5w IV and monitor. Na improved,\n continue free H20.\n 4. Constipation- resolving\n -cont aggressive regimen\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "Physician ",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727183,
"text": "Chief Complaint:\n 24 Hour Events:\n - Started on lasix gtt with good UOP\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:30 AM\n Cefipime - 10:00 PM\n Vancomycin - 07:56 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:55 AM\n Furosemide (Lasix) - 08:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.8\nC (96.4\n HR: 75 (68 - 86) bpm\n BP: 103/54(69) {86/50(62) - 131/87(100)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,783 mL\n 1,513 mL\n PO:\n TF:\n 1,339 mL\n 543 mL\n IVF:\n 1,309 mL\n 446 mL\n Blood products:\n Total out:\n 3,450 mL\n 1,865 mL\n Urine:\n 3,450 mL\n 1,865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 333 mL\n -352 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 417 (389 - 422) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 14 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n SpO2: 90%\n ABG: 7.36/68/71/40/9\n Ve: 7.6 L/min\n PaO2 / FiO2: 142\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: trace bilaterally pitting edema, improving\n Labs / Radiology\n 537 K/uL\n 10.0 g/dL\n 133 mg/dL\n 0.8 mg/dL\n 40 mEq/L\n 4.1 mEq/L\n 40 mg/dL\n 97 mEq/L\n 143 mEq/L\n 32.0 %\n 23.1 K/uL\n [image002.jpg]\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n WBC\n 28.5\n 26.2\n 23.1\n Hct\n 30.2\n 30.6\n 32.0\n Plt\n 446\n 535\n 537\n Cr\n 0.9\n 0.8\n 0.8\n 0.8\n 0.7\n 0.8\n TCO2\n 33\n 33\n 34\n 40\n Glucose\n 194\n 166\n 168\n 150\n 171\n 133\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Multilobar pneumonia & COPD c/b ARDS.\n Difficult to oxygenate without high PEEP/FIO2. Requiring PEEP 14.\n Still significantly positive for the stay. Lasix gtt started\n yesterday, but still net positive.\n - decrease FW flushes\n - continue Lasix gtt today\n - ABG today\n - continue prednisone 40 and plan to taper\n - Flovent 4 puffs \n - continue nebs\n - continue high PEEP\n - PM Lytes\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, and azithromycin for 8-day course to\n end \n - change IV meds to PO if possible\n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # Hypernatremia: free water deficit resolved\n - decrease FW flushes\n - pm lytes\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-04-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727184,
"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: 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation. Intubated 5 days ago.\n 24 Hour Events:\n Excellent UOP on lasix, but only 500cc neg\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:30 AM\n Cefipime - 10:00 PM\n Vancomycin - 07:56 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Lasix gtt at 10mg/hr\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:55 AM\n Furosemide (Lasix) - 08:05 AM\n Colace\n Protonix\n RISS\n Po narcan\n Prednisone 40mg daily\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 08:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.8\nC (96.4\n HR: 75 (68 - 86) bpm\n BP: 103/54(69) {86/50(62) - 131/87(100)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,783 mL\n 1,518 mL\n PO:\n TF:\n 1,339 mL\n 546 mL\n IVF:\n 1,309 mL\n 447 mL\n Blood products:\n Total out:\n 3,450 mL\n 1,865 mL\n Urine:\n 3,450 mL\n 1,865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 333 mL\n -347 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 442 (389 - 442) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 14 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n SpO2: 91%\n ABG: 7.36/68/71/40/9\n Ve: 7.7 L/min\n PaO2 / FiO2: 142\n Physical Examination\n Gen:intubated, lightly sedated but awakens to voice and nods yes/no\n HEENT:PERRL, anicteric\n CV:RRR, no m/r/g\n PULM:CTA bilat\n ABD:soft, NTND\n EXTREM:\n SKIN:no rashes\n NEURO:sedated, able to answer questions\n Labs / Radiology\n 10.0 g/dL\n 537 K/uL\n 133 mg/dL\n 0.8 mg/dL\n 40 mEq/L\n 4.1 mEq/L\n 40 mg/dL\n 97 mEq/L\n 143 mEq/L\n 32.0 %\n 23.1 K/uL\n [image002.jpg]\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n WBC\n 28.5\n 26.2\n 23.1\n Hct\n 30.2\n 30.6\n 32.0\n Plt\n 446\n 535\n 537\n Cr\n 0.9\n 0.8\n 0.8\n 0.8\n 0.7\n 0.8\n TCO2\n 33\n 33\n 34\n 40\n Glucose\n 194\n 166\n 168\n 150\n 171\n 133\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS, now\n improving slowly.\n -wean FiO2 to maintain PaO2 > 60; increase PEEP to 12 since O2 sat on\n low side\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n Continue lasix gtt (low rate) for slow continuous diuresis\n -vanco + cefepime + azithro --> plan for empiric 8d course pending cx\n data\n -prednisone 40mg daily pNGT. Will decrease to 30mg in 2 days\n -flovent\n -Stable on PSV. Will decrease PEEP later today if able to get 1-2L\n negative\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa, improved. Decrease free H2O boluses, continue diuresis\n 4. Constipation- resolving\n -cont aggressive regimen\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 AM\n Prophylaxis:\n DVT: sc heparin\n Stress ulcer: pepcid\n VAP: chlorhexidine, HOB 30 degrees\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 35 min\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727426,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. On A/C 350x16\n 50% +16peep. RR 22 with sats 90%. LS clear with diminished bases.\n Hemodynamically stable. On lasix gtt at 7mg/hr. Afebrile with WBC 24.5.\n Action:\n No change in sedation. Continue vanco and cefepime for PNA. Lasix gtt\n increased to 10mg/hr. Added diamox for contraction alkalosis. MDI\ns and\n steroids as ordered. No vent changes.\n Response:\n Was +370cc at midnight. Remains with 2+ generalized edema. RR with sats\n %.\n Plan:\n Wean vent as tolerated.\n Check ABG\ns. Goal sats 88-92% with Pao2 >60.\n Goal fluid balance -1L/day.\n To finish antibiotics today.\n MDI\ns and steroids.\n v Positive bowel sounds, abdomen soft and obese. Brown, loose\n stool via flexiseal.\n v On sedation patient will open eyes, follow commands and MAE.\n Denies pain. Restrained for safety of lines and tubes.\n v HR 60-90\ns SR with occasional ectopy. SBP 90-1110\n v Full code.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727475,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. On A/C 350x16\n 50% +16peep. RR 22 with sats 90%. LS clear with diminished bases.\n Hemodynamically stable. On lasix gtt at 7mg/hr. Afebrile with WBC 24.5.\n Action:\n No change in sedation. Continue vanco and cefepime for PNA. Lasix gtt\n increased to 10mg/hr. Added diamox for contraction alkalosis. MDI\ns and\n steroids as ordered. No vent changes. CXR done.\n Response:\n Was +370cc at midnight. Currently 228cc negative. Remains with 2+\n generalized edema. ABG\ns 7.44/68/75/48, morning ABG unchanged. No\n difference in alkalosis with diamox. RR 19-26 with sats 90-95%. Lung\n sounds diminished.\n Plan:\n Wean vent as tolerated.\n Check ABG\ns. Goal sats 88-92% with Pao2 >60. F/u on CXR.\n Goal fluid balance -1L/day.\n To finish antibiotics today.\n MDI\ns and steroids.\n Most likely need Trach and PEG soon.\n v Positive bowel sounds, abdomen soft and obese. Brown, loose\n stool via flexiseal.\n v On sedation patient will open eyes, follow commands and MAE.\n Denies pain. Restrained for safety of lines and tubes.\n v HR 60-90\ns SR with occasional ectopy. SBP 90-1110\ns. HCT stable\n @30.\n v Full code.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726617,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n Respiratory failure, chronic\n Assessment:\n This am on 70% fio2 tv 450 a/c rate of 24 breathing 24 with peep of\n 10. sats low 90\ns. bs with upper insp wheeze and diminished at bases.\n Suctioned for minimal secretions. afebrile\n Action:\n Cont vancomycin, cefipime and azithromycin. Cont albuterol and\n atrovent mdi. Methylprednsionlone to end today. Changed to ps vent.\n Placed on 70% fio2 peep of 10 and ps of 12.\n Response:\n On above vent settings breathing low to mid 20\ns with tv of 350 or\n greater. Abg 7.35/54/60/31 when sat was 90%. Dr made aware and\n am leaving her on this setting as sat now 91-92%.\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Has had no stool since admission and episode of aspiration of tf this\n am.\n Action:\n Given 1 ducolax supp and 2mg naloxaone per ngt.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726700,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n Events- new ogt placed. Placement confirmed by xray per dr .\n Required reintubation as not getting volumes at 1700.\n Anesthesia called and up to see the patient. Tube pulled and\n reintubated after receiving 20mg etomidate and 100mg succinylcholine\n R espiratory failure, chronic\n Assessment:\n This am on 70% fio2 tv 450 a/c rate of 24 breathing 24 with peep of\n 10. sats low 90\ns. bs with upper insp wheeze and diminished at bases.\n Suctioned for minimal secretions. afebrile\n Action:\n Cont vancomycin, cefipime and azithromycin. Cont albuterol and\n atrovent mdi. Methylprednsionlone to end today. Changed to ps vent.\n Placed on 70% fio2 peep of 10 and ps of 12. 40 mg iv lasix ordered and\n given with goal of having patient neg 1-2l for today.\n Response:\n On above vent settings breathing low to mid 20\ns with tv of 350 or\n greater. Abg 7.35/54/60/31 when sat was 90%. Dr made aware and\n am leaving her on this setting as sat now 91-92%. Loosing volumes with\n obvious leak of air from mouth. Anesthesia called and old tube removed\n and patient reinutubated with # 7.5 tube. Placed on 80% fio2 tv 450 a/c\n rate of 16 and 10 peep. Xray pending. . abg sent.\n Plan:\n Check xray for tube placement and result of abg. Vanco random level to\n be checked at 1900.\n Constipation (Obstipation, FOS)\n Assessment:\n Has had no stool since admission and episode of aspiration of tf this\n am.\n Action:\n Given 1 ducolax supp and 2mg naloxaone per ngt.\n Response:\n Had not stooled by 1300. Dr. made aware and lactulose 30cc q 6\n hours prn ordered. Dose given. Had only a smear of stool. Dr made\n aware. Was to get a dose of lactulsoe at 1700 when had issues with ett.\n Dose held as ogt placement needs to reconfirmed with xray.\n Plan:\n Check for placement of ogt by xray done. Readminister lactulose 30cc q\n 3 hours till stools.\n Hypernatremia (high sodium)\n Assessment:\n Na 149 this am.\n Action:\n Ordered for free h20 boluses 250cc q 4hours. This was not to start till\n she stooled as ? aspirated due to constipation.\n Response:\n Had not stooled despite intervention at 1400. Dr. made aware and\n d5w at 100cc/hr for 500cc ordered and hung.\n Plan:\n Lytes at 1900.\n Social- social services is working on contacting sister who is next of\n .\n ------ Protected Section ------\n Dr. looked at patient\ns cxr post intubation this evening. Ett\n position ok. She can not confirm ogt position. Will need to check with\n radiologist. Do not use ogt till placement confirmed. Of note Dr\n was able to contact and talk to patient\ns sister. She was\n updated on plan of care. Can switch back to ps per Dr .\n ------ Protected Section Addendum Entered By: , RN\n on: 18:23 ------\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726701,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n Events- new ogt placed. Placement confirmed by xray per dr .\n Required reintubation as not getting volumes at 1700.\n Anesthesia called and up to see the patient. Tube pulled and\n reintubated after receiving 20mg etomidate and 100mg succinylcholine\n R espiratory failure, chronic\n Assessment:\n This am on 70% fio2 tv 450 a/c rate of 24 breathing 24 with peep of\n 10. sats low 90\ns. bs with upper insp wheeze and diminished at bases.\n Suctioned for minimal secretions. afebrile\n Action:\n Cont vancomycin, cefipime and azithromycin. Cont albuterol and\n atrovent mdi. Methylprednsionlone to end today. Changed to ps vent.\n Placed on 70% fio2 peep of 10 and ps of 12. 40 mg iv lasix ordered and\n given with goal of having patient neg 1-2l for today.\n Response:\n On above vent settings breathing low to mid 20\ns with tv of 350 or\n greater. Abg 7.35/54/60/31 when sat was 90%. Dr made aware and\n am leaving her on this setting as sat now 91-92%. Loosing volumes with\n obvious leak of air from mouth. Anesthesia called and old tube removed\n and patient reinutubated with # 7.5 tube. Placed on 80% fio2 tv 450 a/c\n rate of 16 and 10 peep. Xray pending. . abg sent.\n Plan:\n Check xray for tube placement and result of abg. Vanco random level to\n be checked at 1900.\n Constipation (Obstipation, FOS)\n Assessment:\n Has had no stool since admission and episode of aspiration of tf this\n am.\n Action:\n Given 1 ducolax supp and 2mg naloxaone per ngt.\n Response:\n Had not stooled by 1300. Dr. made aware and lactulose 30cc q 6\n hours prn ordered. Dose given. Had only a smear of stool. Dr made\n aware. Was to get a dose of lactulsoe at 1700 when had issues with ett.\n Dose held as ogt placement needs to reconfirmed with xray.\n Plan:\n Check for placement of ogt by xray done. Readminister lactulose 30cc q\n 3 hours till stools.\n Hypernatremia (high sodium)\n Assessment:\n Na 149 this am.\n Action:\n Ordered for free h20 boluses 250cc q 4hours. This was not to start till\n she stooled as ? aspirated due to constipation.\n Response:\n Had not stooled despite intervention at 1400. Dr. made aware and\n d5w at 100cc/hr for 500cc ordered and hung.\n Plan:\n Lytes at 1900.\n Social- social services is working on contacting sister who is next of\n .\n ------ Protected Section ------\n Dr. looked at patient\ns cxr post intubation this evening. Ett\n position ok. She can not confirm ogt position. Will need to check with\n radiologist. Do not use ogt till placement confirmed. Of note Dr\n was able to contact and talk to patient\ns sister. She was\n updated on plan of care. Can switch back to ps per Dr .\n ------ Protected Section Addendum Entered By: , RN\n on: 18:23 ------\n ------ Protected Section Addendum Entered By: , RN\n on: 18:23 ------\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727161,
"text": "Chief Complaint:\n 24 Hour Events:\n - Started on lasix gtt with good UOP\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:30 AM\n Cefipime - 10:00 PM\n Vancomycin - 07:56 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:55 AM\n Furosemide (Lasix) - 08:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.8\nC (96.4\n HR: 75 (68 - 86) bpm\n BP: 103/54(69) {86/50(62) - 131/87(100)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,783 mL\n 1,513 mL\n PO:\n TF:\n 1,339 mL\n 543 mL\n IVF:\n 1,309 mL\n 446 mL\n Blood products:\n Total out:\n 3,450 mL\n 1,865 mL\n Urine:\n 3,450 mL\n 1,865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 333 mL\n -352 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 417 (389 - 422) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 14 cmH2O\n FiO2: 50%\n PIP: 27 cmH2O\n SpO2: 90%\n ABG: 7.36/68/71/40/9\n Ve: 7.6 L/min\n PaO2 / FiO2: 142\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: trace bilaterally pitting edema, improving\n Labs / Radiology\n 537 K/uL\n 10.0 g/dL\n 133 mg/dL\n 0.8 mg/dL\n 40 mEq/L\n 4.1 mEq/L\n 40 mg/dL\n 97 mEq/L\n 143 mEq/L\n 32.0 %\n 23.1 K/uL\n [image002.jpg]\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n WBC\n 28.5\n 26.2\n 23.1\n Hct\n 30.2\n 30.6\n 32.0\n Plt\n 446\n 535\n 537\n Cr\n 0.9\n 0.8\n 0.8\n 0.8\n 0.7\n 0.8\n TCO2\n 33\n 33\n 34\n 40\n Glucose\n 194\n 166\n 168\n 150\n 171\n 133\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Multilobar loneumonia & COPD c/b ARDS.\n Difficult to oxygenate without high PEEP/FIO2. Still significantly\n positive for the stay.\n - Lasix gtt today\n - ABG today\n - Methylpred->Flovent 4 puffs \n - continue nebs\n - Increase PEEP to 12\n - PM Lytes\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, and azithromycin for 8-day course to\n end \n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # Hypernatremia: free water deficit is about 4L.\n - 500cc D5W now\n - 250 cc free water bolus q4h if TF continues working\n - pm lytes\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-04-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727164,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:30 AM\n Cefipime - 10:00 PM\n Vancomycin - 07:56 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:55 AM\n Furosemide (Lasix) - 08:05 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 08:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.8\nC (96.4\n HR: 75 (68 - 86) bpm\n BP: 103/54(69) {86/50(62) - 131/87(100)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,783 mL\n 1,518 mL\n PO:\n TF:\n 1,339 mL\n 546 mL\n IVF:\n 1,309 mL\n 447 mL\n Blood products:\n Total out:\n 3,450 mL\n 1,865 mL\n Urine:\n 3,450 mL\n 1,865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 333 mL\n -347 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 442 (389 - 442) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 14 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n SpO2: 91%\n ABG: 7.36/68/71/40/9\n Ve: 7.7 L/min\n PaO2 / FiO2: 142\n Physical Examination\n Gen:\n HEENT:\n CV:\n PULM:\n ABD:\n EXTREM:\n SKIN:\n NEURO:\n Labs / Radiology\n 10.0 g/dL\n 537 K/uL\n 133 mg/dL\n 0.8 mg/dL\n 40 mEq/L\n 4.1 mEq/L\n 40 mg/dL\n 97 mEq/L\n 143 mEq/L\n 32.0 %\n 23.1 K/uL\n [image002.jpg]\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n WBC\n 28.5\n 26.2\n 23.1\n Hct\n 30.2\n 30.6\n 32.0\n Plt\n 446\n 535\n 537\n Cr\n 0.9\n 0.8\n 0.8\n 0.8\n 0.7\n 0.8\n TCO2\n 33\n 33\n 34\n 40\n Glucose\n 194\n 166\n 168\n 150\n 171\n 133\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -wean FiO2 to maintain PaO2 > 60; increase PEEP to 12 since O2 sat on\n low side\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n Change to lasix gtt (low rate) for slow continuous diuresis\n -vanco + cefepime + azithro --> plan for empiric 8d course pending cx\n data\n -tx COPD exac w/ Solu-Medrol --> change to prednisone 40mg daily pNGT\n -will need CT scan at some point to re-evaluate, poss bronch given RUL\n collapse seen in , can be deferred til better on vent\n -flovent\n -will try to wean sedation and transition to PSV over the course of the\n day\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa- monitor w/ diuresis;\n -start free H20 boluses per NGT plus d5w IV and monitor. Na improved,\n continue free H20.\n 4. Constipation- resolving\n -cont aggressive regimen\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727427,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. On A/C 350x16\n 50% +16peep. RR 22 with sats 90%. LS clear with diminished bases.\n Hemodynamically stable. On lasix gtt at 7mg/hr. Afebrile with WBC 24.5.\n Action:\n No change in sedation. Continue vanco and cefepime for PNA. Lasix gtt\n increased to 10mg/hr. Added diamox for contraction alkalosis. MDI\ns and\n steroids as ordered. No vent changes.\n Response:\n Was +370cc at midnight. Remains with 2+ generalized edema. ABG\n 7.44/68/75/48 and RR with sats %.\n Plan:\n Wean vent as tolerated.\n Check ABG\ns. Goal sats 88-92% with Pao2 >60.\n Goal fluid balance -1L/day.\n To finish antibiotics today.\n MDI\ns and steroids.\n v Positive bowel sounds, abdomen soft and obese. Brown, loose\n stool via flexiseal.\n v On sedation patient will open eyes, follow commands and MAE.\n Denies pain. Restrained for safety of lines and tubes.\n v HR 60-90\ns SR with occasional ectopy. SBP 90-1110\n v Full code.\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 726625,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 24 Hour Events:\n weaned off norepi yest am. hypoxemic distress yesterday afternoon. tube\n feed-like material suctioned from ETT. Vent support was increased.\n Diuresed overnight.\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Azithromycin - 07:35 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 125 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:25 PM\n Heparin Sodium (Prophylaxis) - 07:31 AM\n Other medications:\n Heparin sc, Atrovent MDI, Protonix, Solu-Medrol 125 q8, azithro, RISS,\n Peridex, Cefepime, vanco\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.1\nC (98.7\n HR: 70 (65 - 88) bpm\n BP: 98/73(84) {85/45(58) - 129/75(93)} mmHg\n RR: 24 (18 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 1 (1 - 3)mmHg\n Total In:\n 2,558 mL\n 691 mL\n PO:\n TF:\n 1,000 mL\n 243 mL\n IVF:\n 1,147 mL\n 398 mL\n Blood products:\n Total out:\n 2,350 mL\n 1,635 mL\n Urine:\n 2,350 mL\n 1,635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 208 mL\n -944 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 410 (361 - 449) mL\n PS : 10 cmH2O\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n SpO2: 92%\n ABG: 7.37/49/66/25/1\n Ve: 11.1 L/min\n PaO2 / FiO2: 94\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\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 : ant)\n Abdominal: Soft, Bowel sounds present, Obese\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 9.6 g/dL\n 435 K/uL\n 149 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 49 mg/dL\n 114 mEq/L\n 149 mEq/L\n 30.5 %\n 27.2 K/uL\n [image002.jpg]\n 03:14 AM\n 05:00 AM\n 05:57 AM\n 08:37 AM\n 10:26 AM\n 03:58 AM\n 04:27 AM\n 04:58 AM\n 06:22 AM\n 06:25 AM\n WBC\n 27.2\n Hct\n 30.5\n Plt\n 435\n Cr\n 1.1\n 0.9\n TCO2\n 25\n 26\n 26\n 25\n 25\n 31\n 28\n 29\n Glucose\n 140\n 149\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR- no sig change since yest\n Microbiology: Sputum- GPCs, yeast\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia. Prior partial RUL\n collapse from will need further evaluation down the road and might\n have predisposed to current pna. desat yest w/ poss aspiration? will\n have to monitor for infxn but so far clinically defervescing and no new\n infiltrate\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -wean FiO2 to maintain PaO2 > 60\n -tolerate autoPEEP for now as Pplat < 30 and hemodyn stable\n -assess spont breathing tolerance today but caution on weaning\n -start aggressive diuresis w/ goal -1-2L neg today; will check pm lytes\n -vanco + cefepime + azithro (change to IV) for now --> plan for empiric\n 8d course pending cx data\n -tx COPD exac w/ Solu-Medrol --> cont 125 q8 today and scheduled nebs;\n wean steroids tomorrow\n -will need CT scan at some point to re-evaluate, poss bronch\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa- monitor w/ diuresis; may need need free H2O boluses\n 4. Possible aspiration- has not had BM since admit; constipation might\n be contributing\n -replace OGT\n -aggressive bowel regimen w/ Dulcolax and PO Narcan; hold on enteral\n feee H20 and tube feeds till bowels are moving\n ICU Care\n Nutrition:\n Comments: replaced OGT\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\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: 30 minutes\n Patient is critically ill\n ------ Protected Section ------\n Patient seen and examined with Dr. , and house staff team.\n I have reviewed his note and agree with assessment and plan. Would\n add/emphasize.\n 67 yo women with severe COPD, admitted with PNA , respiratory failure,\n septic shock.\n On exam: is arousable to voice.\n Lungs improved BS on right\n CV: reg\n Abd: soft\n Ext: 2+ U/E edema\n A/P\n PNA/respiratory failure: overall improvement with reduced WBC, but\n still requiring high level of oxygen likely reflects severity of\n underlying COPD with PNA. Continue current ventilator settings.\n COPD: can start weaning steroids tomorrow.\n Septic shock: Off pressors.\n CC 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 14:04 ------\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726938,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation\n Events- sedation increased this am as attempting to push out ett with\n tongue this am.\n Switched to ards net vent.\n Bit through pilot of ett at 1700. reintubated with # 8 ett by\n anesthesia. Awaiting xray confirmation.\n Hypernatremia (high sodium)\n Assessment:\n Na this am 148.\n Action:\n Giving 500cc d5w at 200cc/hr this afternoon and then will hopefully\n change to free h20 boluses via ogt if cont to tolerate his tf as she\n has been. Check na at 1800/.\n Response:\n Able to tolerate 1400 free h20 bolus. No residuals at 1600. labs drawn\n at 1730. needs re confirmation of ogt now that he has been reintubated.\n Plan:\n Check result of 1730 na. restart free h20 boluses via ogt once\n confirmation of tube confirmed\n Constipation (Obstipation, FOS)\n Assessment:\n Passing malodorous stool via flexiseal today. Stool guiac neg brown\n loose.\n Action:\n Cont on bowel regimen. Able to start tf again.\n Response:\n Tolerating tf. Tf stopped at 170 when patient required reintubation.\n Cont to pass a lot of gas. Some stool.\n Plan:\n Cont bowel regimen. Restart tf once ogt placement reconfirmed by xray.\n Respiratory failure, chronic\n Assessment:\n This am on 80% fio2 peep of 10 and ps of 12 with resp rate high teens\n to low 20\ns. tv mid 300 or greater. Abg 7.36/56/76/33. sats in the mid\n 90\n Action:\n Weaned to 70% fio2. changed to ards net protocol due to infected right\n lung and emphysetic left lung. Cont on cefipime, vanco, and\n azithromycin. Cont on albuterol and atrovent mdi\ns. methylprednisolone\n weaned to 100mg iv q 12 hours today. Lasix 40mg given with goal 2.5 l\n neg for the day.\n Response:\n Abg 7.37/56/71/34 on 70% fio2 tv 340/ a/c rate of 16 breathing 19 and\n 10 peep. Neg 400cc at 1600. Dr. made aware. Wants to see 1800\n lytes prior to redosing lasix. Bit through pilot of ett at 1700.\n anesthesia here. Received 20 mg of etomidate and 100mg of\n succinylcholine 100mg iv for reintubation.\n Plan:\n Will accept ph of down to 7.20 on ards net vent. Check results of lytes\n at 1800 to see if we want to give more lasix. Needs xray confirmation\n of ett. This was ordered.\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 726774,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation; Comments: Reintubated with same size ETT,\n after tube had migrated above vocal cords.\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments: Scant to small thick white/pale yellow 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 :\n Comments: Received vented on PSV/CPAP mode. Patient continues to have\n high FIO2 & PEEP requirement to prevent hypoxemia. ABG slightly\n improved: 76/56/7.36. Prior CXR showed no change in extensive\n right-sided opacification. Continues to require assistance to clear\n bronchopulmonary secretions, as well as diuresis.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727255,
"text": "Chief Complaint:\n 24 Hour Events:\n - more difficulty with oxygenation in the afternoon, CXR unchanged, up\n from 50% to 70% FiO2 all afternoon\n - decreased FW boluses to attempt to get net negative, still on lasix\n gtt at 10\n - stopped lasix gtt for hypotension (90/60) ~ 1700, still net negative\n ~1.5L/24h\n - able to go back to 60% FiO2 early AM\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 09:02 AM\n Vancomycin - 08:02 PM\n Cefipime - 10:18 PM\n Infusions:\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 08:05 AM\n Pantoprazole (Protonix) - 10:08 AM\n Heparin Sodium (Prophylaxis) - 12:19 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 04:02 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: 36.6\nC (97.8\n HR: 73 (67 - 79) bpm\n BP: 93/59(70) {90/48(62) - 129/94(108)} mmHg\n RR: 16 (15 - 21) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 4,214 mL\n 346 mL\n PO:\n TF:\n 1,600 mL\n 266 mL\n IVF:\n 1,493 mL\n 81 mL\n Blood products:\n Total out:\n 5,900 mL\n 180 mL\n Urine:\n 5,900 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,686 mL\n 166 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 412 (323 - 442) mL\n PS : 12 cmH2O\n RR (Spontaneous): 13\n PEEP: 14 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 26 cmH2O\n SpO2: 94%\n ABG: 7.44/64/81./42/15\n Ve: 5.1 L/min\n PaO2 / FiO2: 137\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 537 K/uL\n 10.0 g/dL\n 176 mg/dL\n 0.8 mg/dL\n 42 mEq/L\n 4.4 mEq/L\n 43 mg/dL\n 92 mEq/L\n 141 mEq/L\n 32.0 %\n 23.1 K/uL\n [image002.jpg]\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n 02:09 PM\n 06:04 PM\n 08:49 PM\n WBC\n 26.2\n 23.1\n Hct\n 30.6\n 32.0\n Plt\n 535\n 537\n Cr\n 0.8\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 33\n 34\n 40\n 40\n 45\n Glucose\n 168\n 150\n 171\n 133\n 176\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:27 PM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-04-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727256,
"text": "Chief Complaint:\n 24 Hour Events:\n - more difficulty with oxygenation in the afternoon, CXR unchanged, up\n from 50% to 70% FiO2 all afternoon\n - decreased FW boluses to attempt to get net negative, still on lasix\n gtt at 10\n - stopped lasix gtt for hypotension (90/60) ~ 1700, still net negative\n ~1.5L/24h\n - able to go back to 60% FiO2 early AM\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 09:02 AM\n Vancomycin - 08:02 PM\n Cefipime - 10:18 PM\n Infusions:\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 08:05 AM\n Pantoprazole (Protonix) - 10:08 AM\n Heparin Sodium (Prophylaxis) - 12:19 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 04:02 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: 36.6\nC (97.8\n HR: 73 (67 - 79) bpm\n BP: 93/59(70) {90/48(62) - 129/94(108)} mmHg\n RR: 16 (15 - 21) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 4,214 mL\n 346 mL\n PO:\n TF:\n 1,600 mL\n 266 mL\n IVF:\n 1,493 mL\n 81 mL\n Blood products:\n Total out:\n 5,900 mL\n 180 mL\n Urine:\n 5,900 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,686 mL\n 166 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 412 (323 - 442) mL\n PS : 12 cmH2O\n RR (Spontaneous): 13\n PEEP: 14 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 26 cmH2O\n SpO2: 94%\n ABG: 7.44/64/81./42/15\n Ve: 5.1 L/min\n PaO2 / FiO2: 137\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: trace bilaterally pitting edema, improving\n Labs / Radiology\n 537 K/uL\n 10.0 g/dL\n 176 mg/dL\n 0.8 mg/dL\n 42 mEq/L\n 4.4 mEq/L\n 43 mg/dL\n 92 mEq/L\n 141 mEq/L\n 32.0 %\n 23.1 K/uL\n [image002.jpg]\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n 02:09 PM\n 06:04 PM\n 08:49 PM\n WBC\n 26.2\n 23.1\n Hct\n 30.6\n 32.0\n Plt\n 535\n 537\n Cr\n 0.8\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 33\n 34\n 40\n 40\n 45\n Glucose\n 168\n 150\n 171\n 133\n 176\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Multilobar pneumonia & COPD c/b ARDS.\n Difficult to oxygenate without high PEEP/FIO2. Requiring PEEP 14.\n Still significantly positive for the stay. Lasix gtt started\n yesterday, but still net positive.\n - decrease FW flushes\n - continue Lasix gtt today\n - ABG today\n - continue prednisone 40 and plan to taper\n - Flovent 4 puffs \n - continue nebs\n - continue high PEEP\n - PM Lytes\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, and azithromycin for 8-day course to\n end \n - change IV meds to PO if possible\n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # Hypernatremia: free water deficit resolved\n - decrease FW flushes\n - pm lytes\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727474,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. On A/C 350x16\n 50% +16peep. RR 22 with sats 90%. LS clear with diminished bases.\n Hemodynamically stable. On lasix gtt at 7mg/hr. Afebrile with WBC 24.5.\n Action:\n No change in sedation. Continue vanco and cefepime for PNA. Lasix gtt\n increased to 10mg/hr. Added diamox for contraction alkalosis. MDI\ns and\n steroids as ordered. No vent changes. CXR done.\n Response:\n Was +370cc at midnight. Currently 228cc negative. Remains with 2+\n generalized edema. ABG\ns 7.44/68/75/48, morning ABG unchanged. No\n difference in alkalosis with diamox. RR 19-26 with sats 90-95%. Lung\n sounds diminished.\n Plan:\n Wean vent as tolerated.\n Check ABG\ns. Goal sats 88-92% with Pao2 >60. F/u on CXR.\n Goal fluid balance -1L/day.\n To finish antibiotics today.\n MDI\ns and steroids.\n Most likely need Trach and PEG soon.\n v Positive bowel sounds, abdomen soft and obese. Brown, loose\n stool via flexiseal.\n v On sedation patient will open eyes, follow commands and MAE.\n Denies pain. Restrained for safety of lines and tubes.\n v HR 60-90\ns SR with occasional ectopy. SBP 90-1110\n v Full code.\n"
},
{
"category": "Nutrition",
"chartdate": "2192-04-02 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 727363,
"text": "Objective\n Pertinent medications: Fentanyl drip, Versed drip, Lasix drip, ABX,\n Heparin, Colace, Pantoprazole, Prednisone, Humalog insulin sliding\n scale\n Labs:\n Value\n Date\n Glucose\n 132 mg/dL\n 04:16 AM\n Glucose Finger Stick\n 126\n 12:00 PM\n BUN\n 47 mg/dL\n 04:16 AM\n Creatinine\n 0.8 mg/dL\n 04:16 AM\n Sodium\n 142 mEq/L\n 04:16 AM\n Potassium\n 4.1 mEq/L\n 04:16 AM\n Chloride\n 93 mEq/L\n 04:16 AM\n TCO2\n 45 mEq/L\n 04:16 AM\n PO2 (arterial)\n 84. mm Hg\n 04:22 AM\n PO2 (venous)\n 42 mm Hg\n 09:59 AM\n PCO2 (arterial)\n 66 mm Hg\n 04:22 AM\n PCO2 (venous)\n 65 mm Hg\n 04:39 AM\n pH (arterial)\n 7.41 units\n 04:22 AM\n pH (venous)\n 7.16 units\n 04:39 AM\n pH (urine)\n 6.0 units\n 07:39 PM\n CO2 (Calc) arterial\n 43 mEq/L\n 04:22 AM\n CO2 (Calc) venous\n 24 mEq/L\n 04:39 AM\n Albumin\n 3.0 g/dL\n 03:58 AM\n Calcium non-ionized\n 8.2 mg/dL\n 04:16 AM\n Phosphorus\n 3.9 mg/dL\n 04:16 AM\n Ionized Calcium\n 1.13 mmol/L\n 03:14 AM\n Magnesium\n 1.9 mg/dL\n 04:16 AM\n ALT\n 29 IU/L\n 03:58 AM\n Alkaline Phosphate\n 103 IU/L\n 03:58 AM\n AST\n 13 IU/L\n 03:58 AM\n Total Bilirubin\n 0.2 mg/dL\n 03:58 AM\n WBC\n 24.5 K/uL\n 04:16 AM\n Hgb\n 9.7 g/dL\n 04:16 AM\n Hematocrit\n 30.5 %\n 04:16 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Replete with Fiber @ 65ml/hr, 250ml water flushes every 12\n hours\n GI: soft/obese, hypoactive bowel sounds, loose stool\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n 67 YO female with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated. Tube feed resumed after being\n held for OGT replacement and lack of bm. Tolerating tube feed at goal\n via OGT to provide 1560 calories and 97g protein. Water flushes\n increased over the weekend due to 4 liter water deficit, now resolved.\n On lasix drip. Tube feed providing ~1.3 liters of water/day.\n Stooling.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Continue\n tube feed at goal\n o Check residuals, hold tube feed if greater than 200ml\n o Multivitamin / Mineral supplement: in tube feed\n Check chemistry 10 panel\n BS management\n Monitor hydration, Na and need to change to more\n concentrated tube feed formula\n Will follow, page if questions *\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 726443,
"text": "Demographics\n Day of mechanical ventilation: 3\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 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: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: 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 response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment:\n Comments: Pt placed on PSV settings as charted today & is tolerating\n well.\n Plan\n Next 24-48 hours: Continue ventilating as ordered.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 726865,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 24 Hour Events:\n air leak on vent yest pm --> ETT changed by Anesthesia w/ resolution.\n This am denies pain.\n History obtained from Patient\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:33 AM\n Vancomycin - 09:17 AM\n Cefipime - 10:33 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 5 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:33 AM\n Pantoprazole (Protonix) - 10:33 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 11:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.5\nC (97.7\n HR: 76 (64 - 86) bpm\n BP: 117/89(101) {93/59(79) - 151/89(107)} mmHg\n RR: 18 (17 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 1 (1 - 5)mmHg\n Total In:\n 2,179 mL\n 1,474 mL\n PO:\n TF:\n 243 mL\n 95 mL\n IVF:\n 1,766 mL\n 1,029 mL\n Blood products:\n Total out:\n 4,965 mL\n 1,755 mL\n Urine:\n 4,965 mL\n 1,605 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n -2,786 mL\n -281 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 461 (323 - 470) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 21\n PEEP: 10 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 11 cmH2O\n Plateau: 25 cmH2O\n Compliance: 30 cmH2O/mL\n SpO2: 93%\n ABG: 7.36/56/76./31/3\n Ve: 8 L/min\n PaO2 / FiO2: 109\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 9.7 g/dL\n 446 K/uL\n 166 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 36 mg/dL\n 109 mEq/L\n 148 mEq/L\n 30.2 %\n 28.5 K/uL\n [image002.jpg]\n 03:58 AM\n 04:27 AM\n 04:58 AM\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n WBC\n 27.2\n 28.5\n Hct\n 30.5\n 30.2\n Plt\n 435\n 446\n Cr\n 1.1\n 0.9\n 0.9\n 0.8\n TCO2\n 31\n 28\n 29\n 31\n 33\n 33\n Glucose\n 140\n 149\n 194\n 166\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Imaging: CXR- no change\n Microbiology: Sputum ()- yeast, GPC in pairs\n All other cx neg or pending\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -switch to better ARDSnet ventilation --> A/CV w/ 6cc/kg Vt and\n permissive hypercpania, tolerating pH down to 7.20\n -wean FiO2 to maintain PaO2 > 60; keep PEEP\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes\n -vanco + cefepime + azithro --> plan for empiric 8d course pending cx\n data\n -tx COPD exac w/ Solu-Medrol --> wean steroids to 125 q12 today\n -will need CT scan at some point to re-evaluate, poss bronch given RUL\n collapse seen in , can be deferred til better on vent\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa- monitor w/ diuresis;\n -start free H20 boluses per NGT plus d5w IV and monitor\n 4. Constipation- resolving\n -cont aggressive regimen\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:30 AM 25 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n ------ Protected Section ------\n Patient seen and examined with Dr. , and house staff team.\n I have reviewed his note and agree with assessment and plan. Would\n add/emphasize.\n 67 yo women with COPD, respiratory failure, PNA, sepsis. Largely\n unchanged from yesterday. Required ETT change.\n Exam: notable for arousable and follows some commands. Crackles along\n right lung. Abd: soft , ext: trace edema in LE.\n A/P\n Respiratory failure: Slight improvement in Abg from yesterday\n PO2\n now 71. Continued ARDS/PNA in background of severe COPD. Continue\n antibiotics, wean steroids. ARDsnet ventilation.\n Septic shock: now stable off pressors.\n Hypernatremia: due to lasix, increase free water.\n CC 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 12:55 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-04-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 727470,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\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: /\n Sputum source/amount: /\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 Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726438,
"text": "A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n Respiratory failure\n Assessment:\n Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with\n O2 sats 90-92%, last ABG- 7.27/53/70/-.\n L/S clear to diminished @ bases., sputum spec has GPC\ns. Suctioning\n white thick secretions CXR--. R-sided opacification, L hyperinflation;\n B effusions. Desat\nd to 87%, on FIO2-60% Peep-10.\n Action:\n Changed vent mode from A/C to PS, suctioning q3-4hr . -- FIO2 was\n placed back up to 70%.\n Response:\n Remains acidotic, and hypoxic, no improvement of PNX, and COPD\n exacerbation.\n Plan:\n Continue with pulmonary toilet, asses ABG\ns and O2 sats, adjust vent\n setting as needed.\n Sepsis without organ dysfunction\n Assessment:\n Rec\nd on Levo Gtt @ .03mcq, with BP 98-114/50, HR 70-80\ns with APC\n CVP-. Temp 99.2 Po max. U/O 50-60cc/hr. BUN/CRe improved. WBC\n 35.6,\n Action:\n Levo Gtt stopped, IV antibx\ns were increased.\n Response:\n BP down to 85-100/50, with Levo off, MAP\ns60-63.\n Plan:\n Monitor U/O and BP off of Levo, tolerating MAP 60, continue with IV\n antibx\ns check results of cultures.\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727051,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation. Intubated 5 days ago.\n 24 Hour Events:\n Lasix 80mg IV given last night, now negative 800cc.\n ETT had to be replaced last night due to injury to the cuff and air\n leak.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Cefepime - 10:33 AM\n Vancomycin - 08:00 PM\n Azithromycin - 07:30 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:33 AM\n Heparin Sodium (Prophylaxis) - 03:17 PM\n Furosemide (Lasix) - 06:41 PM\n Fentanyl - 07:30 AM\n Po narcan q6\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 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.4\nC (97.6\n HR: 79 (75 - 92) bpm\n BP: 113/59(76) {105/50(67) - 146/89(102)} mmHg\n RR: 19 (10 - 27) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 10 (1 - 13)mmHg\n Total In:\n 3,362 mL\n 805 mL\n PO:\n TF:\n 418 mL\n 340 mL\n IVF:\n 1,945 mL\n 404 mL\n Blood products:\n Total out:\n 4,150 mL\n 520 mL\n Urine:\n 4,000 mL\n 520 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n -788 mL\n 285 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 339 (339 - 339) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 3\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 91%\n ABG: 7.37/56/71/34/4\n Ve: 6.5 L/min\n PaO2 / FiO2: 118\n Physical Examination\n Gen:Intubated, sedated but awakens to voice\n HEENT: PERRL, anicteric\n CV: RRR, no m/r/g\n PULM: coarse BS bilaterally\n ABD:soft, reducible hernia unchanged\n Extrem: 1+ edema both legs, improved from previous\n Neuro: sedated but easily arousable\n Skin: no rashes\n Labs / Radiology\n 9.7 g/dL\n 535 K/uL\n 150 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 104 mEq/L\n 145 mEq/L\n 30.6 %\n 26.2 K/uL\n [image002.jpg]\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n WBC\n 28.5\n 26.2\n Hct\n 30.2\n 30.6\n Plt\n 446\n 535\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 31\n 33\n 33\n 34\n Glucose\n 149\n 194\n 166\n 168\n 150\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -wean FiO2 to maintain PaO2 > 60; increase PEEP to 12 since O2 sat on\n low side\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n Change to lasix gtt (low rate) for slow continuous diuresis\n -vanco + cefepime + azithro --> plan for empiric 8d course pending cx\n data\n -tx COPD exac w/ Solu-Medrol --> change to prednisone 40mg daily pNGT\n -will need CT scan at some point to re-evaluate, poss bronch given RUL\n collapse seen in , can be deferred til better on vent\n -flovent\n -will try to wean sedation and transition to PSV over the course of the\n day\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa- monitor w/ diuresis;\n -start free H20 boluses per NGT plus d5w IV and monitor. Na improved,\n continue free H20.\n 4. Constipation- resolving\n -cont aggressive regimen\n ICU Care\n Nutrition: tube feeds\n Replete with Fiber (Full) - 08:00 PM 55 mL/hour\n Glycemic Control: RISS\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 AM\n Prophylaxis:\n DVT: sc heparin\n Stress ulcer: PPI\n VAP: chlorhexidine, HOB 30 degrees\n Communication: in touch with family\n Code status: Full code\n Disposition : ICU\n Total time spent: 35 min, patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727225,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation. Intubated 5 days ago.\n Hypernatremia (high sodium)\n Assessment:\n Na 143. TF at goal of 65cc/hr. No residuals noted.\n Action:\n Free water flushes decreased to 250cc .\n Response:\n Will check pm lytes to assess Na.\n Plan:\n Continue to monitor. Adjust free water flushes as necessary\n Respiratory failure, chronic\n Assessment:\n Pt remains vented on PSV 12/14 5 70%. ABG: 7.45/56/63/40. Pt had\n episode after turning on left side of decreased O2 sats to 87-88%. LS\n diminished at bases otherwise CTA. Pt receiving antibx for PNA. Lasix\n drip remains at 10mg/hr for goal of liters negative today.\n Action:\n FIo2 increased to 70% with Saturation drop. CXR obtained. 1 time 40mg\n lasix dose given .\n Response:\n CXR showed improving PNA but continues to have fluid. ABG unchanged.\n Pt is currently approx. neg. 1.5 liters negative today thus far.\n Plan:\n Continue with diuresises. Wean FIO2 if possible.\n"
},
{
"category": "Nutrition",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 726608,
"text": "Objective\n Pertinent medications: Fentanyl drip, versed drip, normal saline @\n 10ml/hr, ABX, Pantoprazole, Lasix, Solu-medrol, Humalog insulin sliding\n scale, Colace (held due to no access)\n Labs:\n Value\n Date\n Glucose\n 149 mg/dL\n 06:22 AM\n Glucose Finger Stick\n 171\n 06:00 AM\n BUN\n 49 mg/dL\n 06:22 AM\n Creatinine\n 0.9 mg/dL\n 06:22 AM\n Sodium\n 149 mEq/L\n 06:22 AM\n Potassium\n 5.0 mEq/L\n 06:25 AM\n Chloride\n 114 mEq/L\n 06:22 AM\n TCO2\n 25 mEq/L\n 06:22 AM\n PO2 (arterial)\n 66 mm Hg\n 06:25 AM\n PO2 (venous)\n 42 mm Hg\n 09:59 AM\n PCO2 (arterial)\n 49 mm Hg\n 06:25 AM\n PCO2 (venous)\n 65 mm Hg\n 04:39 AM\n pH (arterial)\n 7.37 units\n 06:25 AM\n pH (venous)\n 7.16 units\n 04:39 AM\n pH (urine)\n 6.0 units\n 07:39 PM\n CO2 (Calc) arterial\n 29 mEq/L\n 06:25 AM\n CO2 (Calc) venous\n 24 mEq/L\n 04:39 AM\n Albumin\n 3.0 g/dL\n 03:58 AM\n Calcium non-ionized\n 8.5 mg/dL\n 06:22 AM\n Phosphorus\n 2.8 mg/dL\n 06:22 AM\n Ionized Calcium\n 1.13 mmol/L\n 03:14 AM\n Magnesium\n 2.4 mg/dL\n 06:22 AM\n ALT\n 29 IU/L\n 03:58 AM\n Alkaline Phosphate\n 103 IU/L\n 03:58 AM\n AST\n 13 IU/L\n 03:58 AM\n Total Bilirubin\n 0.2 mg/dL\n 03:58 AM\n WBC\n 27.2 K/uL\n 03:58 AM\n Hgb\n 9.6 g/dL\n 03:58 AM\n Hematocrit\n 30.5 %\n 03:58 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: OFF ( Replete with Fiber @ 65ml/hr)\n GI: soft/distended, positive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n Patient w/ respiratory failure due to pneumonia and COPD exacerbation.\n Remains intubated/sedated. Tube feed running at goal until early this\n a.m. found to have tube feed like substance oozing from mouth,\n suctioned for tube feed/ thick sputum. OGT discontinued. RN, OGT\n just replaced, awaiting bm (none since admit). Pending Narcan and\n Ducolax. Tube feed goal will provide 1560 calories and 97g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations:\n o Resume tube feed when medically feasible\n Replete with fiber\n @ 65ml/hr\n Check residuals, hold tube feed if greater than 200ml\n Multivitamin / Mineral supplement: in tube feed\n Check chemistry 10 panel\n BS management\n Bowel regimen\n Will follow, page if questions *\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727289,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Hypernatremia (high sodium)\n Assessment:\n Na 141. TF infusing at goal of 65cc/hr.\n Action:\n Free water flushes of 250cc now .\n Response:\n Morning sodium 142.\n Plan:\n Continue to monitor.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. On CPAP w/PS\n 12/+14 70%. RR 18 with sats 93%. LS clear with diminished bases.\n Hemodynamically stable. On lasix gtt at 10mg/hr.\n Action:\n No change in sedation. Pao2 82 and Fio2 weaned to 60%. Continue vanco,\n cefepime and azithromycin for PNA. Lasix gtt stopped for mild\n hypotension. MDI\ns and steroids as ordered.\n Response:\n Was -1.7L at midnight. Currently running ~200cc positive off lasix gtt.\n Remains with 2+ generalized edema. RR 15-21 with sats 91-94% and TV\n 300-400cc. Morning Pao2 was 84 and Fio2 was weaned to 50%. Suctioned\n for thick tan to yellow sputum. Afebrile with WBC 24.5.\n Plan:\n Wean vent as tolerated.\n Check ABG\ns. Goal sats 88-92% with Pao2 >60\n v Positive bowel sounds, abdomen soft and obese. Brown, loose\n stool via flexiseal.\n v On sedation patient will open eyes, follow commands and MAE.\n Denies pain. Restrained for safety of lines and tubes.\n v HR 60-70\ns SR with frequent ectopy. SBP 90-129. Hct stable\n @30.5.\n v Full code.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726684,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n Events- new ogt placed. Placement confirmed by xray per dr .\n Required reintubation as not getting volumes at 1700.\n Anesthesia called and up to see the patient. Tube pulled and\n reintubated after receiving 20mg etomidate and 100mg succinylcholine\n R espiratory failure, chronic\n Assessment:\n This am on 70% fio2 tv 450 a/c rate of 24 breathing 24 with peep of\n 10. sats low 90\ns. bs with upper insp wheeze and diminished at bases.\n Suctioned for minimal secretions. afebrile\n Action:\n Cont vancomycin, cefipime and azithromycin. Cont albuterol and\n atrovent mdi. Methylprednsionlone to end today. Changed to ps vent.\n Placed on 70% fio2 peep of 10 and ps of 12. 40 mg iv lasix ordered and\n given with goal of having patient neg 1-2l for today.\n Response:\n On above vent settings breathing low to mid 20\ns with tv of 350 or\n greater. Abg 7.35/54/60/31 when sat was 90%. Dr made aware and\n am leaving her on this setting as sat now 91-92%. Loosing volumes with\n obvious leak of air from mouth. Anesthesia called and old tube removed\n and patient reinutubated with # 7.5 tube. Placed on 80% fio2 tv 450 a/c\n rate of 16 and 10 peep. Xray pending. . abg sent.\n Plan:\n Check xray for tube placement and result of abg. Vanco random level to\n be checked at 1900.\n Constipation (Obstipation, FOS)\n Assessment:\n Has had no stool since admission and episode of aspiration of tf this\n am.\n Action:\n Given 1 ducolax supp and 2mg naloxaone per ngt.\n Response:\n Had not stooled by 1300. Dr. made aware and lactulose 30cc q 6\n hours prn ordered. Dose given. Had only a smear of stool. Dr made\n aware. Was to get a dose of lactulsoe at 1700 when had issues with ett.\n Dose held as ogt placement needs to reconfirmed with xray.\n Plan:\n Check for placement of ogt by xray done. Readminister lactulose 30cc q\n 3 hours till stools.\n Hypernatremia (high sodium)\n Assessment:\n Na 149 this am.\n Action:\n Ordered for free h20 boluses 250cc q 4hours. This was not to start till\n she stooled as ? aspirated due to constipation.\n Response:\n Had not stooled despite intervention at 1400. Dr. made aware and\n d5w at 100cc/hr for 500cc ordered and hung.\n Plan:\n Lytes at 1900.\n Social- social services is working on contacting sister who is next of\n .\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726864,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation\n Events- sedation increased this am as attempting to push out ett with\n tongue this am.\n Switched to ards net vent.\n Hypernatremia (high sodium)\n Assessment:\n Na this am 148.\n Action:\n Giving 500cc d5w at 200cc/hr this afternoon and then will hopefully\n change to free h20 boluses via ogt if cont to tolerate his tf as she\n has been. Check na at 1800/.\n Response:\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Passing malodorous stool via flexiseal today. Stool guiac neg brown\n loose.\n Action:\n Cont on bowel regimen. Able to start tf again.\n Response:\n Plan:\n Respiratory failure, chronic\n Assessment:\n This am on 80% fio2 peep of 10 and ps of 12 with resp rate high teens\n to low 20\ns. tv mid 300 or greater. Abg 7.36/56/76/33. sats in the mid\n 90\n Action:\n Weaned to 70% fio2. changed to ards net protocol due to infected right\n lung and emphysetic left lung. Cont on cefipime, vanco, and\n azithromycin. Cont on albuterol and atrovent mdi\n Response:\n Abg 7.37/56/71/34 on 70% fio2 tv 340/ a/c rate of 16 breathing 19 and\n 10 peep.\n Plan:\n Will accept ph of down to 7.20 on ards net vent.\n Social- Dr updated patient\ns sister in yesterday.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726856,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation\n Hypernatremia (high sodium)\n Assessment:\n Na this am 148.\n Action:\n Response:\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Passing malodorous stool via flexiseal today. Stool guiac neg brown\n loose.\n Action:\n Cont on bowel regimen. Able to start tf again.\n Response:\n Plan:\n Respiratory failure, chronic\n Assessment:\n This am on 80% fio2 peep of 10 and ps of 12 with resp rate high teens\n to low 20\ns. tv mid 300 or greater. Abg 7.36/56/76/33. sats in the mid\n 90\n Action:\n Weaned to 70% fio2. Cont on cefipime, vanco, and azithromycin. Cont on\n albuterol and atrovent mdi\n Response:\n Plan:\n Social- Dr updated patient\ns sister in yesterday.\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726859,
"text": "Chief Complaint:\n 24 Hour Events:\n - called sister after SW helped find # (pasted above) - voicemail, left\n message requesting that she call for update\n - no BM with PO narcan x 1, switched to lactulose, awaiting BM to\n restart TF\n - lasix 40 mg IV x 1 -->~1500cc UOP/3 hours, net ~2.5L negative for the\n day\n - started FW repletion IV, then via OG but increased residuals so had\n to stop\n - 1700 air leak ? tube came out vs hole-->extubated, reintubated, back\n on AC-->going back to PSV 12/10\n - having small BM after lactulose and PO narcan, both written for\n standing until more BM\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 09:45 PM\n Azithromycin - 07:33 AM\n Infusions:\n Fentanyl - 125 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:10 AM\n Furosemide (Lasix) - 10:10 AM\n Heparin Sodium (Prophylaxis) - 07:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 77 (64 - 86) bpm\n BP: 138/69(91) {93/59(79) - 148/85(107)} mmHg\n RR: 17 (11 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 1 (1 - 5)mmHg\n Total In:\n 2,179 mL\n 1,031 mL\n PO:\n TF:\n 243 mL\n 38 mL\n IVF:\n 1,766 mL\n 703 mL\n Blood products:\n Total out:\n 4,965 mL\n 1,195 mL\n Urine:\n 4,965 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,786 mL\n -164 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 429 (323 - 510) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 25 cmH2O\n Compliance: 30 cmH2O/mL\n SpO2: 94%\n ABG: 7.36/56/76./31/3\n Ve: 7.5 L/min\n PaO2 / FiO2: 95\n Physical Examination\n GEN: intubated\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender\n EXTREMITIES: trace bilaterally pitting edema\n Labs / Radiology\n 446 K/uL\n 9.7 g/dL\n 166 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 36 mg/dL\n 109 mEq/L\n 148 mEq/L\n 30.2 %\n 28.5 K/uL\n [image002.jpg]\n 03:58 AM\n 04:27 AM\n 04:58 AM\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n WBC\n 27.2\n 28.5\n Hct\n 30.5\n 30.2\n Plt\n 435\n 446\n Cr\n 1.1\n 0.9\n 0.9\n 0.8\n TCO2\n 31\n 28\n 29\n 31\n 33\n 33\n Glucose\n 140\n 149\n 194\n 166\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n # Respiratory failure: Multilobar loneumonia & COPD. Likely volume\n overload is now also contributing. LOS still 5.6 L net positive.\n Remains on PSV 12/10, but FiO2 requirement seems to be going up. GPCs\n in sputum from are most likely coag-neg Staph, with oral flora.\n Legionella (-)\n - f/u final sputum cx report\n - diurese more with furosemide 40 mg IV x 1 now; goal\n2 L net negative\n again today\n - will change to AC settings with ARDsnet protocol to decrease volumes\n -serial ABG\n - decrease methylprednisolone to 100 mg q12h\n - continue nebs\n .\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, and azithromycin for 8-day course\n - might bronch tomorrow\n - consider chest CT\n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # Hypernatremia: free water deficit is about 4L.\n - 500cc D5W now\n - 250 cc free water bolus q4h if TF continues working\n - pm lytes\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 726860,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 24 Hour Events:\n air leak on vent yest pm --> ETT changed by Anesthesia w/ resolution.\n This am denies pain.\n History obtained from Patient\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:33 AM\n Vancomycin - 09:17 AM\n Cefipime - 10:33 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 5 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:33 AM\n Pantoprazole (Protonix) - 10:33 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 11:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.5\nC (97.7\n HR: 76 (64 - 86) bpm\n BP: 117/89(101) {93/59(79) - 151/89(107)} mmHg\n RR: 18 (17 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 1 (1 - 5)mmHg\n Total In:\n 2,179 mL\n 1,474 mL\n PO:\n TF:\n 243 mL\n 95 mL\n IVF:\n 1,766 mL\n 1,029 mL\n Blood products:\n Total out:\n 4,965 mL\n 1,755 mL\n Urine:\n 4,965 mL\n 1,605 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n -2,786 mL\n -281 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 461 (323 - 470) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 21\n PEEP: 10 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 11 cmH2O\n Plateau: 25 cmH2O\n Compliance: 30 cmH2O/mL\n SpO2: 93%\n ABG: 7.36/56/76./31/3\n Ve: 8 L/min\n PaO2 / FiO2: 109\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 9.7 g/dL\n 446 K/uL\n 166 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 36 mg/dL\n 109 mEq/L\n 148 mEq/L\n 30.2 %\n 28.5 K/uL\n [image002.jpg]\n 03:58 AM\n 04:27 AM\n 04:58 AM\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n WBC\n 27.2\n 28.5\n Hct\n 30.5\n 30.2\n Plt\n 435\n 446\n Cr\n 1.1\n 0.9\n 0.9\n 0.8\n TCO2\n 31\n 28\n 29\n 31\n 33\n 33\n Glucose\n 140\n 149\n 194\n 166\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Imaging: CXR- no change\n Microbiology: Sputum ()- yeast, GPC in pairs\n All other cx neg or pending\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -switch to better ARDSnet ventilation --> A/CV w/ 6cc/kg Vt and\n permissive hypercpania, tolerating pH down to 7.20\n -wean FiO2 to maintain PaO2 > 60; keep PEEP\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes\n -vanco + cefepime + azithro --> plan for empiric 8d course pending cx\n data\n -tx COPD exac w/ Solu-Medrol --> wean steroids to 125 q12 today\n -will need CT scan at some point to re-evaluate, poss bronch given RUL\n collapse seen in , can be deferred til better on vent\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa- monitor w/ diuresis;\n -start free H20 boluses per NGT plus d5w IV and monitor\n 4. Constipation- resolving\n -cont aggressive regimen\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:30 AM 25 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-03 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727526,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to ARDS from pneumonia and COPD exacerbation.\n 24 Hour Events:\n Acetazolamide 250 q6 started overnight.\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Cefipime - 10:00 PM\n Vancomycin - 08:43 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:47 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 10:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.9\nC (98.5\n HR: 78 (67 - 93) bpm\n BP: 120/60(79) {87/47(61) - 124/70(89)} mmHg\n RR: 20 (19 - 26) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,608 mL\n 1,250 mL\n PO:\n TF:\n 1,560 mL\n 655 mL\n IVF:\n 1,448 mL\n 536 mL\n Blood products:\n Total out:\n 3,240 mL\n 1,680 mL\n Urine:\n 3,240 mL\n 1,680 mL\n NG:\n Stool:\n Drains:\n Balance:\n 368 mL\n -430 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 25 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 96%\n ABG: 7.43/68/76./46/16\n Ve: 9.3 L/min\n PaO2 / FiO2: 152\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ant)\n Abdominal: Soft, Bowel sounds present, Obese\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: Purposeful, Tone: Not assessed\n Labs / Radiology\n 9.3 g/dL\n 475 K/uL\n 114 mg/dL\n 0.9 mg/dL\n 46 mEq/L\n 4.2 mEq/L\n 48 mg/dL\n 91 mEq/L\n 143 mEq/L\n 29.6 %\n 24.7 K/uL\n [image002.jpg]\n 02:09 PM\n 06:04 PM\n 08:49 PM\n 04:16 AM\n 04:22 AM\n 05:09 PM\n 05:22 PM\n 10:16 PM\n 03:59 AM\n 04:03 AM\n WBC\n 24.5\n 24.7\n Hct\n 30.5\n 29.6\n Plt\n 557\n 475\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 40\n 45\n 43\n 48\n 48\n 47\n Glucose\n 176\n 132\n 185\n 114\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:4.0 mg/dL\n Imaging: CXR- ? worsened RLL infiltrate\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -cont ARDSnet ventilation --> A/CV w/ 6cc/kg Vt and permissive\n hypercpania, tolerating pH down to 7.20\n -wean FiO2 and PEEP to maintain PaO2 > 60\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n have added azetazolamide to help w/ HCO3 wasting in the setting of\n contraction alkalosis\n -will concentrate IVF and tube feeds\n -complete 8d course of ABX today\n -steroids weaning to 30 qd tomorrow\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:43 AM 65 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\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: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727527,
"text": "Chief Complaint:\n 24 Hour Events:\n - furosemide gtt restarted; MAP remains in mid 60s\n - trying to get IV meds and TF concentrated to reduce intake\n - back on AC with Tv in low 300s\n - started acetazolamide\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 08:39 AM\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:47 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 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.5\n HR: 70 (67 - 93) bpm\n BP: 87/48(61) {87/47(61) - 124/70(89)} mmHg\n RR: 22 (16 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,608 mL\n 710 mL\n PO:\n TF:\n 1,560 mL\n 469 mL\n IVF:\n 1,448 mL\n 241 mL\n Blood products:\n Total out:\n 3,240 mL\n 920 mL\n Urine:\n 3,240 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n 368 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 0 (0 - 343) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 25 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 95%\n ABG: 7.43/68/76./46/16\n Ve: 6.9 L/min\n PaO2 / FiO2: 152\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: trace bilaterally pitting edema, improving\n Labs / Radiology\n 475 K/uL\n 9.3 g/dL\n 114 mg/dL\n 0.9 mg/dL\n 46 mEq/L\n 4.2 mEq/L\n 48 mg/dL\n 91 mEq/L\n 143 mEq/L\n 29.6 %\n 24.7 K/uL\n [image002.jpg]\n 02:09 PM\n 06:04 PM\n 08:49 PM\n 04:16 AM\n 04:22 AM\n 05:09 PM\n 05:22 PM\n 10:16 PM\n 03:59 AM\n 04:03 AM\n WBC\n 24.5\n 24.7\n Hct\n 30.5\n 29.6\n Plt\n 557\n 475\n Cr\n 0.8\n 0.8\n 0.9\n 0.9\n TCO2\n 40\n 45\n 43\n 48\n 48\n 47\n Glucose\n 176\n 132\n 185\n 114\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Day 8 of intubation today for multilobar\n pneumonia & COPD c/b ARDS. Difficult to oxygenate without high\n PEEP/FIO2. Requiring high PEEP and PSV. Still significantly positive\n for the stay- LOS 4.5 liters. She does have RLL effusion that may be\n contributing.\n - bedside ultrasound today to evaluate for effusion that might be\n -able (although this would be risky given high pressure)\n - Continue lasix gtt, plan for goal I/O negative 1 liter-2liter\n - PM lytes\n - continue diamox\n - taper prednisone to 30mg daily today\n .\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, d/c azithromycin for 8-day course to\n end \n - change IV meds to PO if possible\n .\n # Alkalosis: secondary to aggressive diuresis\n - continue acetazolamide\n .\n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds (will concentrate\n to assist with tube feeds)\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726585,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n Respiratory failure, chronic\n Assessment:\n This am on 70% fio2 tv 450 a/c rate of 24 breathing 24 with peep of\n 10. sats low 90\ns. bs with upper insp wheeze and diminished at bases.\n Suctioned for minimal secretions. afebrile\n Action:\n Cont vancomycin, cefipime and azithromycin.\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726587,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 05:25 AM\n - BP improved, able to give 20+20 Lasix on night shift, significant UOP\n - ~4:30am tube feeds found in ET tube, unclear source, worsening\n oxygenation\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Azithromycin - 07:35 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 125 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:25 PM\n Heparin Sodium (Prophylaxis) - 07:31 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 09:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.1\nC (98.7\n HR: 70 (65 - 88) bpm\n BP: 98/73(84) {85/45(58) - 129/75(93)} mmHg\n RR: 24 (18 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 1 (1 - 3)mmHg\n Total In:\n 2,558 mL\n 691 mL\n PO:\n TF:\n 1,000 mL\n 243 mL\n IVF:\n 1,147 mL\n 398 mL\n Blood products:\n Total out:\n 2,350 mL\n 1,635 mL\n Urine:\n 2,350 mL\n 1,635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 208 mL\n -944 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 410 (361 - 449) mL\n PS : 10 cmH2O\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n SpO2: 92%\n ABG: 7.37/49/66/25/1\n Ve: 11.1 L/min\n PaO2 / FiO2: 94\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 435 K/uL\n 9.6 g/dL\n 149 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 49 mg/dL\n 114 mEq/L\n 149 mEq/L\n 30.5 %\n 27.2 K/uL\n [image002.jpg]\n 03:14 AM\n 05:00 AM\n 05:57 AM\n 08:37 AM\n 10:26 AM\n 03:58 AM\n 04:27 AM\n 04:58 AM\n 06:22 AM\n 06:25 AM\n WBC\n 27.2\n Hct\n 30.5\n Plt\n 435\n Cr\n 1.1\n 0.9\n TCO2\n 25\n 26\n 26\n 25\n 25\n 31\n 28\n 29\n Glucose\n 140\n 149\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 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": "2192-03-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726588,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 05:25 AM\n - BP improved, able to give 20+20 Lasix on night shift, significant UOP\n - ~4:30am tube feeds found in ET tube, unclear source, worsening\n oxygenation\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Azithromycin - 07:35 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 125 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:25 PM\n Heparin Sodium (Prophylaxis) - 07:31 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 09:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.1\nC (98.7\n HR: 70 (65 - 88) bpm\n BP: 98/73(84) {85/45(58) - 129/75(93)} mmHg\n RR: 24 (18 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 1 (1 - 3)mmHg\n Total In:\n 2,558 mL\n 691 mL\n PO:\n TF:\n 1,000 mL\n 243 mL\n IVF:\n 1,147 mL\n 398 mL\n Blood products:\n Total out:\n 2,350 mL\n 1,635 mL\n Urine:\n 2,350 mL\n 1,635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 208 mL\n -944 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 410 (361 - 449) mL\n PS : 10 cmH2O\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n SpO2: 92%\n ABG: 7.37/49/66/25/1\n Ve: 11.1 L/min\n PaO2 / FiO2: 94\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 435 K/uL\n 9.6 g/dL\n 149 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 49 mg/dL\n 114 mEq/L\n 149 mEq/L\n 30.5 %\n 27.2 K/uL\n [image002.jpg]\n 03:14 AM\n 05:00 AM\n 05:57 AM\n 08:37 AM\n 10:26 AM\n 03:58 AM\n 04:27 AM\n 04:58 AM\n 06:22 AM\n 06:25 AM\n WBC\n 27.2\n Hct\n 30.5\n Plt\n 435\n Cr\n 1.1\n 0.9\n TCO2\n 25\n 26\n 26\n 25\n 25\n 31\n 28\n 29\n Glucose\n 140\n 149\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n # Respiratory failure: Multilobar Pneumonia & COPD. Possible that she\n has some sort of endobronchial lesion (? malignancy given smoking hx)\n contributing. In any case, because of her very severe baseline\n obstructive disease, she remains a very tenuous respiratory place right\n now. She now requires PEEP of 10 for adequate O2. CXR unchanged. GPCs\n in pairs, Legionella (-)\n -\n - F/U blood cx\n - methylprednisolone to 125 mg q8h\n - fluticasone inh\n - albuterol nebs ,decrease to q4h\n - ipratropium nebs q6h\n -continue vent; trial of PSV\n - try to diurese if pressors are weaned\n .\n # PNA: GPCs in pairs, Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, and azithromycin for broad bacterial\n coverage including atypical pathogens.\n - redose abx renally per pharmacy\n - plan to reconsider abx tomorrow when sputum speciation returns\n - consider bronch prior to extubation if stabilizes tomorrow\n #. Shock: Pressor requirement lessening. Septic from PNA,\n leukocytosis, requiring pressors but is fluid responsive. No recent\n abx exposure.\n - Abx as above\n - Norepi as needed to keep MAP >60, allow for sedation\n - LOS 6 L positive; plan to avoid excessive IVF unless UOP falls (and\n diurese if off pressors)\n # kidney injury: improved with signficant fluid hydration.\n - F/U urine lytes\n - trend creatinine\n # hx hypertension: hypotensive on pressors\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , patient does not know #, SW is working on reaching family\n - d/w SW if family has been contact\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 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": "2192-03-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726589,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 05:25 AM\n - BP improved, able to give 20+20 Lasix on night shift, significant UOP\n - ~4:30am tube feeds found in ET tube, unclear source, worsening\n oxygenation\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Azithromycin - 07:35 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 125 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:25 PM\n Heparin Sodium (Prophylaxis) - 07:31 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 09:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.1\nC (98.7\n HR: 70 (65 - 88) bpm\n BP: 98/73(84) {85/45(58) - 129/75(93)} mmHg\n RR: 24 (18 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 1 (1 - 3)mmHg\n Total In:\n 2,558 mL\n 691 mL\n PO:\n TF:\n 1,000 mL\n 243 mL\n IVF:\n 1,147 mL\n 398 mL\n Blood products:\n Total out:\n 2,350 mL\n 1,635 mL\n Urine:\n 2,350 mL\n 1,635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 208 mL\n -944 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 410 (361 - 449) mL\n PS : 10 cmH2O\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n SpO2: 92%\n ABG: 7.37/49/66/25/1\n Ve: 11.1 L/min\n PaO2 / FiO2: 94\n Physical Examination\n GEN: intubated\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender\n EXTREMITIES: trace bilaterally pitting edema\n Labs / Radiology\n 435 K/uL\n 9.6 g/dL\n 149 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 49 mg/dL\n 114 mEq/L\n 149 mEq/L\n 30.5 %\n 27.2 K/uL\n [image002.jpg]\n 03:14 AM\n 05:00 AM\n 05:57 AM\n 08:37 AM\n 10:26 AM\n 03:58 AM\n 04:27 AM\n 04:58 AM\n 06:22 AM\n 06:25 AM\n WBC\n 27.2\n Hct\n 30.5\n Plt\n 435\n Cr\n 1.1\n 0.9\n TCO2\n 25\n 26\n 26\n 25\n 25\n 31\n 28\n 29\n Glucose\n 140\n 149\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n # Respiratory failure: Multilobar oneumonia & COPD. CXR unchanged,\n still with L-sided pleural effusion. GPCs in sputum from are\n most likely coag-neg Staph, with oral flora. Legionella (-)\n - f/u final sputum cx report\n - diurese more with furosemide 40 mg IV x 1 now; goal\n1 L net I/O\n - will try to wean down FiO2 and PEEP today if possible; prepare for\n extubation tomorrow\n - methylprednisolone to 125 mg q8h\n - continue nebs\n - ipratropium nebs q6h\n -continue vent; trial of PSV\n .\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, and azithromycin for 8-day course\n - might bronch tomorrow\n - consider chest CT\n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # Hypernatremia: free water deficit is about 4L.\n - 250 cc free water bolus q4h\n - pm lytes\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , patient does not know #, SW is working on reaching family\n - d/w SW if family has been contact\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 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": "2192-03-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 726590,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 24 Hour Events:\n weaned off norepi yest am. hypoxemic distress yesterday afternoon. tube\n feed-like material suctioned from ETT. Vent support was increased.\n Diuresed overnight.\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 10:00 PM\n Azithromycin - 07:35 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 125 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 09:25 PM\n Heparin Sodium (Prophylaxis) - 07:31 AM\n Other medications:\n Heparin sc, Atrovent MDI, Protonix, Solu-Medrol 125 q8, azithro, RISS,\n Peridex, Cefepime, vanco\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.1\nC (98.7\n HR: 70 (65 - 88) bpm\n BP: 98/73(84) {85/45(58) - 129/75(93)} mmHg\n RR: 24 (18 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 1 (1 - 3)mmHg\n Total In:\n 2,558 mL\n 691 mL\n PO:\n TF:\n 1,000 mL\n 243 mL\n IVF:\n 1,147 mL\n 398 mL\n Blood products:\n Total out:\n 2,350 mL\n 1,635 mL\n Urine:\n 2,350 mL\n 1,635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 208 mL\n -944 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 410 (361 - 449) mL\n PS : 10 cmH2O\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n SpO2: 92%\n ABG: 7.37/49/66/25/1\n Ve: 11.1 L/min\n PaO2 / FiO2: 94\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\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 : ant)\n Abdominal: Soft, Bowel sounds present, Obese\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 9.6 g/dL\n 435 K/uL\n 149 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 49 mg/dL\n 114 mEq/L\n 149 mEq/L\n 30.5 %\n 27.2 K/uL\n [image002.jpg]\n 03:14 AM\n 05:00 AM\n 05:57 AM\n 08:37 AM\n 10:26 AM\n 03:58 AM\n 04:27 AM\n 04:58 AM\n 06:22 AM\n 06:25 AM\n WBC\n 27.2\n Hct\n 30.5\n Plt\n 435\n Cr\n 1.1\n 0.9\n TCO2\n 25\n 26\n 26\n 25\n 25\n 31\n 28\n 29\n Glucose\n 140\n 149\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR- no sig change since yest\n Microbiology: Sputum- GPCs, yeast\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia. Prior partial RUL\n collapse from will need further evaluation down the road and might\n have predisposed to current pna. desat yest w/ poss aspiration? will\n have to monitor for infxn but so far clinically defervescing and no new\n infiltrate\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -wean FiO2 to maintain PaO2 > 60\n -tolerate autoPEEP for now as Pplat < 30 and hemodyn stable\n -assess spont breathing tolerance today but caution on weaning\n -start aggressive diuresis w/ goal -1-2L neg today; will check pm lytes\n -vanco + cefepime + azithro (change to IV) for now --> plan for empiric\n 8d course pending cx data\n -tx COPD exac w/ Solu-Medrol --> cont 125 q8 today and scheduled nebs;\n wean steroids tomorrow\n -will need CT scan at some point to re-evaluate, poss bronch\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa- monitor w/ diuresis; may need need free H2O boluses\n 4. Possible aspiration- has not had BM since admit; constipation might\n be contributing\n -replace OGT\n -aggressive bowel regimen w/ Dulcolax and PO Narcan; hold on enteral\n feee H20 and tube feeds till bowels are moving\n ICU Care\n Nutrition:\n Comments: replaced OGT\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\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: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726848,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-04-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 727280,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Pt remained stable throughout the night on CPAP . FIO2 was\n decreased from 70% to 50%. Will continue to follow and wean as\n tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726420,
"text": "A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n Respiratory failure\n Assessment:\n Remains intubated and vented presently on PS-10/Peep-10, FIO2-60% with\n O2 sats 90-92%, last ABG- 7.27/53/70/-.\n L/S clear to diminished @ bases., sputum spec has GPC\ns. Suctioning\n white thick secretions CXR--. R-sided opacification, L hyperinflation;\n B effusions. Desat\nd to 87%, on FIO2-60% Peep-10.\n Action:\n Changed vent mode from A/C to PS, suctioning q3-4hr . , and FIO2 was\n placed back up to 70%.\n Response:\n Remains acidotic, and hypoxic, no improvement of PNX,\n Plan:\n Continue with pulmonary toilet, asses ABG\ns and O2 sats, adjust vent\n setting as needed.\n Sepsis without organ dysfunction\n Assessment:\n Rec\nd on Levo Gtt @ .03mcq, with BP 98-114/50, HR 70-80\ns with APC\n CVP-. Temp 99.2 Po max. U/O 50-60cc/hr. BUN/CRe improved. WBC\n 35.6,\n Action:\n Levo Gtt stopped, IV antibx\ns were increased.\n Response:\n BP down to 85-94/50, with Levo off, MAP\ns60-63.\n Plan:\n Monitor U/O and BP off of Levo, tolerating MAP 60, continue with IV\n antibx\ns check results of cultures.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726749,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n Events- new ogt placed. Placement confirmed by xray per dr .\n Required reintubation as not getting volumes at 1700.\n Anesthesia called and up to see the patient. Tube pulled and\n reintubated after receiving 20mg etomidate and 100mg succinylcholine\n Respiratory failure, chronic\n Assessment:\n Received pt s/p reintubation for possible dislodging of ETT. Pt on PSV\n 80%/ with ABG 7.36/56/65. Pt with COPD, goal PO2 65, goal sats\n 88-93%. LS ronchorous/diminished. Pt suctioned for small amts tan thick\n secretions via ETT. Sats 92-94%. Pt afebrile. Lg amts CYU via foley s/p\n IV lasix.\n Action:\n Pt given last dose methylprednisolone @ MN. Cont on IV ABX for PNA.\n Pulmonary toilet.\n Response:\n No vent changes made this shift. ABG this AM slightly improved to\n 7.36/56/76. Sats remain 92-94% throughout shift. Pt cont to diurese.\n Plan:\n Attempt to wean vent as tolerated. No SBT this shift as it is\n contraindicated with current vent settings. Goal sats 88-93%, goal PO2\n 65, goal negative 1-2L to keep fluid out of lungs.\n Constipation (Obstipation, FOS)\n Assessment:\n Pt received with no stool output since admission. Aggressive bowel\n regimen had been started on day shift. On assessment, pt with\n small amt liquid brown stool.\n Action:\n Pt cont on naloxone 2mg Q6. Also given colace, lactulose, senna. At MN,\n pt noted to be soiled in more stool so FMS placed. TF restarted @ 0230\n at starting rate 25cc/hr since pt had stooled.\n Response:\n Pt with small to moderate stool output, large amt of gas. FMS remains\n in place with stool leaking around device at times. Pt with residual\n 60cc after 1.5hrs of intiation of tube feeds so feeding stopped.\n Plan:\n Cont with aggressive bowel regimen. Cont to reassess for proper time to\n restart TF.\n Hypernatremia (high sodium)\n Assessment:\n Na+ 148 on 1900 labs. Pt s/p 500cc IV D5W. Pt unable to receive free\n water via OGT constipation/high residuals and ? aspiration.\n Action:\n Pt given another 500cc D5W. Aggressive bowel regimen implemented in\n attempt to make pt stool so that free water boluses may be given via\n OGT in attempt to decrease sodium.\n Response:\n AM Na+ ____. Pt began stooling minimally but with initiation of TF,\n residuals high so unable to give free water.\n Plan:\n Cont to monitor sodium levels. Plan to give free water boluses once\n able to resume TF. While unable to give free water, may need to\n administer more D5W.\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726996,
"text": "Chief Complaint:\n 24 Hour Events:\n - received furosemide 40 mg IV x 2; reached contraction alkolosis\n - bit on ET tube, creating air leaks; had to be extubated and\n re-intubated\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:33 AM\n Cefipime - 10:33 AM\n Vancomycin - 08:00 PM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:33 AM\n Heparin Sodium (Prophylaxis) - 03:17 PM\n Furosemide (Lasix) - 06:41 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 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.7\n HR: 79 (75 - 92) bpm\n BP: 113/59(76) {105/50(67) - 151/89(105)} mmHg\n RR: 19 (10 - 27) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 10 (1 - 13)mmHg\n Total In:\n 3,362 mL\n 477 mL\n PO:\n TF:\n 418 mL\n 301 mL\n IVF:\n 1,945 mL\n 146 mL\n Blood products:\n Total out:\n 4,150 mL\n 460 mL\n Urine:\n 4,000 mL\n 460 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n -788 mL\n 17 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 339 (339 - 461) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 3\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 91%\n ABG: 7.37/56/71/34/4\n Ve: 6.5 L/min\n PaO2 / FiO2: 118\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 535 K/uL\n 9.7 g/dL\n 150 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 104 mEq/L\n 145 mEq/L\n 30.6 %\n 26.2 K/uL\n [image002.jpg]\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n WBC\n 28.5\n 26.2\n Hct\n 30.2\n 30.6\n Plt\n 446\n 535\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 31\n 33\n 33\n 34\n Glucose\n 149\n 194\n 166\n 168\n 150\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-03-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726997,
"text": "Chief Complaint:\n 24 Hour Events:\n - received furosemide 40 mg IV x 2; reached contraction alkolosis\n - bit on ET tube, creating air leaks; had to be extubated and\n re-intubated\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:33 AM\n Cefipime - 10:33 AM\n Vancomycin - 08:00 PM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:33 AM\n Heparin Sodium (Prophylaxis) - 03:17 PM\n Furosemide (Lasix) - 06:41 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 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.7\n HR: 79 (75 - 92) bpm\n BP: 113/59(76) {105/50(67) - 151/89(105)} mmHg\n RR: 19 (10 - 27) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 10 (1 - 13)mmHg\n Total In:\n 3,362 mL\n 477 mL\n PO:\n TF:\n 418 mL\n 301 mL\n IVF:\n 1,945 mL\n 146 mL\n Blood products:\n Total out:\n 4,150 mL\n 460 mL\n Urine:\n 4,000 mL\n 460 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n -788 mL\n 17 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 339 (339 - 461) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 3\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 91%\n ABG: 7.37/56/71/34/4\n Ve: 6.5 L/min\n PaO2 / FiO2: 118\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 535 K/uL\n 9.7 g/dL\n 150 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 104 mEq/L\n 145 mEq/L\n 30.6 %\n 26.2 K/uL\n [image002.jpg]\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n WBC\n 28.5\n 26.2\n Hct\n 30.2\n 30.6\n Plt\n 446\n 535\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 31\n 33\n 33\n 34\n Glucose\n 149\n 194\n 166\n 168\n 150\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n # Respiratory failure: Multilobar loneumonia & COPD. Likely volume\n overload is now also contributing. LOS still 5.6 L net positive.\n Remains on PSV 12/10, but FiO2 requirement seems to be going up. GPCs\n in sputum from are most likely coag-neg Staph, with oral flora.\n Legionella (-)\n - f/u final sputum cx report\n - diurese more with furosemide 40 mg IV x 1 now; goal\n2 L net negative\n again today\n - will change to AC settings with ARDsnet protocol to decrease volumes\n -serial ABG\n - decrease methylprednisolone to 100 mg q12h\n - continue nebs\n .\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, and azithromycin for 8-day course\n - might bronch tomorrow\n - consider chest CT\n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # Hypernatremia: free water deficit is about 4L.\n - 500cc D5W now\n - 250 cc free water bolus q4h if TF continues working\n - pm lytes\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-03-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726998,
"text": "Chief Complaint:\n 24 Hour Events:\n - received furosemide 40 mg IV x 2; reached contraction alkolosis\n - bit on ET tube, creating air leaks; had to be extubated and\n re-intubated\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:33 AM\n Cefipime - 10:33 AM\n Vancomycin - 08:00 PM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:33 AM\n Heparin Sodium (Prophylaxis) - 03:17 PM\n Furosemide (Lasix) - 06:41 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 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.7\n HR: 79 (75 - 92) bpm\n BP: 113/59(76) {105/50(67) - 151/89(105)} mmHg\n RR: 19 (10 - 27) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 10 (1 - 13)mmHg\n Total In:\n 3,362 mL\n 477 mL\n PO:\n TF:\n 418 mL\n 301 mL\n IVF:\n 1,945 mL\n 146 mL\n Blood products:\n Total out:\n 4,150 mL\n 460 mL\n Urine:\n 4,000 mL\n 460 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n -788 mL\n 17 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 339 (339 - 461) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 3\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 91%\n ABG: 7.37/56/71/34/4\n Ve: 6.5 L/min\n PaO2 / FiO2: 118\n Physical Examination\n GEN: intubated\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender\n EXTREMITIES: trace bilaterally pitting edema\n Labs / Radiology\n 535 K/uL\n 9.7 g/dL\n 150 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 104 mEq/L\n 145 mEq/L\n 30.6 %\n 26.2 K/uL\n [image002.jpg]\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n WBC\n 28.5\n 26.2\n Hct\n 30.2\n 30.6\n Plt\n 446\n 535\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 31\n 33\n 33\n 34\n Glucose\n 149\n 194\n 166\n 168\n 150\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n # Respiratory failure: Multilobar loneumonia & COPD. Likely volume\n overload is now also contributing. LOS still 5.6 L net positive.\n Remains on PSV 12/10, but FiO2 requirement seems to be going up. GPCs\n in sputum from are most likely coag-neg Staph, with oral flora.\n Legionella (-)\n - f/u final sputum cx report\n - diurese more with furosemide 40 mg IV x 1 now; goal\n2 L net negative\n again today\n - will change to AC settings with ARDsnet protocol to decrease volumes\n -serial ABG\n - decrease methylprednisolone to 100 mg q12h\n - continue nebs\n .\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, and azithromycin for 8-day course\n - might bronch tomorrow\n - consider chest CT\n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # Hypernatremia: free water deficit is about 4L.\n - 500cc D5W now\n - 250 cc free water bolus q4h if TF continues working\n - pm lytes\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-03-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727004,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 24 Hour Events:\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 10:33 AM\n Vancomycin - 08:00 PM\n Azithromycin - 07:30 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:33 AM\n Heparin Sodium (Prophylaxis) - 03:17 PM\n Furosemide (Lasix) - 06:41 PM\n Fentanyl - 07:30 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 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.4\nC (97.6\n HR: 79 (75 - 92) bpm\n BP: 113/59(76) {105/50(67) - 146/89(102)} mmHg\n RR: 19 (10 - 27) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 10 (1 - 13)mmHg\n Total In:\n 3,362 mL\n 805 mL\n PO:\n TF:\n 418 mL\n 340 mL\n IVF:\n 1,945 mL\n 404 mL\n Blood products:\n Total out:\n 4,150 mL\n 520 mL\n Urine:\n 4,000 mL\n 520 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n -788 mL\n 285 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 339 (339 - 339) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 3\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 91%\n ABG: 7.37/56/71/34/4\n Ve: 6.5 L/min\n PaO2 / FiO2: 118\n Physical Examination\n Gen:\n HEENT:\n CV:\n PULM:\n ABD:\n Extrem:\n Neuro:\n Labs / Radiology\n 9.7 g/dL\n 535 K/uL\n 150 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 104 mEq/L\n 145 mEq/L\n 30.6 %\n 26.2 K/uL\n [image002.jpg]\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n WBC\n 28.5\n 26.2\n Hct\n 30.2\n 30.6\n Plt\n 446\n 535\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 31\n 33\n 33\n 34\n Glucose\n 149\n 194\n 166\n 168\n 150\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:00 PM 55 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "Physician ",
"chartdate": "2192-03-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727005,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 24 Hour Events:\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 10:33 AM\n Vancomycin - 08:00 PM\n Azithromycin - 07:30 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:33 AM\n Heparin Sodium (Prophylaxis) - 03:17 PM\n Furosemide (Lasix) - 06:41 PM\n Fentanyl - 07:30 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 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.4\nC (97.6\n HR: 79 (75 - 92) bpm\n BP: 113/59(76) {105/50(67) - 146/89(102)} mmHg\n RR: 19 (10 - 27) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 10 (1 - 13)mmHg\n Total In:\n 3,362 mL\n 805 mL\n PO:\n TF:\n 418 mL\n 340 mL\n IVF:\n 1,945 mL\n 404 mL\n Blood products:\n Total out:\n 4,150 mL\n 520 mL\n Urine:\n 4,000 mL\n 520 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n -788 mL\n 285 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 339 (339 - 339) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 3\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 91%\n ABG: 7.37/56/71/34/4\n Ve: 6.5 L/min\n PaO2 / FiO2: 118\n Physical Examination\n Gen:\n HEENT:\n CV:\n PULM:\n ABD:\n Extrem:\n Neuro:\n Labs / Radiology\n 9.7 g/dL\n 535 K/uL\n 150 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 104 mEq/L\n 145 mEq/L\n 30.6 %\n 26.2 K/uL\n [image002.jpg]\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n WBC\n 28.5\n 26.2\n Hct\n 30.2\n 30.6\n Plt\n 446\n 535\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 31\n 33\n 33\n 34\n Glucose\n 149\n 194\n 166\n 168\n 150\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -switch to better ARDSnet ventilation --> A/CV w/ 6cc/kg Vt and\n permissive hypercpania, tolerating pH down to 7.20\n -wean FiO2 to maintain PaO2 > 60; keep PEEP\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes\n -vanco + cefepime + azithro --> plan for empiric 8d course pending cx\n data\n -tx COPD exac w/ Solu-Medrol --> wean steroids to 125 q12 today\n -will need CT scan at some point to re-evaluate, poss bronch given RUL\n collapse seen in , can be deferred til better on vent\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa- monitor w/ diuresis;\n -start free H20 boluses per NGT plus d5w IV and monitor\n 4. Constipation- resolving\n -cont aggressive regimen\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:00 PM 55 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "Physician ",
"chartdate": "2192-03-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727014,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation. Intubated 5 days ago.\n 24 Hour Events:\n Lasix 80mg IV given last night, now negative 800cc.\n ETT had to be replaced last night due to injury to the cuff and air\n leak.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 10:33 AM\n Vancomycin - 08:00 PM\n Azithromycin - 07:30 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:33 AM\n Heparin Sodium (Prophylaxis) - 03:17 PM\n Furosemide (Lasix) - 06:41 PM\n Fentanyl - 07:30 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 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.4\nC (97.6\n HR: 79 (75 - 92) bpm\n BP: 113/59(76) {105/50(67) - 146/89(102)} mmHg\n RR: 19 (10 - 27) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 10 (1 - 13)mmHg\n Total In:\n 3,362 mL\n 805 mL\n PO:\n TF:\n 418 mL\n 340 mL\n IVF:\n 1,945 mL\n 404 mL\n Blood products:\n Total out:\n 4,150 mL\n 520 mL\n Urine:\n 4,000 mL\n 520 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n -788 mL\n 285 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 339 (339 - 339) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 3\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 91%\n ABG: 7.37/56/71/34/4\n Ve: 6.5 L/min\n PaO2 / FiO2: 118\n Physical Examination\n Gen:Intubated, sedated\n HEENT: PERRL, anicteric\n CV: RRR, no m/r/g\n PULM: coarse BS bilaterally\n ABD:\n Extrem:\n Neuro: sedated\n Labs / Radiology\n 9.7 g/dL\n 535 K/uL\n 150 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 104 mEq/L\n 145 mEq/L\n 30.6 %\n 26.2 K/uL\n [image002.jpg]\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n WBC\n 28.5\n 26.2\n Hct\n 30.2\n 30.6\n Plt\n 446\n 535\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 31\n 33\n 33\n 34\n Glucose\n 149\n 194\n 166\n 168\n 150\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -switch to better ARDSnet ventilation --> A/CV w/ 6cc/kg Vt and\n permissive hypercpania, tolerating pH down to 7.20\n -wean FiO2 to maintain PaO2 > 60; keep PEEP\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes\n -vanco + cefepime + azithro --> plan for empiric 8d course pending cx\n data\n -tx COPD exac w/ Solu-Medrol --> wean steroids to 125 q12 today\n -will need CT scan at some point to re-evaluate, poss bronch given RUL\n collapse seen in , can be deferred til better on vent\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa- monitor w/ diuresis;\n -start free H20 boluses per NGT plus d5w IV and monitor\n 4. Constipation- resolving\n -cont aggressive regimen\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:00 PM 55 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "Physician ",
"chartdate": "2192-03-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727016,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation. Intubated 5 days ago.\n 24 Hour Events:\n Lasix 80mg IV given last night, now negative 800cc.\n ETT had to be replaced last night due to injury to the cuff and air\n leak.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Cefepime - 10:33 AM\n Vancomycin - 08:00 PM\n Azithromycin - 07:30 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:33 AM\n Heparin Sodium (Prophylaxis) - 03:17 PM\n Furosemide (Lasix) - 06:41 PM\n Fentanyl - 07:30 AM\n Po narcan q6\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 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.4\nC (97.6\n HR: 79 (75 - 92) bpm\n BP: 113/59(76) {105/50(67) - 146/89(102)} mmHg\n RR: 19 (10 - 27) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 10 (1 - 13)mmHg\n Total In:\n 3,362 mL\n 805 mL\n PO:\n TF:\n 418 mL\n 340 mL\n IVF:\n 1,945 mL\n 404 mL\n Blood products:\n Total out:\n 4,150 mL\n 520 mL\n Urine:\n 4,000 mL\n 520 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n -788 mL\n 285 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 339 (339 - 339) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 3\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 91%\n ABG: 7.37/56/71/34/4\n Ve: 6.5 L/min\n PaO2 / FiO2: 118\n Physical Examination\n Gen:Intubated, sedated\n HEENT: PERRL, anicteric\n CV: RRR, no m/r/g\n PULM: coarse BS bilaterally\n ABD:\n Extrem:\n Neuro: sedated\n Labs / Radiology\n 9.7 g/dL\n 535 K/uL\n 150 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 104 mEq/L\n 145 mEq/L\n 30.6 %\n 26.2 K/uL\n [image002.jpg]\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n WBC\n 28.5\n 26.2\n Hct\n 30.2\n 30.6\n Plt\n 446\n 535\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 31\n 33\n 33\n 34\n Glucose\n 149\n 194\n 166\n 168\n 150\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -switch to better ARDSnet ventilation --> A/CV w/ 6cc/kg Vt and\n permissive hypercpania, tolerating pH down to 7.20\n -wean FiO2 to maintain PaO2 > 60; keep PEEP\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes\n -vanco + cefepime + azithro --> plan for empiric 8d course pending cx\n data\n -tx COPD exac w/ Solu-Medrol --> wean steroids to 125 q12 today\n -will need CT scan at some point to re-evaluate, poss bronch given RUL\n collapse seen in , can be deferred til better on vent\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa- monitor w/ diuresis;\n -start free H20 boluses per NGT plus d5w IV and monitor\n 4. Constipation- resolving\n -cont aggressive regimen\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:00 PM 55 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "Physician ",
"chartdate": "2192-03-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 727017,
"text": "Chief Complaint:\n 24 Hour Events:\n - received furosemide 40 mg IV x 2; reached contraction alkolosis\n - bit on ET tube, creating air leaks; had to be extubated and\n re-intubated\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:33 AM\n Cefipime - 10:33 AM\n Vancomycin - 08:00 PM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:33 AM\n Heparin Sodium (Prophylaxis) - 03:17 PM\n Furosemide (Lasix) - 06:41 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 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.7\n HR: 79 (75 - 92) bpm\n BP: 113/59(76) {105/50(67) - 151/89(105)} mmHg\n RR: 19 (10 - 27) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 10 (1 - 13)mmHg\n Total In:\n 3,362 mL\n 477 mL\n PO:\n TF:\n 418 mL\n 301 mL\n IVF:\n 1,945 mL\n 146 mL\n Blood products:\n Total out:\n 4,150 mL\n 460 mL\n Urine:\n 4,000 mL\n 460 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n -788 mL\n 17 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 339 (339 - 461) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 3\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 91%\n ABG: 7.37/56/71/34/4\n Ve: 6.5 L/min\n PaO2 / FiO2: 118\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: trace bilaterally pitting edema, improving\n Labs / Radiology\n 535 K/uL\n 9.7 g/dL\n 150 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 104 mEq/L\n 145 mEq/L\n 30.6 %\n 26.2 K/uL\n [image002.jpg]\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n WBC\n 28.5\n 26.2\n Hct\n 30.2\n 30.6\n Plt\n 446\n 535\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 31\n 33\n 33\n 34\n Glucose\n 149\n 194\n 166\n 168\n 150\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n # Respiratory failure: Multilobar loneumonia & COPD c/b ARDS.\n Difficult to oxygenate without high PEEP/FIO2. Still significantly\n positive for the stay.\n - Lasix gtt today\n - ABG today\n - Methylpred->Flovent 4 puffs \n - continue nebs\n - Increase PEEP to 12\n - PM Lytes\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, and azithromycin for 8-day course to\n end \n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # Hypernatremia: free water deficit is about 4L.\n - 500cc D5W now\n - 250 cc free water bolus q4h if TF continues working\n - pm lytes\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:00 PM 45 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-03-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727018,
"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 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation. Intubated 5 days ago.\n 24 Hour Events:\n Lasix 80mg IV given last night, now negative 800cc.\n ETT had to be replaced last night due to injury to the cuff and air\n leak.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Cefepime - 10:33 AM\n Vancomycin - 08:00 PM\n Azithromycin - 07:30 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:33 AM\n Heparin Sodium (Prophylaxis) - 03:17 PM\n Furosemide (Lasix) - 06:41 PM\n Fentanyl - 07:30 AM\n Po narcan q6\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 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.4\nC (97.6\n HR: 79 (75 - 92) bpm\n BP: 113/59(76) {105/50(67) - 146/89(102)} mmHg\n RR: 19 (10 - 27) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 10 (1 - 13)mmHg\n Total In:\n 3,362 mL\n 805 mL\n PO:\n TF:\n 418 mL\n 340 mL\n IVF:\n 1,945 mL\n 404 mL\n Blood products:\n Total out:\n 4,150 mL\n 520 mL\n Urine:\n 4,000 mL\n 520 mL\n NG:\n Stool:\n 150 mL\n Drains:\n Balance:\n -788 mL\n 285 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 339 (339 - 339) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 3\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 91%\n ABG: 7.37/56/71/34/4\n Ve: 6.5 L/min\n PaO2 / FiO2: 118\n Physical Examination\n Gen:Intubated, sedated but awakens to voice\n HEENT: PERRL, anicteric\n CV: RRR, no m/r/g\n PULM: coarse BS bilaterally\n ABD:soft, reducible hernia unchanged\n Extrem: 1+ edema both legs, improved from previous\n Neuro: sedated but easily arousable\n Skin: no rashes\n Labs / Radiology\n 9.7 g/dL\n 535 K/uL\n 150 mg/dL\n 0.8 mg/dL\n 34 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 104 mEq/L\n 145 mEq/L\n 30.6 %\n 26.2 K/uL\n [image002.jpg]\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n WBC\n 28.5\n 26.2\n Hct\n 30.2\n 30.6\n Plt\n 446\n 535\n Cr\n 0.9\n 0.9\n 0.8\n 0.8\n 0.8\n TCO2\n 29\n 31\n 33\n 33\n 34\n Glucose\n 149\n 194\n 166\n 168\n 150\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.4 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS.\n -will have asymmetric lung physiology as L lung is emphysematous and R\n lung is infected, so will need to be cautious of L lung volu- and\n -trauma\n -wean FiO2 to maintain PaO2 > 60; increase PEEP to 12 since O2 sat on\n low side\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n Change to lasix gtt (low rate) for slow continuous diuresis\n -vanco + cefepime + azithro --> plan for empiric 8d course pending cx\n data\n -tx COPD exac w/ Solu-Medrol --> change to prednisone 40mg daily pNGT\n -will need CT scan at some point to re-evaluate, poss bronch given RUL\n collapse seen in , can be deferred til better on vent\n -flovent\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa- monitor w/ diuresis;\n -start free H20 boluses per NGT plus d5w IV and monitor. Na improved,\n continue free H20.\n 4. Constipation- resolving\n -cont aggressive regimen\n ICU Care\n Nutrition: tube feeds\n Replete with Fiber (Full) - 08:00 PM 55 mL/hour\n Glycemic Control: RISS\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 AM\n Prophylaxis:\n DVT: sc heparin\n Stress ulcer: PPI\n VAP: chlorhexidine, HOB 30 degrees\n Communication: in touch with family\n Code status: Full code\n Disposition : ICU\n Total time spent: 35 min\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727091,
"text": "A 67 yo woman with a history of very severe COPD with PNA/ARDS,\n continues to be intubated/sedated.\n Hypernatremia (high sodium)\n Assessment:\n Na 145. TF infusing at goal of 65cc/hr.\n Action:\n Continue with free water flushes of 250cc every 4 hours. Pm lytes\n drawn\n Response:\n Awaiting chemistry results.\n Plan:\n Continue to monitor.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. LS\n diminished. Hemodynamically stable.\n Action:\n Vent settings changed to PSV 12/14 @ 50%. Pt started on lasix drip for\n goal removal of 1 liter today. Pt also given 1x 40mg lasix dose.\n Response:\n Pt is only negative 375cc thus far today. ABG: 7.36/68/71/40. No\n changes with vent.\n Plan:\n ? need to increase lasix drip to obtain fluid removal goal. Morning\n abg.\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 727216,
"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: 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation. Intubated 5 days ago.\n 24 Hour Events:\n Excellent UOP on lasix, but only 500cc neg\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Azithromycin - 07:30 AM\n Cefipime - 10:00 PM\n Vancomycin - 07:56 AM\n Infusions:\n Furosemide (Lasix) - 10 mg/hour\n Fentanyl - 200 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Lasix gtt at 10mg/hr\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:55 AM\n Furosemide (Lasix) - 08:05 AM\n Colace\n Protonix\n RISS\n Po narcan\n Prednisone 40mg daily\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 08:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.8\nC (96.4\n HR: 75 (68 - 86) bpm\n BP: 103/54(69) {86/50(62) - 131/87(100)} mmHg\n RR: 18 (16 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 3,783 mL\n 1,518 mL\n PO:\n TF:\n 1,339 mL\n 546 mL\n IVF:\n 1,309 mL\n 447 mL\n Blood products:\n Total out:\n 3,450 mL\n 1,865 mL\n Urine:\n 3,450 mL\n 1,865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 333 mL\n -347 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 340 (340 - 340) mL\n Vt (Spontaneous): 442 (389 - 442) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 14 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n SpO2: 91%\n ABG: 7.36/68/71/40/9\n Ve: 7.7 L/min\n PaO2 / FiO2: 142\n Physical Examination\n Gen:intubated, lightly sedated but awakens to voice and nods yes/no\n HEENT:PERRL, anicteric\n CV:RRR, no m/r/g\n PULM:CTA bilat\n ABD:soft, NTND\n EXTREM:\n SKIN:no rashes\n NEURO:sedated, able to answer questions\n Labs / Radiology\n 10.0 g/dL\n 537 K/uL\n 133 mg/dL\n 0.8 mg/dL\n 40 mEq/L\n 4.1 mEq/L\n 40 mg/dL\n 97 mEq/L\n 143 mEq/L\n 32.0 %\n 23.1 K/uL\n [image002.jpg]\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n 12:28 PM\n 05:35 PM\n 02:20 AM\n 05:40 PM\n 06:02 PM\n 03:16 AM\n WBC\n 28.5\n 26.2\n 23.1\n Hct\n 30.2\n 30.6\n 32.0\n Plt\n 446\n 535\n 537\n Cr\n 0.9\n 0.8\n 0.8\n 0.8\n 0.7\n 0.8\n TCO2\n 33\n 33\n 34\n 40\n Glucose\n 194\n 166\n 168\n 150\n 171\n 133\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation.\n 1. Resp failure- severe COPD exac due to pneumonia w/ ARDS, now\n improving slowly.\n -wean FiO2 to maintain PaO2 > 60; increase PEEP to 12 since O2 sat on\n low side\n -cont aggressive diuresis w/ goal -1-2L neg today; will check pm lytes.\n Continue lasix gtt (low rate) for slow continuous diuresis\n -vanco + cefepime + azithro --> plan for empiric 8d course pending cx\n data\n -CXR today shows continued failure with fluid in fissure on R. PNA\n substantially improved from film on .\n -prednisone 40mg daily pNGT. Will decrease to 30mg in 2 days\n -flovent\n -Stable on PSV. Will decrease PEEP later today if able to get 1-2L\n negative\n 2. Shock- resolved, likely multifactorial, sepsis vs meds\n -recent echo w/ nl EF\n 3. HyperNa, improved. Decrease free H2O boluses, continue diuresis\n 4. Constipation- resolving\n -cont aggressive regimen\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:39 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 AM\n Prophylaxis:\n DVT: sc heparin\n Stress ulcer: pepcid\n VAP: chlorhexidine, HOB 30 degrees\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 35 min\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727277,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Hypernatremia (high sodium)\n Assessment:\n Na 141. TF infusing at goal of 65cc/hr.\n Action:\n Free water flushes of 250cc now .\n Response:\n Morning sodium 142.\n Plan:\n Continue to monitor.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. On CPAP w/PS\n 12/+14 70%. RR 18 with sats 93%. LS clear with diminished bases.\n Hemodynamically stable. On lasix gtt at 10mg/hr.\n Action:\n No change in sedation. Pao2 82 and Fio2 weaned to 60%. Continue vanco,\n cefepime and azithromycin for PNA. Lasix gtt stopped for mild\n hypotension. MDI\ns and steroids as ordered.\n Response:\n Was -1.7L at midnight. Currently running ~200cc positive off lasix gtt.\n Remains with 2+ generalized edema. RR 15-21 with sats 91-94% and TV\n 300-400cc. Morning Pao2 was 84 and Fio2 was weaned to 50%. Suctioned\n for thick tan to yellow sputum.\n Plan:\n Wean vent as tolerated.\n Check ABG\ns. Goal sats 88-92% with Pao2 >60\n v Positive bowel sounds, abdomen soft and obese. Brown, loose\n stool via flexiseal.\n v On sedation patient will open eyes, follow commands and MAE.\n Denies pain. Restrained for safety of lines and tubes.\n v HR 60-70\ns SR with frequent ectopy. SBP 90-129. Hct stable\n @30.5.\n v Full code.\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726554,
"text": "67 y/o pt with long standing history of severe COPD & chronic asthma.\n Pt lives in an facility and had been c/o SOB x 1 wk.\n EMS found pt to have a 70% O2 sat on RA. Placed on NRB and given\n nebs. Also found to be tachypneic to the 40's with obvious increased\n WOB. CXR significant for large right sided PNA. Given Azithromycin,\n Ceftriaxone, nebs and steroids in ED. Admitted to MICU for further\n observation.\n Respiratory Failure\n Assessment:\n Received pt vented on PSV 70% 10/10. Versed @ 2mg/hr, Fentanyl @\n 125mcg/hr. Pt easily arousable & is able to respond to yes/no\n questions. Pt appearing uncomfortable @ change of shift, biting/nawing\n on EET and moving all extremeties. I/E wheezes noted in BUL, diminished\n @ bases. O2 sat 92-95%. Of note, pt does have confirmed GPC in pairs\n within sputum. Suctioning Q3-4hrs for thick, white/yellow sputum.\n Strong cough/gag noted.\n Action:\n Overnight pt did receive Lasix 20mg IV x 2 w/ great UOP (>1L) &\n >100cc/hr thereafter. Upon entering room during AM assessment, pt noted\n to have what appeared like tubefeed oozing from corner of mouth. Tube\n feeds immediately shut off. Pt desatting slowly to 85%. RT @ bedside.\n Pt was suctioned via ETT & orally multiple times for white also\n appeared like tube feed &/or thick sputum. LS as noted above. <10cc\n residual noted in OGT & ausculation of placement heard without\n difficulty. CXR obtained to evaulate lung fields & OGT. Please see\n Metavision for ABG results. Dr. also @ bedside. This RN & MD\n did remove OGT for troubleshooting purposes. Pt is receiving triple\n abx, stress dose steroids & inhalers via RT ATC. Current vent settings\n after episode AC 70% x 450 x 24 w/ 10 PEEP.\n Response:\n WBC improving. Originally 59 on arrival to MICU , currently 27.2.\n Lactate this AM 1.3. K+ elevated this AM @ 5.4. EKG obtained. Per Dr.\n , lytes/ABG sent redrawn @ 0630. ABG 7.37/49/66 (team\n tolerated PO2 >65)\n Plan:\n Trend ABG\ns & follow O2 sats (goal O2 sat >88%) Awaiting AM lyte\n results. ? CT chest to evaluate for malignant process on top of PNA\n given elevated WBC. Wean vent settings as tolerated. Trend\n labs/culture data. ? bronch for clean out and additional specimen if\n needed.\n R IJ TLC\n L Radial ALINE\n PIV x 1\n Pt does not have OGT/NGT access @ this time.\n Full Code\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 726555,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-03-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 726564,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Pt was placed back on Assist Control following desaturation.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726823,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 09:45 PM\n Azithromycin - 07:33 AM\n Infusions:\n Fentanyl - 125 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:10 AM\n Furosemide (Lasix) - 10:10 AM\n Heparin Sodium (Prophylaxis) - 07:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 77 (64 - 86) bpm\n BP: 138/69(91) {93/59(79) - 148/85(107)} mmHg\n RR: 17 (11 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 1 (1 - 5)mmHg\n Total In:\n 2,179 mL\n 1,031 mL\n PO:\n TF:\n 243 mL\n 38 mL\n IVF:\n 1,766 mL\n 703 mL\n Blood products:\n Total out:\n 4,965 mL\n 1,195 mL\n Urine:\n 4,965 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,786 mL\n -164 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 429 (323 - 510) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 25 cmH2O\n Compliance: 30 cmH2O/mL\n SpO2: 94%\n ABG: 7.36/56/76./31/3\n Ve: 7.5 L/min\n PaO2 / FiO2: 95\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 446 K/uL\n 9.7 g/dL\n 166 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 36 mg/dL\n 109 mEq/L\n 148 mEq/L\n 30.2 %\n 28.5 K/uL\n [image002.jpg]\n 03:58 AM\n 04:27 AM\n 04:58 AM\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n WBC\n 27.2\n 28.5\n Hct\n 30.5\n 30.2\n Plt\n 435\n 446\n Cr\n 1.1\n 0.9\n 0.9\n 0.8\n TCO2\n 31\n 28\n 29\n 31\n 33\n 33\n Glucose\n 140\n 149\n 194\n 166\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 04:31 AM\n 18 Gauge - 11:59 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": "2192-03-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726985,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation\n Events- sedation increased this am as attempting to push out ett with\n tongue this am.\n Switched to ards net vent.\n Bit through pilot of ett at 1700. reintubated with # 8 ett by\n anesthesia.\n Hypernatremia (high sodium)\n Assessment:\n Na this am 145.\n Action:\n Free water bolus 250ml q4h\n Response:\n Able to tolerate free h20 bolus. No residuals getting tube feeds @\n 45ml/hr\n Plan:\n Advance tube feed 10ml Q4h to reach goal 65ml/hr.\n Constipation (Obstipation, FOS)\n Assessment:\n Passing malodorous stool via flexiseal today. Stool guiac neg brown\n loose.\n Action:\n Cont on bowel regimen. Able to start tf again.\n Response:\n Tolerating tf. Cont to pass a lot of gas. Some stool.\n Plan:\n Cont bowel regimen.\n Respiratory failure, chronic\n Assessment:\n Sedated and vented lung fields diminished,\n Action:\n No vent changes overnight on ards net protocol due to infected right\n lung and emphysetic left lung. Cont on cefipime, vanco, and\n azithromycin. Cont on albuterol and atrovent mdi\ns. methylprednisolone\n weaned to 100mg iv q 12 hours today. Lasix 40mg given with goal 2.5 l\n neg for the day.\n Response:\n Sating low 90\n Plan:\n Will accept ph of down to 7.20 on ards net vent.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727383,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. On CPAP w/PS\n 12/+14 50%. RR 18-20 with sats 90-92%. LS clear with diminished bases.\n Hemodynamically stable.\n Action:\n No change in sedation. Continue vanco, cefepime and azithromycin for\n PNA. Lasix gtt restarted for goal -1L . MDI\ns and steroids as ordered.\n Vent settings changed to CMV 350x 16 PEEP 14 and FiO2 50% for ARDS.\n Response:\n O2 sat 88-92% this shift. PM lytes done and ABG:\n Plan:\n Wean vent as tolerated.\n Check ABG\ns. Goal sats 88-92% with Pao2 >60\n v Positive bowel sounds, abdomen soft and obese. Brown, loose\n stool via flexiseal.\n v On sedation patient will open eyes, follow commands and MAE.\n Denies pain. Restrained for safety of lines and tubes.\n v HR 60-70\ns SR with frequent ectopy. SBP 90-129. Hct stable\n @30.5.\n v Full code.\n"
},
{
"category": "Nutrition",
"chartdate": "2192-04-03 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 727521,
"text": "Objective\n Labs:\n Value\n Date\n Glucose\n 114 mg/dL\n 03:59 AM\n Glucose Finger Stick\n 145\n 12:00 AM\n BUN\n 48 mg/dL\n 03:59 AM\n Creatinine\n 0.9 mg/dL\n 03:59 AM\n Sodium\n 143 mEq/L\n 03:59 AM\n Potassium\n 4.2 mEq/L\n 03:59 AM\n Chloride\n 91 mEq/L\n 03:59 AM\n TCO2\n 46 mEq/L\n 03:59 AM\n PO2 (arterial)\n 76. mm Hg\n 04:03 AM\n PO2 (venous)\n 42 mm Hg\n 09:59 AM\n PCO2 (arterial)\n 68 mm Hg\n 04:03 AM\n PCO2 (venous)\n 65 mm Hg\n 04:39 AM\n pH (arterial)\n 7.43 units\n 04:03 AM\n pH (venous)\n 7.16 units\n 04:39 AM\n pH (urine)\n 6.0 units\n 07:39 PM\n CO2 (Calc) arterial\n 47 mEq/L\n 04:03 AM\n CO2 (Calc) venous\n 24 mEq/L\n 04:39 AM\n Albumin\n 3.0 g/dL\n 03:58 AM\n Calcium non-ionized\n 8.4 mg/dL\n 03:59 AM\n Phosphorus\n 4.0 mg/dL\n 03:59 AM\n Ionized Calcium\n 1.13 mmol/L\n 03:14 AM\n Magnesium\n 2.0 mg/dL\n 03:59 AM\n ALT\n 29 IU/L\n 03:58 AM\n Alkaline Phosphate\n 103 IU/L\n 03:58 AM\n AST\n 13 IU/L\n 03:58 AM\n Total Bilirubin\n 0.2 mg/dL\n 03:58 AM\n WBC\n 24.7 K/uL\n 03:59 AM\n Hgb\n 9.3 g/dL\n 03:59 AM\n Hematocrit\n 29.6 %\n 03:59 AM\n Current diet order / nutrition support: Replete with Fiber @ 65ml/hr\n Assessment of Nutritional Status\n Specifics:\n Verbal consult by MD for changing tube feed formula to further decrease\n free water. Lasix drip continues, changing IV meds to po. See full\n follow-up note .\n Medical Nutrition Therapy Plan - Recommend the Following\n Change tube feed to Nutren 2.0 @ 35ml/hr + 21g Beneprotein =\n 1755 calories and 85g protein\n o Monitor residuals, hydration, FSBG\n Will follow, page if questions *\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-03-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 726366,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n :\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": "2192-03-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 726825,
"text": "Chief Complaint:\n 24 Hour Events:\n - called sister after SW helped find # (pasted above) - voicemail, left\n message requesting that she call for update\n - no BM with PO narcan x 1, switched to lactulose, awaiting BM to\n restart TF\n - lasix 40 mg IV x 1 -->~1500cc UOP/3 hours, net ~2.5L negative for the\n day\n - started FW repletion IV, then via OG but increased residuals so had\n to stop\n - 1700 air leak ? tube came out vs hole-->extubated, reintubated, back\n on AC-->going back to PSV 12/10\n - having small BM after lactulose and PO narcan, both written for\n standing until more BM\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefipime - 09:45 PM\n Azithromycin - 07:33 AM\n Infusions:\n Fentanyl - 125 mcg/hour\n Midazolam (Versed) - 4 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:10 AM\n Furosemide (Lasix) - 10:10 AM\n Heparin Sodium (Prophylaxis) - 07:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 77 (64 - 86) bpm\n BP: 138/69(91) {93/59(79) - 148/85(107)} mmHg\n RR: 17 (11 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 1 (1 - 5)mmHg\n Total In:\n 2,179 mL\n 1,031 mL\n PO:\n TF:\n 243 mL\n 38 mL\n IVF:\n 1,766 mL\n 703 mL\n Blood products:\n Total out:\n 4,965 mL\n 1,195 mL\n Urine:\n 4,965 mL\n 1,195 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,786 mL\n -164 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 429 (323 - 510) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 18\n PEEP: 10 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 23 cmH2O\n Plateau: 25 cmH2O\n Compliance: 30 cmH2O/mL\n SpO2: 94%\n ABG: 7.36/56/76./31/3\n Ve: 7.5 L/min\n PaO2 / FiO2: 95\n Physical Examination\n GEN: intubated\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender\n EXTREMITIES: trace bilaterally pitting edema\n Labs / Radiology\n 446 K/uL\n 9.7 g/dL\n 166 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 4.6 mEq/L\n 36 mg/dL\n 109 mEq/L\n 148 mEq/L\n 30.2 %\n 28.5 K/uL\n [image002.jpg]\n 03:58 AM\n 04:27 AM\n 04:58 AM\n 06:22 AM\n 06:25 AM\n 11:19 AM\n 05:56 PM\n 06:32 PM\n 03:39 AM\n 04:03 AM\n WBC\n 27.2\n 28.5\n Hct\n 30.5\n 30.2\n Plt\n 435\n 446\n Cr\n 1.1\n 0.9\n 0.9\n 0.8\n TCO2\n 31\n 28\n 29\n 31\n 33\n 33\n Glucose\n 140\n 149\n 194\n 166\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:92.0 %, Band:5.0 %, Lymph:2.0 %,\n Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.0 g/dL,\n Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD on home O2 presents\n with pneumonia and COPD exacerbation requiring MICU admission.\n # Respiratory failure: Multilobar oneumonia & COPD. CXR unchanged,\n still with L-sided pleural effusion. GPCs in sputum from are\n most likely coag-neg Staph, with oral flora. Legionella (-)\n - f/u final sputum cx report\n - diurese more with furosemide 40 mg IV x 1 now; goal\n1 L net I/O\n - will try to wean down FiO2 and PEEP today if possible; prepare for\n extubation tomorrow\n - methylprednisolone to 125 mg q8h\n - continue nebs\n - ipratropium nebs q6h\n -continue vent; trial of PSV\n .\n # PNA: sputum cx unrevealing so far. GPC from sputum most likely\n coag-neg Stap. Legionella (-) in sputum, other cx negative.\n - continue vancomycin, cefepime, and azithromycin for 8-day course\n - might bronch tomorrow\n - consider chest CT\n #. Shock: Resolved. No longer needs pressor.\n - Abx as above\n # Kidney injury: improved with signficant fluid hydration, Cr now 0.9\n # Hx of hypertension: recently hypotensive on pressors. BP now\n normotensive.\n - hold all antihypertensives\n # Hypernatremia: free water deficit is about 4L.\n - 250 cc free water bolus q4h\n - pm lytes\n # FEN: IVF boluses / replete lytes prn / tube feeds\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ, L radial Art line, PIV x 1\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , patient does not know #, SW is working on reaching family\n - d/w SW if family has been contact\n # ICU CONSENT: signed, in chart\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n"
},
{
"category": "Nursing",
"chartdate": "2192-03-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 726913,
"text": "67 yo w/ prior smoker w/ severe COPD on home O2 admitted w/ resp\n failure due to pneumonia and COPD exacerbation\n Events- sedation increased this am as attempting to push out ett with\n tongue this am.\n Switched to ards net vent.\n Bit through pilot of ett at 1700. reintubated with # 8 ett by\n anesthesia. Awaiting xray confirmation.\n Hypernatremia (high sodium)\n Assessment:\n Na this am 148.\n Action:\n Giving 500cc d5w at 200cc/hr this afternoon and then will hopefully\n change to free h20 boluses via ogt if cont to tolerate his tf as she\n has been. Check na at 1800/.\n Response:\n Able to tolerate 1400 free h20 bolus. No residuals at 1600. labs drawn\n at 1730. needs re confirmation of ogt now that he has been reintubated.\n Plan:\n Check result of 1730 na. restart free h20 boluses via ogt once\n confirmation of tube confirmed\n Constipation (Obstipation, FOS)\n Assessment:\n Passing malodorous stool via flexiseal today. Stool guiac neg brown\n loose.\n Action:\n Cont on bowel regimen. Able to start tf again.\n Response:\n Tolerating tf. Tf stopped at 170 when patient required reintubation.\n Cont to pass a lot of gas. Some stool.\n Plan:\n Cont bowel regimen. Restart tf once ogt placement reconfirmed by xray.\n Respiratory failure, chronic\n Assessment:\n This am on 80% fio2 peep of 10 and ps of 12 with resp rate high teens\n to low 20\ns. tv mid 300 or greater. Abg 7.36/56/76/33. sats in the mid\n 90\n Action:\n Weaned to 70% fio2. changed to ards net protocol due to infected right\n lung and emphysetic left lung. Cont on cefipime, vanco, and\n azithromycin. Cont on albuterol and atrovent mdi\ns. methylprednisolone\n weaned to 100mg iv q 12 hours today. Lasix 40mg given with goal 2.5 l\n neg for the day.\n Response:\n Abg 7.37/56/71/34 on 70% fio2 tv 340/ a/c rate of 16 breathing 19 and\n 10 peep. Neg 400cc at 1600. Dr. made aware. Wants to see 1800\n lytes prior to redosing lasix. Bit through pilot of ett at 1700.\n anesthesia here. Received 20 mg of etomidate and 100mg of\n succinylcholine 100mg iv for reintubation.\n Plan:\n Will accept ph of down to 7.20 on ards net vent. Check results of lytes\n at 1800 to see if we want to give more lasix. Needs xray confirmation\n of ett. This was ordered.\n Social- Dr updated patient\ns sister in yesterday.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727268,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Hypernatremia (high sodium)\n Assessment:\n Na 141. TF infusing at goal of 65cc/hr.\n Action:\n Free water flushes of 250cc now .\n Response:\n Morning sodium 142.\n Plan:\n Continue to monitor.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. On CPAP w/PS\n 12/+14 70%. RR 18 with sats 93%. LS clear with diminished bases.\n Hemodynamically stable. On lasix gtt at 10mg/hr.\n Action:\n No change in sedation. Pao2 82 and Fio2 weaned to 60%. Continue vanco,\n cefepime and azithromycin for PNA. Lasix gtt stopped for mild\n hypotension.\n Response:\n Was -1.7L at midnight. Currently running ~200cc positive off lasix gtt.\n Remains with 2+ generalized edema. RR 15-21 with sats 91-94% and TV\n 300-400cc. Morning Pao2 was 84 and Fio2 was weaned to 50%. Suctioned\n for thick tan to yellow sputum.\n Plan:\n Wean vent as tolerated. Check ABG\ns. Goal sats 88-92% with Pao2 >60\n v Positive bowel sounds, abdomen soft and obese. Brown, loose\n stool via flexiseal.\n v On sedation patient will open eyes, follow commands and MAE.\n Denies pain. Restrained for safety of lines and tubes.\n v HR 60-70\ns SR with frequent ectopy. SBP 90-129. Hct stable\n @30.5..\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727269,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Hypernatremia (high sodium)\n Assessment:\n Na 141. TF infusing at goal of 65cc/hr.\n Action:\n Free water flushes of 250cc now .\n Response:\n Morning sodium 142.\n Plan:\n Continue to monitor.\n Respiratory failure, chronic\n Assessment:\n Pt remains intubated and sedated on fentanyl and versed. On CPAP w/PS\n 12/+14 70%. RR 18 with sats 93%. LS clear with diminished bases.\n Hemodynamically stable. On lasix gtt at 10mg/hr.\n Action:\n No change in sedation. Pao2 82 and Fio2 weaned to 60%. Continue vanco,\n cefepime and azithromycin for PNA. Lasix gtt stopped for mild\n hypotension.\n Response:\n Was -1.7L at midnight. Currently running ~200cc positive off lasix gtt.\n Remains with 2+ generalized edema. RR 15-21 with sats 91-94% and TV\n 300-400cc. Morning Pao2 was 84 and Fio2 was weaned to 50%. Suctioned\n for thick tan to yellow sputum.\n Plan:\n Wean vent as tolerated. Check ABG\ns. Goal sats 88-92% with Pao2 >60\n v Positive bowel sounds, abdomen soft and obese. Brown, loose\n stool via flexiseal.\n v On sedation patient will open eyes, follow commands and MAE.\n Denies pain. Restrained for safety of lines and tubes.\n v HR 60-70\ns SR with frequent ectopy. SBP 90-129. Hct stable\n @30.5.\n v Full code.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727880,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Rec\nd pt intubated. Vent settings CMV 50% 350/16/10 PEEP. Fentanyl @\n 200mcg/hr & Versed @ 5mg/hr. Pt is awake/alert & following simple\n commands. Pt often gestures to communicate needs but also responds well\n to yes/no questions. PERRL. O2 sat 92-98%. Lasix gtt decreased to\n 2mg/hr @ change of shift borderline BP via ABP. TF @ goal.\n Action:\n Multiple ABG\ns drawn in attempt to wean PEEP for trach placement.\n Please see Metavision for specifics. Goal UOP 1.5-2L neg @ MN. At ~\n 2100 pt was negative 1.5L. Lasix gtt ranging 2-4mg/hr based on BP &\n UOP. On diamox due to metabolic alkalosis from diuresis. MDI\n Steroids.\n Response:\n ETT rotated. Bite block removed during day shift successfully. Pt has\n remained calm throughout the night. Pt suctioned for minimal to no\n secretions. Aline removed @ 0415 flat waveform & inability to\n manipulate/reposition.\n Plan:\n Cont to diurese with Lasix gtt. Pt should have additional Aline placed\n for frequent ABG\ns & close BP monitoring while on Lasix gtt. MDI\n Wean vent as tolerated. Goal is to decrease PEEP to < 8 for trach\n placement.\n Lasix gtt paused @ 0550 soft BP\ns. Will resume in ~ 1 hr.\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 728111,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:41 PM\n - a-line re-inserted\n - PEEP down to 8\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Furosemide (Lasix) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.6\nC (97.8\n HR: 75 (66 - 80) bpm\n BP: 98/54(69) {91/47(61) - 123/67(87)} mmHg\n RR: 20 (18 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,909 mL\n 829 mL\n PO:\n TF:\n 2,069 mL\n 553 mL\n IVF:\n 530 mL\n 216 mL\n Blood products:\n Total out:\n 2,800 mL\n 1,280 mL\n Urine:\n 2,800 mL\n 1,280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 109 mL\n -451 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n Plateau: 19 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 91%\n ABG: 7.37/69/85./39/10\n Ve: 7.1 L/min\n PaO2 / FiO2: 170\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 425 K/uL\n 9.5 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 39 mEq/L\n 4.7 mEq/L\n 63 mg/dL\n 98 mEq/L\n 145 mEq/L\n 30.2 %\n 19.9 K/uL\n [image002.jpg]\n 11:01 PM\n 02:46 AM\n 03:07 AM\n 05:31 AM\n 03:41 PM\n 08:24 PM\n 03:24 AM\n 03:40 AM\n 05:03 AM\n 06:16 AM\n WBC\n 21.0\n 19.9\n Hct\n 31.0\n 30.2\n Plt\n 478\n 425\n Cr\n 0.9\n 1.0\n 0.8\n TCO2\n 46\n 47\n 48\n 44\n 43\n 42\n 41\n Glucose\n 115\n 136\n 112\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.6 mg/dL, Mg++:2.6 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:41 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 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": "2192-04-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 728112,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 02:41 PM\n - a-line re-inserted\n - PEEP down to 8\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:43 AM\n Cefipime - 10:01 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Furosemide (Lasix) - 6 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.6\nC (97.8\n HR: 75 (66 - 80) bpm\n BP: 98/54(69) {91/47(61) - 123/67(87)} mmHg\n RR: 20 (18 - 23) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 100.9 kg\n Height: 67 Inch\n Total In:\n 2,909 mL\n 829 mL\n PO:\n TF:\n 2,069 mL\n 553 mL\n IVF:\n 530 mL\n 216 mL\n Blood products:\n Total out:\n 2,800 mL\n 1,280 mL\n Urine:\n 2,800 mL\n 1,280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 109 mL\n -451 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n Plateau: 19 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 91%\n ABG: 7.37/69/85./39/10\n Ve: 7.1 L/min\n PaO2 / FiO2: 170\n Physical Examination\n GEN: intubated, sedated, but easily arousable and following commands\n HEENT:JVP not elevated\n CHEST: very poor air movement, expiratory wheezes diffusely\n CARDIAC: difficult to auscultate under breath sounds, distant, regular,\n no murmurs audible\n ABDOMEN: scar R of umbilicus well-healed, obese, soft, nontender;\n prominent bowel sounds\n EXTREMITIES: no edema, no sacral edema\n Labs / Radiology\n 425 K/uL\n 9.5 g/dL\n 112 mg/dL\n 0.8 mg/dL\n 39 mEq/L\n 4.7 mEq/L\n 63 mg/dL\n 98 mEq/L\n 145 mEq/L\n 30.2 %\n 19.9 K/uL\n [image002.jpg]\n 11:01 PM\n 02:46 AM\n 03:07 AM\n 05:31 AM\n 03:41 PM\n 08:24 PM\n 03:24 AM\n 03:40 AM\n 05:03 AM\n 06:16 AM\n WBC\n 21.0\n 19.9\n Hct\n 31.0\n 30.2\n Plt\n 478\n 425\n Cr\n 0.9\n 1.0\n 0.8\n TCO2\n 46\n 47\n 48\n 44\n 43\n 42\n 41\n Glucose\n 115\n 136\n 112\n Other labs: PT / PTT / INR:12.5/23.7/1.1, ALT / AST:29/13, Alk Phos / T\n Bili:103/0.2, Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %,\n Mono:3.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:9.6 mg/dL, Mg++:2.6 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n A 67 yo woman with a history of very severe COPD with PNA/,\n continues to be intubated/sedated.\n # Respiratory failure: Day 10 of intubation today for multilobar\n pneumonia & COPD c/b . Difficult to oxygenate without high\n PEEP/FIO2. I/O neg 1.3 L on furosemide gtt. Bedside u/s showed no\n tappable effusion. Attempt to diurese 1-2 liters again today and plan\n on weaning PEEP as tolerated.\n - continue lasix gtt, plan for goal I/O negative 1 liter-2liter\n - PM lytes\n - continue acetazolamide\n - continue prednisone to 30mg daily for 2 more days\n -attempt A line replacement\n - problem is , PNA has been treated fully, monitor temp and\n WBC\n .\n # Alkalosis: secondary to aggressive diuresis\n - continue acetazolamide as above\n .\n # Hx of hypertension: now normotensive.\n - hold all antihypertensives\n # FEN: IVF boluses / replete lytes prn / tube feeds (will concentrate\n to assist with tube feeds)\n # PPX: PPI per home regimen, heparin SQ, bowel regimen, VAP Care\n # ACCESS: RIJ\n # CODE: Full, discussed with patient\n # CONTACT: with patient. Emergency contact is sister, \n , number in chart\n # ICU CONSENT: signed, in chart\n # DISPOSITION: ICU\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:41 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM\n Arterial Line - 02:41 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": "2192-04-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727977,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Rec\nd pt intubated. Vent settings CMV 50% 350/16/12 PEEP. Fentanyl @\n 200mcg/hr & Versed @ 5mg/hr. Pt is awake/alert & following simple\n commands. Pt often gestures to communicate needs but also responds well\n to yes/no questions. PERRL. O2 sat 92-98%. Lasix gtt off low NBP\n readings. TF @ goal.\n Action:\n ABG drawn after peep was decreased to 10. Please see Metavision for\n specifics. Restarted lasix gtt around 1530 after A-line was placed.\n pt is maintaing good urine out put on her own we are still\n trying to get her peep to 8 for trach placement. On diamox due to\n metabolic alkalosis from diuresis. MDI\ns. Steroids.\n Response:\n Pt has remained calm throughout the day. Pt suctioned for minimal to no\n secretions. Aline placed around 1400. Pt was able to have her peep\n weaned to 10 today. Pt\ns cxray is improved and her edema has decreased.\n Plan:\n Cont to diurese with Lasix gtt. Wean vent as tolerated. Goal is to\n decrease PEEP to < 8 for trach placement.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728085,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Rec\nd pt intubated. Vent settings CMV 50% 350/18/10 PEEP. Fentanyl @\n 200mcg/hr & Versed @ 5mg/hr. Pt is awake/alert & following simple\n commands. Pt often gestures to communicate needs but also responds well\n to yes/no questions. PERRL. O2 sat 92-98%. Lasix gtt @ 2mg/hr (resumed\n in PM after Aline placement) Pt suctioned Q2-4 hrs for\n thick/yellow secretions. TF @ goal.\n Action:\n Multiple ABG\ns drawn in attempt to decrease vent settings for trach\n placement. Please see Metavision for specifics. Lasix gtt increased to\n 6mg O/N. SBP 100\ns. MAPs 70\ns. Remains on Diamox due to intial\n metabolic alkalosis from diuresis. MDI\ns. Steroids.\n Response:\n Pt has remained calm throughout the night. Occasional biting of ETT\n noted. CXR showing much improved edema. PEEP successfully\n decreased to 8 @ this time. ABG @ 0600: 7.37/69/85\n Plan:\n Cont to diurese with Lasix gtt. Wean vent as tolerated. Pt will need\n to maintain PEEP <10 for trach placement.\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 728392,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated\n Respiratory failure, chronic\n Assessment:\n Pt cont to do well on PSV of , with no c/o SOB\n Action:\n Sedation weaned down to Fentanyl 50mcg/hr and Versed 1mg/hr, Checked\n ABG and Sx only ever 6hrs. TF turned of at 4am in anticipation of\n ?extubation. Lasix drip cont at 3mg and she was 2l Neg at mn She cont\n on her inhalers\n Response:\n She has had no c/o SOB through the night, O2 sats 90-94% with min\n secretions and a good ABG for her.. She has not been increasingly\n agitated as sedation is weaned down . Attempt at SBT and PEEP at 0\n Brought on an O2 sat of 85% so she is back to PSV of . u/o\n 60-120cc/hr . No changes with VS as yet\n Plan:\n Will eval for extubation, cont inhalers\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-07 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 728399,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Furosemide (Lasix) - 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 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.7\nC (98\n HR: 79 (72 - 82) bpm\n BP: 129/67 {89/45 - 143/76} mmHg\n RR: 19 (17 - 28) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt current: 92.4 kg admit: 100.9 kg\n Height: 67 Inch\n Total In:\n 1,851 mL\n 267 mL\n PO:\n TF:\n 1,137 mL\n 140 mL\n IVF:\n 574 mL\n 127 mL\n Blood products:\n Total out:\n 3,840 mL\n 680 mL\n Urine:\n 3,840 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,989 mL\n -413 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 356 (320 - 424) mL\n PS : 8 cmH2O\n RR (Set): 20\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 97\n PIP: 14 cmH2O\n Plateau: 17 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 90%\n ABG: 7.39 / 63 / 73 / 38 / 9\n Ve: 8.8 L/min\n PaO2 / FiO2: 146\n Physical Examination\n Gen:\n HEENT:\n CV:\n Lungs:\n Ab:\n Ext:\n Neuro:\n Labs / Radiology\n 10.0 g/dL\n 435 K/uL\n 93 mg/dL\n 0.8 mg/dL\n 38 mEq/L\n 4.4 mEq/L\n 63 mg/dL\n 101 mEq/L\n 148 mEq/L\n 31.3 %\n 20.8 K/uL\n [image002.jpg]\n Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %, Mono:3.0 %, Eos:0.0\n %,\n 03:41 PM\n 08:24 PM\n 03:24 AM\n 03:40 AM\n 05:03 AM\n 06:16 AM\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n WBC\n 19.9\n 20.8\n Hct\n 30.2\n 31.3\n Plt\n 425\n 435\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n TCO2\n 44\n 43\n 42\n 41\n 42\n 40\n Glucose\n 136\n 112\n 143\n 93\n Other labs:\n PT / PTT / INR:10.8/28.4/0.9,\n ALT / AST:29/13, Alk Phos / T Bili:103/0.2,\n Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.0 mg/dL, Mg++:2.7 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n CONSTIPATION (OBSTIPATION, FOS)\n RESPIRATORY FAILURE, CHRONIC\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM and Arterial Line - 02:41\n PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2192-04-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 727673,
"text": "Demographics\n Day of mechanical ventilation: 10\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n 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: Utilize ARDSnet protocol, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Tolerating slow peep wean with sats >94%.\n"
},
{
"category": "Physician ",
"chartdate": "2192-04-07 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 728420,
"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 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with ARDS / respiratory failure who was admitted on .\n 24 Hour Events:\n Lasix gtt shut off briefly yesterday for hypotension. Now lasix gtt\n back on.\n PEEP titrated down to 5.\n Tube feeds off.\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Heparin 5K TID\n Colace \n Atrovent 6 puffs q6\n Protonix 40mg IV q24h\n Peridex \n RSSI\n Prednisone 30mg q24h\n Fluticasone 220mcg 4 puffs \n Free H2O 250mg \n Narcan 1mg PO q6h\n Changes to medical 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: 37\nC (98.6\n Tcurrent: 36.7\nC (98\n HR: 79 (72 - 82) bpm\n BP: 129/67 {89/45 - 143/76} mmHg\n RR: 19 (17 - 28) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt current: 92.4 kg admit: 100.9 kg\n Height: 67 Inch\n Total In:\n 1,851 mL\n 267 mL\n PO:\n TF:\n 1,137 mL\n 140 mL\n IVF:\n 574 mL\n 127 mL\n Blood products:\n Total out:\n 3,840 mL\n 680 mL\n Urine:\n 3,840 mL\n 680 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,989 mL\n -413 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 356 (320 - 424) mL\n PS : 8 cmH2O\n RR (Set): 20\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 97\n PIP: 14 cmH2O\n Plateau: 17 cmH2O\n Compliance: 38.9 cmH2O/mL\n SpO2: 90%\n ABG: 7.39 / 63 / 73 / 38 / 9 on 50%\n Ve: 8.8 L/min\n PaO2 / FiO2: 146\n Physical Examination\n Gen: Looks comfortable on vent, answering yes / no questions\n appropriately.\n HEENT: ETT in place.\n CV: S1S2 RRR w/o m/r/g\ns appreciated.\n Lungs: CTA anteriorly without significant crackles / wheezing.\n Ab: Positive BS\ns. Obese. NT/ND.\n Ext: No significant edema.\n Neuro: Alert, appropriate\n Labs / Radiology\n 10.0 g/dL\n 435 K/uL\n 93 mg/dL\n 0.8 mg/dL\n 38 mEq/L\n 4.4 mEq/L\n 63 mg/dL\n 101 mEq/L\n 148 mEq/L\n 31.3 %\n 20.8 K/uL\n [image002.jpg]\n Differential-Neuts:90.0 %, Band:0.0 %, Lymph:5.0 %, Mono:3.0 %, Eos:0.0\n %\n No chest x-ray this AM.\n 03:41 PM\n 08:24 PM\n 03:24 AM\n 03:40 AM\n 05:03 AM\n 06:16 AM\n 06:02 PM\n 06:17 PM\n 09:10 PM\n 05:51 AM\n WBC\n 19.9\n 20.8\n Hct\n 30.2\n 31.3\n Plt\n 425\n 435\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n TCO2\n 44\n 43\n 42\n 41\n 42\n 40\n Glucose\n 136\n 112\n 143\n 93\n Other labs:\n PT / PTT / INR:10.8/28.4/0.9,\n ALT / AST:29/13, Alk Phos / T Bili:103/0.2,\n Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL,\n Ca++:10.0 mg/dL, Mg++:2.7 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 67yo woman with severe COPD (FEV1 23%), constipation, and other issues\n here with right-sided pneumonia and ARDS / respiratory failure who was\n admitted on .\n HYPERNATREMIA (HIGH SODIUM)\n Continue free water boluses for now.\n CONSTIPATION (OBSTIPATION, FOS)\n D/c Narcan PO.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n Will try SBT with 0/0 trial today. If she passes the SBT with normal\n hemodynamics, RSBI < 105, and an acceptable ABG she could be\n extubatable. Continue Lasix gtt / consider bolus immediately prior to\n extubation.\n Plan to titrate Prednisone to 20mg q24h tomorrow. Continue inhalers.\n If she fails extubation, she would be a candidate for trach.\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:24 AM and Arterial Line - 02:41\n PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2192-04-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 727889,
"text": "67 yo woman with a history of very severe COPD with PNA/ARDS, continues\n to be intubated/sedated.\n Respiratory failure, chronic\n Assessment:\n Rec\nd pt intubated. Vent settings CMV 50% 350/16/10 PEEP. Fentanyl @\n 200mcg/hr & Versed @ 5mg/hr. Pt is awake/alert & following simple\n commands. Pt often gestures to communicate needs but also responds well\n to yes/no questions. PERRL. O2 sat 92-98%. Lasix gtt decreased to\n 2mg/hr @ change of shift borderline BP via ABP. TF @ goal.\n Action:\n Multiple ABG\ns drawn in attempt to wean PEEP for trach placement.\n Please see Metavision for specifics. Goal UOP 1.5-2L neg @ MN. At ~\n 2100 pt was negative 1.5L. Lasix gtt ranging 2-4mg/hr based on BP &\n UOP. On diamox due to metabolic alkalosis from diuresis. MDI\n Steroids.\n Response:\n ETT rotated. Bite block removed during day shift successfully. Pt has\n remained calm throughout the night. Pt suctioned for minimal to no\n secretions. Aline removed @ 0415 flat waveform & inability to\n manipulate/reposition.\n Plan:\n Cont to diurese with Lasix gtt. Pt should have additional Aline placed\n for frequent ABG\ns & close BP monitoring while on Lasix gtt. MDI\n Wean vent as tolerated. Goal is to decrease PEEP to < 8 for trach\n placement.\n Lasix gtt paused @ 0550 soft BP\n Full Code\n No contact w/ family O/N by this RN\n"
},
{
"category": "Radiology",
"chartdate": "2192-03-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124387,
"text": " 6:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval (a) ET tube placement and (b) OG tube placement\n Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with pneumonia, now re-intubated, also new OG tube\n REASON FOR THIS EXAMINATION:\n please eval (a) ET tube placement and (b) OG tube placement\n ______________________________________________________________________________\n WET READ: FRI 10:56 PM\n ETT 3 cm from carina. OGT extends into stomach. Bilateral pulmonary opacities\n unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: ET and OG tube placement with pneumonia.\n\n FINDINGS:\n\n Comparison is made to the prior study of the same day from 04:05 hours.\n\n A right IJ catheter terminates at the superior vena cava. Endotracheal tube\n terminates approximately 2.6 cm above the carina in appropriate position. The\n orogastric tube courses below the diaphragm but the tip is not seen.\n\n The heart is markedly enlarged. There is congestive failure, mild in degree\n with consolidation of the right lower lobe as well as bilateral pleural\n effusions, relatively unchanged from the prior study, with bibasilar\n consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-03-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124100,
"text": " 10:37 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval OG tube\n Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with new OG tube placement\n REASON FOR THIS EXAMINATION:\n eval OG tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: OG tube placement.\n\n FINDINGS: The tip of the OG tube extends at least to the upper stomach, where\n it crosses the edge of the image. No gross change from the prior study on\n this limited study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-04-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124812,
"text": " 4:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with pneumonia and COPD\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia and COPD.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Persistent enlargement of the cardiac silhouette.\n Opacification at the right base is consistent with atelectasis, effusion, or\n supervening pneumonia. The area of consolidation above the minor fissure is\n no longer seen, most likely reflecting prior aspiration.\n\n Increased opacification at the left base is again consistent with atelectasis\n and effusion, though the possibility of supervening pneumonia cannot be\n excluded in the appropriate clinical setting.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-03-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124199,
"text": " 5:27 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate ET tube placement\n Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with newly replaced ET tube.\n REASON FOR THIS EXAMINATION:\n evaluate ET tube placement\n ______________________________________________________________________________\n WET READ: 6:27 PM\n ETT 3.1 cm from carina. NGT sideport at or slightly above GE junction but\n terminates in the stomach. No change in extensive right-sided opacification.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:54 P.M., \n\n HISTORY: Check new endotracheal tube.\n\n IMPRESSION: AP chest compared to studies earlier in the day. ET tube is in\n standard placement, right internal jugular line ends just proximal to the\n junction with the left brachiocephalic vein where the left internal jugular\n line ends. Nasogastric tube passes into the stomach and out of view.\n Moderate right pleural effusion and some basal consolidation persist but\n previous severe right lung consolidation has improved dramatically leading me\n to wonder if it was really pneumonia. Consolidation in the left lower lobe\n which developed between after has improved and could be atelectasis.\n Left upper lung is clear. Heart mildly enlarged. Left pleural effusion\n minimal. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-04-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124967,
"text": " 3:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for change\n Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with pneumonia, intubated\n REASON FOR THIS EXAMINATION:\n evaluate for change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia with intubation.\n\n FINDINGS: In comparison with the study of , there is little change in the\n appearance of the monitoring and support devices. There is persistent\n enlargement of the cardiac silhouette. Opacification at the right base\n persists, consistent with some combination of atelectasis, effusion, or\n supervening pneumonia. Increased opacification at the left base is again\n seen, most likely representing atelectasis and effusion.\n\n IMPRESSION:\n Little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-03-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1123640,
"text": " 3:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o c/p process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with sob\n REASON FOR THIS EXAMINATION:\n r/o c/p process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP.\n\n COMPARISON: .\n\n HISTORY: Shortness of breath.\n\n FINDINGS: There is increased opacity at the right lung base and right mid\n lung consistent with pneumonia. In addition, opacity in the right mid lung,\n which is bounded by the major fissure likely represents combination of fluid\n within the fissure as well as consolidation. Underlying mass lesion cannot be\n excluded. There is mild cardiomegaly. There is no evidence of pneumothorax.\n The mediastinal and hilar contours are within normal limits.\n\n IMPRESSION: Right mid and lower lung opacities consistent with multifocal\n pneumonia with small pleural effusion. Repeat radiograph is recommended after\n treatment to document resolution.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-04-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1125502,
"text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with PNA/ARDS\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 03:56\n\n INDICATION: Pneumonia; check for change.\n\n FINDINGS:\n\n Since the prior study the NGT and ETT have been removed. The right central\n venous catheter remains in place in the superior aspect of the SVC. There is\n less fluid in the minor fissure as well as in the right pleural space.\n Improved aeration is noted with no new focal consolidations. Pulmonary\n vascular markings are not substantially distended. Cardiac silhouette is\n mildly enlarged.\n\n IMPRESSION: Improving chest x-ray with diminished effusions and better lung\n aeration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-04-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1125112,
"text": " 3:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval progression\n Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with intubation\n REASON FOR THIS EXAMINATION:\n interval progression\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Intubated patient.\n\n Comparison is made with prior study performed the day before\n\n Lines and tubes remain in place in standard position. There is no\n pneumothorax. Cardiac size cannot be evaluated. Bilateral pleural effusions,\n right greater than left are unchanged. On the right the pleural fluid is\n tracking through the fissure. Bilateral basal right greater than left\n opacities are most likely a combination of pleural effusion and atelectasis\n but pneumonia cannot be totally excluded. Right upper lobe opacity is likely\n atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-04-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124583,
"text": " 2:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: EVAL FOR NEW HYPOXEMIA\n Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with pna, intubated, now worsening O2\n REASON FOR THIS EXAMINATION:\n EVAL FOR NEW HYPOXEMIA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Pneumonia, hypoxemia.\n\n FINDINGS:\n\n Comparison is made to the prior study from . Endotracheal tube\n terminates at the thoracic inlet. Nasogastric tube courses below the\n diaphragm, but the tip is not seen. Right IJ catheter terminates in the\n superior vena cava. There is focal airspace opacity in the right upper lobe,\n right lower lobe, right middle, and left lower lobe. Bilateral pleural\n effusions persist. Cardiomegaly remains. Very little change since the prior\n study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-03-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124044,
"text": " 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? torn og tube, aspiration, intrapulmonary process\n Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with intubation/og tube, worsening sats\n REASON FOR THIS EXAMINATION:\n ? torn og tube, aspiration, intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation with worsening saturation.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Extensive opacification persists on the right,\n primarily involving the mid and lower lung zones. Retrocardiac opacification\n with extension into the costophrenic border is consistent with atelectasis and\n left pleural effusion. The possibility of supervening pneumonia can certainly\n not be excluded.\n\n The enlargement of the cardiac silhouette is less prominent, possibly\n reflecting the upright position. There may be minimal fullness of the\n pulmonary vessels.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-03-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124229,
"text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval progression\n Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with respiraotry failure\n REASON FOR THIS EXAMINATION:\n interval progression\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory failure.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 4.5 cm above the carina. The right internal jugular line\n tip is at the level of superior SVC. The NG tube tip passes below the\n diaphragm most likely terminating in the stomach. There is no significant\n interval change in the right lung extensive consolidation as well as in the\n left basal consolidation accompanied by pleural effusion. There is no\n evidence of failure.\n\n The left internal jugular line tip is at the junction of left brachiocephalic\n vein and SVC. No pneumothorax is demonstrated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-03-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1123874,
"text": " 3:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval interval changes\n Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with pneumonia, intubated\n REASON FOR THIS EXAMINATION:\n please eval interval changes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 03:06 A.M., \n\n HISTORY: Pneumonia, intubated.\n\n IMPRESSION: AP chest compared to and :\n\n Small-to-moderate left pleural effusion has been increasing, there is\n suggestion of new consolidation in the left lung base. On the right, large\n area of consolidation is still present, slightly improved in the upper lobe\n but not in the lower lung. There is also likely moderate right pleural\n effusion. Severe enlargement of the cardiac silhouette is unchanged, and\n mediastinal vascular engorgement suggests a component of cardiac\n decompensation. ET tube is in standard placement and nasogastric tube passes\n into the stomach and out of view. Right jugular line ends above the junction\n with the right subclavian vein. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-03-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1123705,
"text": " 4:16 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with COPD\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, , 4:25 A.M.\n\n HISTORY: New right IJ line.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the new right IJ line projects over the origin of the right\n brachiocephalic vein, above its junction with the left. Left internal jugular\n line tip projects over the upper SVC. No new mediastinal widening, no\n pneumothorax. The volume of right pleural effusion is difficult to assess\n because lateral aspect of the right lower chest is excluded from the\n examination, but there is greater opacification of the right lower lung which\n indicates either worsening pneumonia there or the development of pleural\n effusion. The vascular congestion seen earlier has improved, heart size has\n decreased and so has caliber of mediastinal and pulmonary veins. Residual\n edema or atelectasis present at the left lung base. No pneumothorax.\n\n ET and OG tubes in standard placements.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-03-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1123686,
"text": " 11:17 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ET tube placement\n Admitting Diagnosis: PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with new intubation\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:34 P.M. ON \n\n HISTORY: New intubation.\n\n IMPRESSION: AP chest compared to at 3:42 p.m.:\n\n Severe consolidation in the right upper and lower lung zones may have worsened\n slightly, but major change is increased pulmonary and mediastinal vascular\n caliber suggesting a component of volume overload. Moderately enlarged heart\n is stable. Left lung base may be developing mild edema and small bilateral\n pleural effusions are presumed. ET tube in standard placement, left jugular\n line tip projects over the upper SVC and a nasogastric tube ends in the\n stomach. No pneumothorax.\n\n\n"
}
] |
23,357 | 122,444 | She was started on Unasyn for presumed intra-abdominal infection. Over the next 24 hours, the patient became progressively septic, hypotensive despite the addition of three pressors. An emergent family meeting was held 24 hours after admission and the decision was made to make the patient comfort measures. The pressors were discontinued. The patient's blood pressure fell and she became asystolic at around 8:35 on the morning of . The ventilator was temporarily turned off. There were no spontaneous respirations and no spontaneous heart sounds. The patient was pronounced dead at 8:35 in the morning of . | Hespan given x1 - am PT 29.2/INR 5.6, Lactate 12.9. PT IS & SEDATED, WITH HIGH PIP & PLATEAU. was then with 0.05mg/kg bolus and maintained @ 0.10mg/kg of cisatracurium.CV: Febrile to 102.6po, HR 43-114SB/ST, ABP 68-103/36-58, Pt. U/S done has + portal vein thrombosis. There is occlusion of the portal vein and right and left branches, as described abovve. FEBRILE TO 102.6. continues with low grade temps - 100.1po, pan cultured, unasyn started. OGT to LIS, with bilious drainage noted. MICU- NPNNEURO: Pt. K+ up to 7.1 - k-exalate PR given. Suctioned for lg. BUN 58, Creat 2.6.ACCESS: Pt. Clot sent to BB. Fluid bolus given x2.Remains intubated with multiple vent changes, see carevue for data. LS coarse t/o, diminished @ right base. started on Dopamine, Levophed, Neosynephrine, and Pitressin - see carevue for data. Sinus tachycardia.Right axis deviationLateral infarct - age undeterminedPossible inferior infarct - age undeterminedLimb leads are reversed Sodium Bicarb 150mEq/L x 8hrs infusing.RESP: Multiple vent changes made over noc, current settings AC/.60/700x28/10PEEP - am ABG 7.01/29/108/8/-23. 2) Slight widening of the right upper mediastinum. amt. Pt. Pt. Pt. Pt. Pt. Pt. LS coarse t/o, suctioned for small amt. Mod. CONCLUSION: 1. MD WAS MADE AWARE AND PT WAS PRONOUNCED. transferred from OSH intubated and sedated. Due for US this am. Access: Right aline, 3 PIV's. IMPRESSION: 1) Atelectasis within the anterior segment of the right upper lobe. PT/PTT and LFT's remain elevated, INR-2.3. MRI. Continues to be NPO. oral secretions.GI: abdomen very distended, pt. to unstable to transport to MRI for abd. given 2mg Versed upon arrival and placed on Fentanyl and Versed gtt. Foley intact, poor UOP since arrival, ictertic urine, spec sent. I&O's 4L's+. There is prominence of the right upper mediastinum. RESP CARE NOTESPT REMAINS INTUBATED, MECH VENTED VIA . initially had Right radial aline which was very dampened and difficult to draw labs from, central access obtained for pressors - right femoral TLC placed and Left femoral aline placed. PM CARE GIVEN. The hepatic arteries and veins are patent. MD AWARE. FINDINGS: There is an endotracheal tube in satisfactory position at the thoracic inlet. There is atelectasis present within the anterior portion of the right upper lobe. CURRENT SETTINGS ARE A/C 700 X 28, 10 PEEP, 60% FIO2, ABG ON THESE SETTINGS REVEALED 6.95/29/120/7/-26, SEVERE PARTIALLY COMPENSATED METABOLIC ACIDOSIS. Color Doppler evaluation demonstrates thrombosis of the portal vein and the proximal right and left branches. No spon movements noted, not responsive, PERL sluggishly.ID: Temp 101.5 PO max, WBC- 19.5 max, Unasyn dose increased to to 3gm and was started on IV Flagyl. nsg death notePT WAS MADE COMFORT CARE THIS AM, PRESSORS WERE D/C'D, CONTINUED ON PAIN MEDS. Abdomen very distended, +BS, no stool out, rectal tube from OSH inplace. Initially OGT to LWIS with bilious output, now clamped for meds.GU: Foley catheter intact, minimal uop over noc - total 20cc of ictertic urine. Hepatomegaly with diffusely heterogeneous liver echo texture. K+6.8 - po k-exalate given via OGT with no response. Urine remains very dark.C/V: BP 100-116/60, HR 100-118 ST no ectopy, this afternoon BP to 90-93/60, rec'ing the 1L NSB @ present. 2. There is an NG tube in position with its distal tip located within the lower stomach. The gallbladder is contracted. Monitor temps, administer IV antibx's. CPK's being cycled q8hr 1st set 270.Neuro: pt on Fentanyl Gtt @ 50mcq/hr and Versed @ .5mg/hr, Versed was stopped and Fentanyl gtt remains @ 50mcq/hr, was up to 75mcq for a breif time. received sedated on Fentanyl @ 50mcg/hr. O2 sats 92-97%. NO stool output over noc even after k-exalate PO/PR. HR 110-120 ST, no ectopy noted. REASON FOR THIS EXAMINATION: r/o cholecystitis, gallstone, extrahepatic dilitation, pancreatic mass FINAL REPORT INDICATION: Patient with hepatomegaly and acute pancreatitis and hepatic failure. A upright chest radiograph is advised to better assess this finding. NPN 7AM-7PM MICU-BS/O: RESPIR: remains intubated on A/C 40%/600/24 Peep-5, AM ABG-7.32/35/96/-, rate decreased to 16 with repeat ABG- 7.27/37/87, spon RR 0-2, vent rate increased to 18 but remains acidotic with last ABG- 7.24/38/89, rate just increased to 20, will repeat ABG in 30min. Evaluate for infiltrates. The heart size is within normal limits. The hepatic arteries and veins are dilated and widely patent. seems adequately sedated, no response to stimuli but remains tachycardic - ? PLAN TO CONTINUE CURRENT SUPPORT. MULT VENT CHANGES MADE THIS SHIFT, SEE RESP FLOWSHEET FOR DETAILS. L/S course bilat, suctioning q3 for mod amts thick yellow sputum, spec sent for C&S.GI: extremely distended with +BS, was having coffee grounds per OGT this AM OB+, but has cleared but has remains OB+. No stool noted.GU: U/O remains poor 30-40cc/hr BUN/CRE 52/1.4, NS IVF @250cc/hr, rec'd NS 1L IVB over 1hr. pain. No Heparin ordered. Check results of cultures and MRI. amt's of thick, white sputum. continued to over-breathe vent and Fentanyl increased to 100mcg/hr and midazolam gtt restarted @ 1mg/hr. FOUND TO HAVE NO HR AND BP @ 0825, FAMILY WAS @ PT'S BEDSIDE. yellow secretions. Family is choosing to withdraw care at this time. The soft tissues and osseous structures are unremarkable. ULTRASOUND FINDINGS: The liver is diffusely heterogeneous in echotexture and enlarged. The splenic vein is not visualized secondary to gaseous distension of the abdomen. FAMILY DECISION TO HAVE A POST DONE. 9:16 AM DUPLEX DOPP ABD/PEL Clip # Reason: HEPATIC FAILURE , GALLSTONE, ESTRAHEPATIC DILITATION, R/O CHOLDECSTITIC MEDICAL CONDITION: 58 year old woman with hepatomegaly, acute pancreatitis and hepatic failure. | 8 | [
{
"category": "Radiology",
"chartdate": "2109-05-13 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 791579,
"text": " 9:16 AM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: HEPATIC FAILURE , GALLSTONE, ESTRAHEPATIC DILITATION, R/O CHOLDECSTITIC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with hepatomegaly, acute pancreatitis and hepatic failure.\n REASON FOR THIS EXAMINATION:\n r/o cholecystitis, gallstone, extrahepatic dilitation, pancreatic mass\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with hepatomegaly and acute pancreatitis and hepatic\n failure.\n\n ULTRASOUND FINDINGS: The liver is diffusely heterogeneous in echotexture and\n enlarged. There are multiple hypo and hyperechoic regions throughout the liver\n and the possibility of underlying liver lesions cannot be excluded on this\n study. There is no intrahepatic or extrahepatic ductal dilatation. The\n gallbladder is contracted. No gallstones are identified. Color Doppler\n evaluation demonstrates thrombosis of the portal vein and the proximal right\n and left branches. The hepatic arteries and veins are dilated and widely\n patent. The splenic vein is not visualized secondary to gaseous distension of\n the abdomen.\n\n CONCLUSION:\n\n 1. There is occlusion of the portal vein and right and left branches, as\n described abovve. The hepatic arteries and veins are patent.\n\n 2. Hepatomegaly with diffusely heterogeneous liver echo texture. The\n heterogeneity of the liver suggests that there may be some underlying nodules,\n and therefore, further imaging with MR can be performed to exclude the\n possibility of underlying liver masses.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-05-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 791558,
"text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with hypercapnic respiratory failure\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58 y/o female with hypercapnic respiratory failure. Evaluate for\n infiltrates.\n\n FINDINGS: There is an endotracheal tube in satisfactory position at the\n thoracic inlet. There is an NG tube in position with its distal tip located\n within the lower stomach. There is atelectasis present within the anterior\n portion of the right upper lobe. There is prominence of the right upper\n mediastinum. The heart size is within normal limits. There is no\n pneumothorax or pleural effusion. The soft tissues and osseous structures are\n unremarkable.\n\n IMPRESSION:\n\n 1) Atelectasis within the anterior segment of the right upper lobe.\n 2) Slight widening of the right upper mediastinum. A upright chest\n radiograph is advised to better assess this finding.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-05-13 00:00:00.000",
"description": "Report",
"row_id": 1567523,
"text": "NPN 7AM-7PM MICU-B\nS/O: RESPIR: remains intubated on A/C 40%/600/24 Peep-5, AM ABG-7.32/35/96/-, rate decreased to 16 with repeat ABG- 7.27/37/87, spon RR 0-2, vent rate increased to 18 but remains acidotic with last ABG- 7.24/38/89, rate just increased to 20, will repeat ABG in 30min. O2 sats 92-97%. L/S course bilat, suctioning q3 for mod amts thick yellow sputum, spec sent for C&S.\n\nGI: extremely distended with +BS, was having coffee grounds per OGT this AM OB+, but has cleared but has remains OB+. OGT to LIS, with bilious drainage noted. U/S done has + portal vein thrombosis. PT/PTT and LFT's remain elevated, INR-2.3. No Heparin ordered. GI consulting, to have MRI, this evening. Continues to be NPO. No stool noted.\n\nGU: U/O remains poor 30-40cc/hr BUN/CRE 52/1.4, NS IVF @250cc/hr, rec'd NS 1L IVB over 1hr. Urine remains very dark.\n\nC/V: BP 100-116/60, HR 100-118 ST no ectopy, this afternoon BP to 90-93/60, rec'ing the 1L NSB @ present. I&O's 4L's+. But may need to start pressors soon if MAP's>60. CPK's being cycled q8hr 1st set 270.\n\nNeuro: pt on Fentanyl Gtt @ 50mcq/hr and Versed @ .5mg/hr, Versed was stopped and Fentanyl gtt remains @ 50mcq/hr, was up to 75mcq for a breif time. No spon movements noted, not responsive, PERL sluggishly.\n\nID: Temp 101.5 PO max, WBC- 19.5 max, Unasyn dose increased to to 3gm and was started on IV Flagyl. BC's PND, sputum spec sent.\n\nSocial: Family in visiting this afternoon, pt's sister is Proxy and spokesperson.\n\nA/P: Monitor BP and I&O's, continue IVB's and start pressors if needed. Monitor temps, administer IV antibx's. Check results of cultures and MRI.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-05-14 00:00:00.000",
"description": "Report",
"row_id": 1567524,
"text": "RESP CARE NOTES\nPT REMAINS INTUBATED, MECH VENTED VIA . MULT VENT CHANGES MADE THIS SHIFT, SEE RESP FLOWSHEET FOR DETAILS. CURRENT SETTINGS ARE A/C 700 X 28, 10 PEEP, 60% FIO2, ABG ON THESE SETTINGS REVEALED 6.95/29/120/7/-26, SEVERE PARTIALLY COMPENSATED METABOLIC ACIDOSIS. PT IS & SEDATED, WITH HIGH PIP & PLATEAU. MD AWARE. FEBRILE TO 102.6. RSBI NOT DONE DUE TO PARALYICS, ACIDOSIS. PLAN TO CONTINUE CURRENT SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-05-13 00:00:00.000",
"description": "Report",
"row_id": 1567522,
"text": "\nPt. transferred from OSH intubated and sedated. Pt. given 2mg Versed upon arrival and placed on Fentanyl and Versed gtt. Pt. seems adequately sedated, no response to stimuli but remains tachycardic - ? pain. Pt. continues with low grade temps - 100.1po, pan cultured, unasyn started. HR 110-120 ST, no ectopy noted. Clot sent to BB. Fluid bolus given x2.Remains intubated with multiple vent changes, see carevue for data. LS coarse t/o, diminished @ right base. Suctioned for lg. amt's of thick, white sputum. Abdomen very distended, +BS, no stool out, rectal tube from OSH inplace. Due for US this am. Foley intact, poor UOP since arrival, ictertic urine, spec sent. Access: Right aline, 3 PIV's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-05-14 00:00:00.000",
"description": "Report",
"row_id": 1567525,
"text": "MICU- NPN\n\nNEURO: Pt. received sedated on Fentanyl @ 50mcg/hr. Pt. continued to over-breathe vent and Fentanyl increased to 100mcg/hr and midazolam gtt restarted @ 1mg/hr. Pt. was then with 0.05mg/kg bolus and maintained @ 0.10mg/kg of cisatracurium.\nCV: Febrile to 102.6po, HR 43-114SB/ST, ABP 68-103/36-58, Pt. started on Dopamine, Levophed, Neosynephrine, and Pitressin - see carevue for data. K+6.8 - po k-exalate given via OGT with no response. K+ up to 7.1 - k-exalate PR given. Hespan given x1 - am PT 29.2/INR 5.6, Lactate 12.9. Sodium Bicarb 150mEq/L x 8hrs infusing.\nRESP: Multiple vent changes made over noc, current settings AC/.60/700x28/10PEEP - am ABG 7.01/29/108/8/-23. LS coarse t/o, suctioned for small amt. yellow secretions. Mod. amt. oral secretions.\nGI: abdomen very distended, pt. to unstable to transport to MRI for abd. MRI. NO stool output over noc even after k-exalate PO/PR. Initially OGT to LWIS with bilious output, now clamped for meds.\nGU: Foley catheter intact, minimal uop over noc - total 20cc of ictertic urine. BUN 58, Creat 2.6.\nACCESS: Pt. initially had Right radial aline which was very dampened and difficult to draw labs from, central access obtained for pressors - right femoral TLC placed and Left femoral aline placed. 3 PIV's intact.\nSOC: Family meeting this am, spoke with attending. Family is choosing to withdraw care at this time. Priest in with family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-05-14 00:00:00.000",
"description": "Report",
"row_id": 1567526,
"text": "nsg death note\nPT WAS MADE COMFORT CARE THIS AM, PRESSORS WERE D/C'D, CONTINUED ON PAIN MEDS. FOUND TO HAVE NO HR AND BP @ 0825, FAMILY WAS @ PT'S BEDSIDE. MD WAS MADE AWARE AND PT WAS PRONOUNCED. FAMILY DECISION TO HAVE A POST DONE. PM CARE GIVEN.\n"
},
{
"category": "ECG",
"chartdate": "2109-05-13 00:00:00.000",
"description": "Report",
"row_id": 286203,
"text": "Sinus tachycardia.\nRight axis deviation\nLateral infarct - age undetermined\nPossible inferior infarct - age undetermined\nLimb leads are reversed\n\n"
}
] |
23,824 | 173,049 | 71 yo female with prior history of asthma, CAD, uncertain diagnosis IPF, CHF who was transferred to from Hospital for further evaluation and treatment of respiratory failure, valvular disease, and ARF. The respiratory failure was secondary to hypoxemia, cardiac vs. pulmonary etiology. The patient carried a diagnosis of IPF (based on radiologic findings) and asthma and had been on oxygen at home for the past three weeks. The initial differential dx included infection (bacterial vs. atypical vs. viral vs. PCP), inflammatory (Churg-, Wegener's), autoimmune, or shunt; a PE was thought to be less likely given PA measurements. She was continued on high dose steroids and given broad antibiotic coverage to include MRSA, atypicals, anaerobes. She underwent bronchoscopy which was consistent with alveolar hemorrhage, although it was unclear whether this was just related to heart failure. Cultures from the BAL were negative. She also underwent a repeat chest CT which showed micronodular pulmonary abnormalities, no evidence of idiopathic pulmonary fibrosis, enlarged mediastinal lymph nodes, and extensive coronary artery and aorta atherosclerotic calcifications. She was ruled out for influenza and legionella. , ANCA, Anti-GBM ab were all negative. In terms of her cardiac disease, the pt had a history of CHF w/ severe MR. She underwent repeat which showed mild global biventricular systolic dysfunction with severe mitral, aortic, and tricuspid regurgitation. Cardiology was consulted and it was felt that she would not be a candidate for valve replacement. She was medically managed with afterload reduction and diuresis. In terms of her renal failure, the patient's creatinine doubled by 50% since admission to the OSH from 1.2-->1.8. The differential included pre-renal from over diuresis vs. AIN from antibiotics, vs. Wegener's. Urine lytes were sent along with UA, urine sediment, and urine eosinophils, which were negative. Following extubation, the patient developed tachycardia with a rhythm most likely aflutter with varying block with demand ventricular pacing, and diltiazem was utilized for rate control. The following day, she was quite stable on minimal supplemental oxygen for several hours. However, around noon she developed a sense of dread and quickly became tachycardic and hypoxic with an oxygen saturation in the 60's, requiring reintubation. The patient's a-line failed, she became hypotensive, and pressors (Levophed and Dobutamine) were initiated. She was intubated, and became pulseless. Full resuscitation was attempted with CPR, electrical defibrillation, and medications but the efforts were stop when she became unresponsively asystolic. The patient expired on . Her HCP and next of were notified and requested an autopsy. . | Murmur.Height: (in) 66Weight (lb): 138BSA (m2): 1.71 m2BP (mm Hg): 118/58HR (bpm): 97Status: InpatientDate/Time: at 12:03Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. The right ventricular cavity ismoderately dilated with mild global right ventricular free wall hypokinesis. There is mild global left ventricular hypokinesis. There is moderatepulmonary artery systolic hypertension. The end-diastolic PR velocity is increased c/w PA diastolichypertension.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. Mild global LV hypokinesis. Albuterol/Atrovent MDI's given Q4hr. Moderate to severe [3+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. Moderate pulmonary hypertension.Dr. Right IJ tip at the level of distal SVC. [Intrinsic RV systolic function likely more depressed given theseverity of TR].AORTA: Normal aortic root diameter.AORTIC VALVE: Three aortic valve leaflets. Transvenous right atrial and ventricular pacer leads, a right internal jugular line, and nasogastric tube are in standard placements respectively. FINDINGS: Right IJ line has been pulled back, and tip now projecting over the expected location of distal SVC. Improved appearance of bilateral hazy opacities perihilar location, likely improved congestive failure. The mitral valve leaflets are mildlythickened, and there is severe mitral annular calcification. Pacemaker leads terminate in the right atrium and right ventricle. Moderate to severe (3+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Unchanged appearance of mild cardiomegaly and bilateral perihilar hazy opacities, suggestive of congestive heart failure. Mild aortic stenosis. Moderate to severe aortic regurgitation.Moderate to severe tricuspid regurgitation. Moderately thickened aortic valveleaflets. HR 80-90s NSR w/ occasional , pt was put on Nitroglycerin GTT @ .12mcg/kg/min and Dilt GTT 12mg/hr, also the 3 of 3 Digoxin loading dose was given 0.25 over 2 min, Hct stable. There is mild aortic valve stenosis. (Over) 11:18 PM CT CHEST W/O CONTRAST Clip # Reason: EVAL EFFUSIONS Admitting Diagnosis: SEVERE MITRAL VALVE REGURGITATION Field of view: 36 FINAL REPORT (Cont) No restingLVOT gradient.RIGHT VENTRICLE: Moderately dilated RV cavity. Moderate to severe(3+) aortic regurgitation is seen. transported to CT for Chest CT. Tolerated well. Mild thickening of mitral valve chordae. LS coarse bilat/dim at bases, sat 98-99%, suction for small bloody secrtion, sputum Cx sent. ABP 101-120/50's, MAP 62-70, given fluid bolus NS 500ccx2 for SBP 88-90 with good respons, goal keep SBP >90 and MAP >60. lactate 2.7->1.9endo: no coverage needed.plan: cont monitoring resp/cardio status cont Diltiazem gtt to titrate HR 80's. A Swan-Ganz catheter ends in the right main pulmonary artery. In the AM RIsbi=27 and tolerated the SBT with an ABG: pao2 63/paco2 43/ph 7.40. Pt is receiving Albuterol MDI 6 puffs Q4 & Atrovent MDI 6 puffs Q4-6. Bronch performed,samples obtained to r/o alveolar hemorraging. Cannot exclude MS. (4+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Sputum CX sent. Query choledocholithiasis. Left anterior descending, left circumflex, right coronary artery, and aorta atherosclerotic calcifications are seen. ABD soft, BS hypoactive, no BM.id: Tmax 99.2, given tylenol 650mg PR, cont Vanco/zocyn. Chest CT done d/t respiratory failure and lungs infilltrates per CxR, result pending.cv: Hr 70-80's Vpaced, ocass PVC's, A-line insert small hematoma after Aline placement. Nasogastric tube terminates in the proximal stomach, with side ports projecting over or just below the expected location of GE junction. Heart is top normal size and small right pleural effusion is slightly larger. Output was adequate, 40mEq Lasix given IV, TF started @ 10cc/hr @ 1230, T=97.5, Lactate 1.9. ABD soft, BS hypoactive. 1900-0700 rn notes micu please see carevue for additional data.neuro: pt received on versed 1mg/hr and fentanyl 125mcg/hr, pt arousable to voice, opens eyes to voice, follows simple commands, MAE. gag/cough reflex intact.resp: recieved intubated AC 100% fio2, overnight vent changes made, currently: AC 40%/TV 600/RR14/Peep 5, last ABG: 7.44/38/74/21, pt does not OVB when on sedation, but does OVB when sedation off ( pt was off sedation for 2hr d/t central line o/wire changes). The patient is intubated and the airways are patent to the segmental level bilaterally. K+ at 2100 3.8 repleted.gi/gu: foley in place, u/o 20-30cc/hr, given Lasix 40mg IV with good effect u/o 75-275cc/hr. Severe (4+)mitral regurgitation is seen. Tip of right IJ at the level of cavoatrial junction. BS: slight bilateral insp. Pt was Bronched today for cell count/BAL/PCP, alveolar hemmorhage was confirmed, suctioned blood and some clots. npn micu west 0700-1900allergy: lipitorfull codeneuro: pt was received sedated on fentanyl 125mcg/hr and versed 1 mg/hr, opening eyes to voice, and able to follow commands. follow up on US results- acute pancreatitis? Severe mitral annularcalcification. IMPRESSION: AP chest compared to and 26: Following extubation, lungs are lower in volume which may be responsible for exaggeration of severe widespread pulmonary infiltrative abnormality. CT CHEST WITHOUT CONTRAST: Diffuse micronodular opacities, best demonstrated by thin collimation images, surrounded by ground- glass opacities are seen throughout the both lungs, more pronounced at the apices, without appreciable septal thickening. FINDINGS: Endotracheal tube terminates approximately 4 cm above the carina. COMPARISON: Chest radiograph . COMPARISON: Chest radiograph . appeared comfortable most of the morning, until 12:45-1:00, pt bcame tachycardic HR 110-117 and BP 140s, Dilt and Nitro GTT were titrated accordingly. IMPRESSION: Swan-Ganz catheter in inferior segment of pulmonary artery. for fluid goal per cardiology. There are small bilateral pleural effusions, left greater than right. CVP 10-13. pt received with Swan-Ganz cath with weidge 20-26 and PAP 53-60/22-30, swan cath was pulled out and changes o/wire triple-lumen. | 19 | [
{
"category": "Nursing/other",
"chartdate": "2182-11-29 00:00:00.000",
"description": "Report",
"row_id": 1573872,
"text": "resp care\nPt initially on 70% cool aerosol with sats ranging from 88-92%. Neb changed to a high system with improvement in sats. Alb/atr neb given as ordered. BS coarse bil. weak cough. Fio2 weaned to 60% this am.Will cont to follow with nebs and wean fio2 as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-11-29 00:00:00.000",
"description": "Report",
"row_id": 1573873,
"text": "micu west 0700-1900 npn\nReceived pt. at 0700 alert and oriented to person, place, and time, moving all four extremeties, pupils 3mm pearl, and following commands. Pt was on Face Tent .60% flow 12L, LS clear, small crackles at bases. HR 80-90s NSR w/ occasional , pt was put on Nitroglycerin GTT @ .12mcg/kg/min and Dilt GTT 12mg/hr, also the 3 of 3 Digoxin loading dose was given 0.25 over 2 min, Hct stable. Output was adequate, 40mEq Lasix given IV, TF started @ 10cc/hr @ 1230, T=97.5, Lactate 1.9. FSBS done and required coverage. Pt. appeared comfortable most of the morning, until 12:45-1:00, pt bcame tachycardic HR 110-117 and BP 140s, Dilt and Nitro GTT were titrated accordingly. Next, pt. began to desats to 88-90%, so a NRB mask was applied immediately. EKG was done, Dr. called and came to bedside. Tean began ambuing patient, and oxygen decrease to 65%, anesthesia called and came to bedside, and at 1:05 a code was initiated, until 1:39, pt was pronounced dead by PEA.\nFamily notified.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-11-27 00:00:00.000",
"description": "Report",
"row_id": 1573865,
"text": "npn micu west 0700-1900\nallergy: lipitor\nfull code\n\n71 yo female w/ extensive cardiac/pulmonary hx including pulmonary fibrosis, alveolar disease, EF 33%, aortic stenosis, mitral regurgitation, CHF, transferred from Hospital to the MICU. Pt initially presented to Hospital for severe SOB, + hemoptysis, but bronchoscopy did not show blood, Swan put in there, no other access.\n\nOther Hx includes: HemoptysisBilateral Masectomy, + lymphadenopathy in UE, osteoperosis, oopherectomy.\n\nneuro: pt is sedated on fentanyl 100mcg/hr and versed 1 mg/hr, opens eyes to voice, follows commands consistently, and nods/comprehends complex sentences, pupils pearl 3mm brisk, lifts and holds all four extremeties.\n\nresp: Pt received intubated ett #8 on vent settings AC/fio2 .60/tv 500/rr 14/ peep 5, sats 100%, LS clear, coarse in posterior left.\n\ncv: hr 70s v-paced, mitral regurg audible, swan cath in place, see carevue for cardiac values, sbp 86-99, Dr. currently attempting to put an A-line IN, Total NS bolus of 750cc for cvp 8, distal pulses palpable.\n\ngu/gi: pt received with catheter, outputing 30-45cc/hr clear/yellow, bs+, NG tube clamped except meds.\n\nid: afebrile, Levoquin, Solumedrol\n\naccess: Swanz\n\nsocial: sister called, she lives in CT and is the spokeswoman. This pt. is divorced, lives alone, and has 3 sons. She has 9 other siblings.\n\nplan: A-line?\n Cont Fluid Bolus if needed\n Mitral valve replacement\n Open Lung Biopsy?\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-11-28 00:00:00.000",
"description": "Report",
"row_id": 1573866,
"text": "Albuterol/Atrovent MDI's given Q4hr. RSBI 27 this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-11-28 00:00:00.000",
"description": "Report",
"row_id": 1573867,
"text": "Respiratory Care:\n\nPatient intubated on mechanical support. Current vent settings Vt 600, A/c rate 14, Fio2 40% and Peep 5. Fio2 weaned from 100% to 40%. Repeat Abg WNL. Bs slightly coarse bilaterally. Sx'd for sm amount of thick bloody secretions. Sputum CX sent. Pt. transported to CT for Chest CT. Tolerated well. No further changes made at this time.\nPlan: Continue with mechanical support and wean to Psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-11-28 00:00:00.000",
"description": "Report",
"row_id": 1573868,
"text": "1900-0700 rn notes micu\n please see carevue for additional data.\n\nneuro: pt received on versed 1mg/hr and fentanyl 125mcg/hr, pt arousable to voice, opens eyes to voice, follows simple commands, MAE. PERL 3mm/brisk. gag/cough reflex intact.\n\nresp: recieved intubated AC 100% fio2, overnight vent changes made, currently: AC 40%/TV 600/RR14/Peep 5, last ABG: 7.44/38/74/21, pt does not OVB when on sedation, but does OVB when sedation off ( pt was off sedation for 2hr d/t central line o/wire changes). LS coarse bilat/dim at bases, sat 98-99%, suction for small bloody secrtion, sputum Cx sent. RSBI morning27. Chest CT done d/t respiratory failure and lungs infilltrates per CxR, result pending.\n\ncv: Hr 70-80's Vpaced, ocass PVC's, A-line insert small hematoma after Aline placement.\n\n ABP 101-120/50's, MAP 62-70, given fluid bolus NS 500ccx2 for SBP 88-90 with good respons, goal keep SBP >90 and MAP >60. CVP 10-13. pt received with Swan-Ganz cath with weidge 20-26 and PAP 53-60/22-30, swan cath was pulled out and changes o/wire triple-lumen. HCT stable at 28-29.morning labs pending.\n\ngi/gu: foley, drainge yellow/clear urine, u/o 25-40cc/hr, UTI pos E.coli from OSH, urine cx sent. ABD soft, BS hypoactive. pt NPO, NGT to low intermitted suction drainge billios secretion.\n\nid: temp 96.1-96.8, start VAnco and Zocyn IV.\n\nendo: cover by RISS.\n\naccess: swan cath pulled out and o/wire changed to triple lumen.\n\nsocial: full code, sister updated by team.\n\nplan: cont monitoring resp/cardio status\n keep MAP >60 and SBP>90\n cardio ECHO\n cardio consult for CHF/MR/valve replacement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-11-28 00:00:00.000",
"description": "Report",
"row_id": 1573869,
"text": "Resp. Care Note\n\nSuccessful SBT performed earlier this AM. ABG of pH: 7.40/43/63 on 5/0 40% during that time. BS: slight bilateral insp. crackles. Suctioned but was unable to remove any secretions. Bronch performed,samples obtained to r/o alveolar hemorraging. Cardiac work-up in progress. Currently intubated on CPAP 5 with PS 5 FiO2 of 40%, with TV 700-800cc and RR 12-14. Pt is receiving Albuterol MDI 6 puffs Q4 & Atrovent MDI 6 puffs Q4-6. Plan to cont current support pending results of w/u.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-11-28 00:00:00.000",
"description": "Report",
"row_id": 1573870,
"text": "npn micu west 0700-1900\nallergy: lipitor\n\nfull code\n\nneuro: pt was received sedated on fentanyl 125mcg/hr and versed 1 mg/hr, opening eyes to voice, and able to follow commands. Pupils pearl 2-3mm brisk, and does not move extremeties on bed unless asked.\n\nresp: Pt was received intubated on AC/.40%/5peep/5ps rr 14, not OBV,tv 600 appeared breathing comfortably. LS coarse bilaterally, although nothing suctioned from lungs. O2 sats>95%. In the AM RIsbi=27 and tolerated the SBT with an ABG: pao2 63/paco2 43/ph 7.40. Pt was then put back on . Pt was Bronched today for cell count/BAL/PCP, alveolar hemmorhage was confirmed, suctioned blood and some clots. Team is considering extubation this evening, ABG result pending.\n\ncv: HR 70-100s V paced, sbp 120-130, A-line sharp wave and intact, small hematoma near site,, CVP 10-12, Mult-lumen IJ intact, dressing changed. Goal SBP>90 and MAP>60. Pulses easily palpable. Cardiac ECHO done today, results pending. OSH EF 33%. No IVF, please run more neg. for fluid goal per cardiology. Cardiology saw pt this evening.\n\ngu/gi: Pt foley outputing 25-40cc/hr clear, yellow urine which tested positive for Ecoli @ OSH. NG tube intermittent suction, draining brown bile 150cc for shift, NPO today, may start TF after midnight, Dr. is considering. Pancreatic enzymes/labs show pancreatitis. Abd (liver and gallbladder) US to be done @ 1830.\n\nid: Pipercillin and Vanco, Tmax 100.0 (following bronch), Dr. made aware. Tylenol PR give to avoid tachycardia in the setting of CHF.\n\ninteg: grossly intact, lymphadenopathy from bilateral masectomy.\n\nendo: bsbs, coverage needed\n\nsocial: sister called today and updated, she is the pt.'s spokesperson.\n\nplan: cont abx/steroids\n follow up on bronch lab results - lung ca+?, PCP?, inflammatory PNA?\n Open Lung Biopsy?\n follow up on US results- acute pancreatitis?\n Also, cardiology follow up - mitral valve replacement?\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-11-29 00:00:00.000",
"description": "Report",
"row_id": 1573871,
"text": "1900-0700 rn notes micu\n\nneuro: receieved extubated A/Ox2-3, follows simple commands, opens eyes spont, moves all extremeties when asked.no c/o pain or nausea.PERL 3mm/brisk.\n\nresp: received 70% Hi flow mask 12L, at the begining of shift pt desat to 88-90%, given nebs tx, Morphine 1mg with good effect, cxr done, sat back to 98-100%, morning ABG: 7.47/35/120, Fio2 down to 60%. LS coarse with crackles at bases,given Lasix 40mg IV.\n\ncv: at begining shift HR 114-117, A flutter with occas V paced and PVC's, start Nitro gtt .12mcg/kg/min, given Diltiazem 10mg Iv with good effect, start Diltiazem gtt 10mg/hr, HR down 88-96, NSR. also start Digoxin Iv, given 2 loading dose 0.5mg and 0.25mg, please give 3rd dose at 1130, digoxin level sent, morning labs pending. K+ at 2100 3.8 repleted.\n\ngi/gu: foley in place, u/o 20-30cc/hr, given Lasix 40mg IV with good effect u/o 75-275cc/hr. ABD US done, result pending. pt NPO, no meds po given. ABD soft, BS hypoactive, no BM.\n\nid: Tmax 99.2, given tylenol 650mg PR, cont Vanco/zocyn. lactate 2.7->1.9\n\nendo: no coverage needed.\n\nplan: cont monitoring resp/cardio status\n cont Diltiazem gtt to titrate HR 80's.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2182-11-28 00:00:00.000",
"description": "Report",
"row_id": 82327,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Mitral valve disease. Murmur.\nHeight: (in) 66\nWeight (lb): 138\nBSA (m2): 1.71 m2\nBP (mm Hg): 118/58\nHR (bpm): 97\nStatus: Inpatient\nDate/Time: at 12:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Normal regional LV\nsystolic function. Mild global LV hypokinesis. [Intrinsic LV systolic function\nlikely depressed given the severity of valvular regurgitation.] No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV free wall\nhypokinesis. [Intrinsic RV systolic function likely more depressed given the\nseverity of TR].\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Mild AS. Moderate to severe (3+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Severe mitral annular\ncalcification. Mild thickening of mitral valve chordae. Cannot exclude MS.\n (4+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. The end-diastolic PR velocity is increased c/w PA diastolic\nhypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is mild global left ventricular hypokinesis.\n[Intrinsic left ventricular systolic function is likely more depressed given\nthe severity of valvular regurgitation.] The right ventricular cavity is\nmoderately dilated with mild global right ventricular free wall hypokinesis.\n[Intrinsic right ventricular systolic function is likely more depressed given\nthe severity of tricuspid regurgitation.] There are three moderately thickened\naortic valve leaflets. There is mild aortic valve stenosis. Moderate to severe\n(3+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened, and there is severe mitral annular calcification. Severe (4+)\nmitral regurgitation is seen. Because of the severity of mitral regurgitation,\nthe study is inadequate to reliably exclude significant mitral valve stenosis.\nModerate to severe [3+] tricuspid regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. The end-diastolic pulmonic\nregurgitation velocity is increased suggesting pulmonary artery diastolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Mild global biventricular systolic dysfunction. Severe mitral\nregurgitation. Mild aortic stenosis. Moderate to severe aortic regurgitation.\nModerate to severe tricuspid regurgitation. Moderate pulmonary hypertension.\n\nDr. was notified of the study results at 4:35p on the day of the study.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2182-11-28 00:00:00.000",
"description": "Report",
"row_id": 205511,
"text": "Atrial sensed ventricular paced\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2182-11-28 00:00:00.000",
"description": "Report",
"row_id": 205509,
"text": "Demand ventricular pacing with ventricular premature beats. Compared to the\nprevious tracing of ventricular arrhythmia is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2182-11-28 00:00:00.000",
"description": "Report",
"row_id": 205510,
"text": "Atrial sensed ventricular paced\nPacemaker rhythm - no further analysis\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-11-28 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 933107,
"text": " 1:52 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please assess position of CVL and r/o Pneumothorax\n Admitting Diagnosis: SEVERE MITRAL VALVE REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with respiratory distress, with new R IJ line replacement\n REASON FOR THIS EXAMINATION:\n Please assess position of CVL and r/o Pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress, right IJ line placement.\n\n COMPARISON: Chest radiograph .\n\n FINDINGS: Endotracheal tube terminates approximately 4 cm above the carina.\n Nasogastric tube terminates in the proximal stomach, with side ports\n projecting over or just below the expected location of GE junction. There is\n a right IJ line, with tip located at the expected location of cavoatrial\n junction. There is mild stable cardiomegaly. There are bilateral perihilar\n hazy opacities, not significantly changed from the previous examination. There\n is retrocardiac density, likely representing atelectasis versus an area of\n consolidation. There is no pneumothorax. There are no sizeable pleural\n effusions noted on this single AP view.\n\n IMPRESSION:\n 1. Tip of right IJ at the level of cavoatrial junction. No pneumothorax.\n 2. Unchanged appearance of mild cardiomegaly and bilateral perihilar hazy\n opacities, suggestive of congestive heart failure. Retrocardiac density may\n represent atelectasis versus pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-11-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 933065,
"text": " 3:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate, edema, evaluate placement of PA cath\n Admitting Diagnosis: SEVERE MITRAL VALVE REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman, intubated, h/o IPF and CHF\n REASON FOR THIS EXAMINATION:\n infiltrate, edema, evaluate placement of PA cath\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Catheter placed, check position.\n\n The tip of the Swan-Ganz catheter lies in the inferior bronchial of the right\n main pulmonary artery. Position of the endotracheal tube and the pacemaker\n leads is satisfactory. The nasogastric tube is also in a good position.\n\n Diffuse interstitial is present in both lungs consistent with history\n of interstitial pulmonary fibrosis. In the absence of effusions or\n significant cardiomegaly, additional cardiac failure seems less likely.\n\n IMPRESSION: Swan-Ganz catheter in inferior segment of pulmonary artery.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-11-27 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 933101,
"text": " 11:18 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: EVAL EFFUSIONS\n Admitting Diagnosis: SEVERE MITRAL VALVE REGURGITATION\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with ? idiopathic pulmonary fibrosis, pulmonary edema,\n intubated\n REASON FOR THIS EXAMINATION:\n would like high-res chest CT to evaluate for interstitial lung disease,\n effusions\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman, intubated with hypoxia. Please evaluate for\n interstitial lung disease.\n\n COMPARISON: Portable AP chest, .\n\n TECHNIQUE: Multidetector helical CT scanning of the chest was reconstructed\n as 1.25- and 5-mm contiguos axial images.\n\n CT CHEST WITHOUT CONTRAST: Diffuse micronodular opacities, best demonstrated\n by thin collimation images, surrounded by ground- glass opacities are seen\n throughout the both lungs, more pronounced at the apices, without appreciable\n septal thickening. Focal areas of airspace opacity at the lung bases are most\n likely consolidation. There are small bilateral pleural effusions, left\n greater than right. The patient is intubated and the airways are patent to\n the segmental level bilaterally.\n\n Soft tissue windows show lymphadenopathy in the right paratracheal and\n precarinal regions measuring up to 15 mm. There are no pathologically\n enlarged axillary or hilar lymph nodes. Heart size is normal. Left anterior\n descending, left circumflex, right coronary artery, and aorta atherosclerotic\n calcifications are seen. The great vessels are normal in caliber. Pacemaker\n leads terminate in the right atrium and right ventricle. A nasogastric tube\n ends in the stomach. A Swan-Ganz catheter ends in the right main pulmonary\n artery. Metal clips denote right axillary surgery.\n\n In the upper abdomen, the imaged portion of liver, pancreas, spleen, adrenal\n glands, and kidneys are normal.\n\n There are no bony findings of malignancy.\n\n IMPRESSION:\n 1. Micronodular pulmonary abnormality could be miliary tuberculosis or\n fungal infection, lymphoid interstitial pneumonia, acute-on-chronic allergic\n alveolitis.\n 2. No evidence of idiopathic pulmonary fibrosis.\n 3. Enlarged mediastinal lymph nodes, most likely reactive in nature.\n 4. Extensive coronary artery and aorta atherosclerotic calcifications.\n\n (Over)\n\n 11:18 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: EVAL EFFUSIONS\n Admitting Diagnosis: SEVERE MITRAL VALVE REGURGITATION\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-11-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 933254,
"text": " 9:38 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for interval changes\n Admitting Diagnosis: SEVERE MITRAL VALVE REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman diffuse alveolar hemorrhage now extubated today 1700,\n increased WOB and crackles bil bases\n REASON FOR THIS EXAMINATION:\n eval for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:45 P.M., ON \n\n HISTORY: Diffuse alveolar hemorrhage.\n\n IMPRESSION: AP chest compared to and 26:\n\n Following extubation, lungs are lower in volume which may be responsible for\n exaggeration of severe widespread pulmonary infiltrative abnormality. \n also be a component of acute pulmonary edema superimposed on the process\n pre-existing in both lungs. Heart is top normal size and small right pleural\n effusion is slightly larger. Transvenous right atrial and ventricular pacer\n leads, a right internal jugular line, and nasogastric tube are in standard\n placements respectively. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-11-28 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 933111,
"text": " 3:46 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: interval change after line repositioning\n Admitting Diagnosis: SEVERE MITRAL VALVE REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with respiratory distress, with new R IJ line replacement,\n pulled back approx 2cm\n REASON FOR THIS EXAMINATION:\n interval change after line repositioning\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress, right IJ line replacement.\n\n COMPARISON: Chest radiograph .\n\n FINDINGS: Right IJ line has been pulled back, and tip now projecting over the\n expected location of distal SVC. ET tube is approximately 4 cm above the\n carina. Nasogastric tube courses below the diaphragms, and is out of view.\n There is stable mild cardiomegaly. Appearance of bilateral perihilar hazy\n opacities has improved in the interval. Retrocardiac density is essentially\n unchanged.\n\n IMPRESSION:\n 1. Right IJ tip at the level of distal SVC. No pneumothorax.\n\n 2. Improved appearance of bilateral hazy opacities perihilar location, likely\n improved congestive failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-11-28 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 933223,
"text": " 4:04 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: eval biliary tract for choledocolithiasis\n Admitting Diagnosis: SEVERE MITRAL VALVE REGURGITATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman, intubated, pulm fibrosis, ALOC, but and lipase both\n elevated (nl AST, ALT, AP, elevated LDH).\n REASON FOR THIS EXAMINATION:\n eval biliary tract for choledocolithiasis\n ______________________________________________________________________________\n WET READ: 7:56 PM\n no cholelithiasis. no evidence of biliary dilatation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pancreatitis. Query choledocholithiasis.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The study is somewhat limited due to patient\n inability to cooperate with examination (intubated). However, within the\n limits of this exam, liver is slightly echogenic, without focal lesions. No\n intrahepatic biliary ductal dilatation is seen. Portal venous flow is\n maintained in the appropriate direction. The common bile duct measures 8 mm,\n which is probably within normal limits for age. Distal common bile duct\n measures 5 mm. No cholelithiasis or choledocholithiasis is identified.\n Pancreas is not well identified due to overlying bowel gas; however, no large\n peripancreatic fluid collection is seen.\n\n IMPRESSION: 1. No evidence of cholelithiasis or choledocholithiasis. Normal\n common bile duct for patient's age.\n\n 2. Diffusely echogenic liver which may reflect diffuse hepatic parenchymal\n disease.\n\n"
}
] |
1,339 | 109,444 | MICU COURSE: Pt was transferred from OSH ED on in respiratory distress on bipap. Bipap was weaned off during the first hospital day. CTA negative for PE. She was initially treated with Vanc/Levo/Zosyn for ?PNA; these were discontinued on as no clinical evidence of infection. She was also initially treated with IV steroids per ENT for upper airway edema. On the patient developed sudden onset respiratory distress and desatted into the 50s. She was emergently intubated. This was thought to be due to flash pulmonary edema vs mucous plug. She subsequently did well, and was taken to the OR for bronchoscopy on ; no upper airway etiology of her respiratory failure was found. She was extubated for the procedure but reintubated due to lethargy/sedation post procedure. She was then extubated on . Of note, she developed a small troponin leak in the setting of her respiratory distress. She was continued on her home cardiac medications. | Respiratory failure, chronic Assessment: CXR revealed Rt LL PNA . Respiratory failure, chronic Assessment: CXR revealed Rt LL PNA . 5) COPD / tracheobronchiomalacia: Would provide standing nebs, Albuterol / Atrovent q4hr and q2hr PRN. 4) COPD / tracheobronchiomalacia: Would provide standing nebs, Albuterol / Atrovent q4hr and q2hr PRN. 4) COPD / tracheobronchiomalacia: Would provide standing nebs, Albuterol / Atrovent q4hr and q2hr PRN. 4) COPD / tracheobronchiomalacia: Would provide standing nebs, Albuterol / Atrovent q4hr and q2hr PRN. <I>## Leukocytosis:<I>Concerning for infection although with normal diff. Became hypotensive to 70s, nitro gtt held. Neosynephrine started. TTE recently done () showed preserved EF with some focal wall motion abnormality. TTE recently done () showed preserved EF with some focal wall motion abnormality. acutely decompensated during am care. HPI: 67 y/o F w/TBM, trach s/p decannulation and fistula repair, admitted with respiratory failure. HPI: 67 y/o F w/TBM, trach s/p decannulation and fistula repair, admitted with respiratory failure. Suspect mucus plug as the etiology 1) ID: CTA demonstrated RLL and RML infiltrate when compared to CT back in was present then. Suspect mucus plug as the etiology 1) ID: CTA demonstrated RLL and RML infiltrate when compared to CT back in was present then. <I>## Leukocytosis:<I>Concerning for infection although with normal diff. <I>## Leukocytosis:<I>Concerning for infection although with normal diff. <I>## Leukocytosis:<I>Concerning for infection although with normal diff. Currently euvolemic, but will continue home lasix dose. Respiratory failure, chronic Assessment: CXR revealed Rt LL PNA . Respiratory failure, chronic Assessment: CXR revealed Rt LL PNA . Hypotension (not Shock) Assessment: Hypotensive during Propofol administration Action: Neo re-started for BP support Response: BP 100s-1teens and MAPS >60 Plan: Wan Neo off when sedation lightened/DCd. CXR yesterday showed mild interstitial edema. Currently euvolemic, but will continue home lasix dose. <I>## Leukocytosis:<I>Concerning for infection although with normal diff. 5) COPD / tracheobronchiomalacia: Would provide standing nebs, Albuterol / Atrovent q4hr and q2hr PRN. <I>## COPD:</I>Likely not etiology of acute respiratory distress overnight, patient without wheezing on exam -continue nebs . <I>## Depression/anxiety:</I> -ativan prn anxiety, caution not to oversedate -Continue home lamotrigine, quetiapine, sertraline . acutely decompensated during am care. Currently euvolemic, but will continue home lasix dose. Currently euvolemic, but will continue home lasix dose. Neosynephrine started. 3) Elevated troponin/Hx CHF: Likely demand in setting of hypotension, now resolving. Respiratory failure, chronic Assessment: Pt. Respiratory failure, chronic Assessment: Pt. -wean neo 3) Elevated troponin: Likely demand in setting of hypotension, now resolving. TTE recently done () showed preserved EF with some focal wall motion abnormality. TTE recently done () showed preserved EF with some focal wall motion abnormality. TTE recently done () showed preserved EF with some focal wall motion abnormality. Neo has been weaned off as of 1630 Respiratory failure, chronic Assessment: Pt. Currently euvolemic, but will continue home lasix dose. Currently euvolemic, but will continue home lasix dose. Currently euvolemic, but will continue home lasix dose. Anticipate extubation today per d/w MD. Anticipate extubation today per d/w MD. Respiratory failure, chronic Assessment: Action: Response: Plan: TTE recently done () showed preserved EF with some focal wall motion abnormality. TTE recently done () showed preserved EF with some focal wall motion abnormality. TTE recently done () showed preserved EF with some focal wall motion abnormality. Neo has been weaned off as of 1630 Respiratory failure, chronic Assessment: Pt. Pre-renal ARF is resolved now. Pre-renal ARF is resolved now. Pre-renal ARF is resolved now. 3) Elevated troponin/Hx CHF: Likely demand in setting of hypotension, now resolving. Respiratory failure, chronic Assessment: Action: Response: Plan: Respiratory failure, chronic Assessment: Action: Response: Plan: TTE recently done () showed preserved EF with some focal wall motion abnormality. TTE recently done () showed preserved EF with some focal wall motion abnormality. Currently euvolemic, but will continue home lasix dose. Currently euvolemic, but will continue home lasix dose. The patient is status post median sternotomy as before. Neo has been weaned off as of 1630 Respiratory failure, chronic Assessment: Pt. Hypotension (not Shock) Assessment: Hypotensive during Propofol administration Action: Neo re-started for BP support Response: BP 100s-1teens and MAPS >60 Plan: Wan Neo off when sedation lightened/DCd. As described on the previous CT of , there is mediastinal and hilar lymphadenopathy. Background pattern of emphysema is noted. PHARYNGEAL PHASE: Velar elevation and upper esophageal sphincter relaxation were within functional limits. pulm edema, ? pulm edema, ? pulm edema, ? pulm edema, ? There were normal primary peristaltic contractions; however, proximal escape was noted. Prior inferior myocardial infarction. Prior inferior myocardialinfarction. Sinus rhythm and frequent atrial ectopy. Small-to-moderate hiatal hernia. Clinical correlation issuggested.TRACING #1 Premature spillage was noted into the pharynx. EXAMINATION: Barium esophagram. HISTORY: Recently extubated after pulmonary edema. There is fluid within the right lower lobe bronchus, with distal atelectasis/consolidation. There is a moderate-sized hiatal hernia. Right PICC ends in the mid SVC. Admitting Diagnosis: PNEUMONIA FINAL REPORT (Cont) Postoperative changes from CABG are present. | 134 | [
{
"category": "Physician ",
"chartdate": "2138-09-22 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 339006,
"text": "Chief Complaint: Respiratory distress x 1 day\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. She was d/c'ed home on\n on Bactrim DS presumptively for extended coverage of her MRSA\n pneumonia (despite having completed course of Vanc.) At ~1AM this\n morning she developed shortness of breath when she got up to go to the\n bathroom. No cough, fevers, chills. She went back to bed, slept for ~1\n hour on CPAP but awoke again with persistent shortness of breath and\n presented to the ER for further evaluation. Denies chest pain /\n pressure, orthopnea, PND. She feels that her volume overload is\n improving. She denies leg swelling or pain. Persistent cough productive\n of white sputum, no purulence noted. No wheezing or stridor.\n Seen in Malborough ER where she received Ceftriaxone, Azithromycin,\n Lasix and IVF for presumptive RLL CAP. She was placed on BiPAP. At\n her ABG was 7.28 / 52 / 74 (? FiO2.) Cardiac enzymes were\n negative, BNP 344. Transferred to where her vitals were notable\n for 98.5, 80s, SBP 90s, 98-100% (FiO2 100%.) She received a dose of\n Levaquin and is admitted to the MICU on BiPAP.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n HOME medications (from d/c):\n Lactulose prn\n Sertraline 100 mg daily\n Docusate\n Senna\n Lamotrigine 25 mg Tablet \n Quetiapine 25 mg TID & 100 mg QHS\n Albuterol Sulfate Q 6 hours prn\n Ipratropium-Albuterol Q4 prn\n Aspirin 81 mg Tablet daily\n Simvastatin 40 mg daily\n Lisinopril 5 mg Tablet daily\n Furosemide 40 mg daily\n Potassium Chloride 20 mEq daily\n Metoprolol Tartrate 12.5mg daily\n Vicodin 5-500 mg Tablet\n Guaifenesin\n Bactroban 2 % Ointment Sig\n 1Bactrim DS 160-800 mg \n Past medical history:\n Family history:\n Social History:\n 1) Pseudomonas pneumonia in c/b tracheobronchiomalacia and\n subglottic stenosis; had been trached and decannulated (.) On \n she had repair of a chronic fistula by ENT c/b MRSA pneumonia.\n 2) HIT.\n 3) COPD.\n 4) S/p THR c/b pseudomonas pneumonia in .\n 5) Paroxysmal A fib.\n 6) Depression / bipolar disorder.\n 7) CAD s/p CABG in .\n 8) Hyperlipidemia.\n 9) Constipation.\n 10) GERD.\n Depression\n Occupation:\n Drugs: None.\n Tobacco: Quit in , ~35 pack-year history.\n Alcohol: No significant EtOH\n Other:\n Review of systems:\n General: Denies fevers, chills, night sweats.\n CV: Denies chest pain, palpitations, orthopnea, PND.\n Lungs: As per HPI.\n GI: Denies nausea, vomiting, diarrhea, constipation, brbpr.\n Derm: No new rashes, bruising or lesions.\n Neuro: No focal deficits, headaches, seizures.\n Flowsheet Data as of 11:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.3\n Tcurrent: 35.7\nC (96.3\n HR: 83 (83 - 85) bpm\n BP: 94/51(63) {90/51(63) - 94/55(64)} mmHg\n RR: 17 (14 - 17) insp/min\n SpO2: 99%\n Total In:\n 156 mL\n PO:\n TF:\n IVF:\n 156 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -144 mL\n Respiratory\n O2 Delivery Device: Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 414 (414 - 414) mL\n PS : 6 cmH2O\n PEEP: 6 cmH2O\n FiO2: 100%\n SpO2: 99%\n ABG: ///27/\n Ve: 8.3 L/min\n Physical Examination\n General: Chronically ill appearing. Breathing with mild accessory\n muscle use.\n HEENT: PERRL, anicteric, OP clear with dry MM.\n CV: S1S2 soft HS\ns irreg irreg, no m/r/g\ns noted. No heave. JVP at\n ~8-10cm without HJR.\n Lungs: CTA bilaterally with right basilar crackles, upper airway\n wheezing.\n Ab: Obese, positive BS\ns, NT/ND.\n Ext: 1+ pitting edema, no c/c.\n Neuro: Awake, alert, answers questions appropriately. No gross motor\n deficits.\n Labs / Radiology\n 443 K/uL\n 32.3 %\n 10.8 g/dL\n 70 mg/dL\n 1.3 mg/dL\n 19 mg/dL\n 27 mEq/L\n 106 mEq/L\n 4.4 mEq/L\n 142 mEq/L\n 13.1 K/uL\n [image002.jpg]\n 09:05 AM\n WBC\n 13.1\n Hct\n 32.3\n Plt\n 443\n Cr\n 1.3\n Glucose\n 70\n Other labs: Lactic Acid:1.3 mmol/L\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. She does have new\n hypoxia, requiring increased supplemental oxygen. Her clinical\n presentation is most consistent with a multifactorial etiology; while\n she had a recent upper airway procedure (fistula repair), there does\n not appear to be evidence of any issues with the surgical site.\n 1) ID: Pneumonia is a possible explanation of her hypoxia and acute\n presentation; she had MRSA bacteremia that was treated with a course of\n Vancomycin during her recent hospitalization and d/c'ed on Bactrim. She\n has a h/o Pseudomonas pneumonia. Therefore empiric treatment for MRSA\n pneumonia is reasonable especially in the setting of her elevated WBC.\n Broadening coverage to gram negative pathogens is reasonable as well.\n Would recommend Zosyn and Cipro initially with a plan for rapid\n de-escalation as culture results become available and her clinical\n course is clarified.\n 2) Pulmonary: PE is a possibility especially in the setting of a recent\n hospitalization, recent surgery and her HIT positive status. Would\n pursue CTA with pre-treatment to minimize any renal toxicity. Would not\n pursue empiric anti-coagulation given h/o HIT and other potential\n causes of hypoxia. PE, however, is important to rule out given her\n clinical circumstances.\n 3) Cardiac: She has a h/o diastolic CHF, however, her current\n presentation is not overly suggestive of a CHF exacerbation being her\n primary issue. Would aim for I/O to be euvolumic.\n 4) Renal: Creatinine 1.3. Follow in the setting of anticipate CTA.\n 5) COPD / tracheobronchiomalacia: Would provide standing nebs,\n Albuterol / Atrovent q4hr and q2hr PRN. Decadron initially with plan\n for transition to Prednisone. Guaifenesin. BiPAP overnight and as\n needed during the day. Should she require intubation, would do it with\n fiberoptic guidance given her recent surgery.\n 6) F/E/N: Cardiac prudent diet. Follow / replete 'lytes as needed. Goal\n euvolumic for now.\n 7) Hosp: Access - pIV, code - full, proph - PPI and SCDs.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 10:15 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": "Respiratory ",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 339152,
"text": "Demographics\n Day of intubation: 0\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Expectorated / Small\n Comments: Pt has spontaneous cough, notably congested\n Ventilation Assessment\n Level of breathing assistance: Continuous non-invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Prolonged exhalation; Comments: Pt takes sleep med at bedtime, after\n this was taken there were re-occuring problems with non OSA apneas,\n appeared to be central in nature. Had to use MMV mode much of the\n night.\n Assessment of breathing comfort:\n Non-invasive ventilation assessment: Tolerated well; Comments: central\n apneas noted reqiring use of MMV with small tidal volume , 380 ml and\n backup rate of 8 to 10. Analgous to ST mode on BIPAP machine.\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with nightly use of NIV or use of patient's\n own BIPAP which she plans to have in hospital soon. Make known to MD\n that sleeping pills may be contributing to sleep apnea.\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 NIV vent with medium foam mask. In addition to OSA, apparent\n central apnea possibly in part due to sleeping pills.\n Saturation was mostly 93 to 95 % overnight.\n"
},
{
"category": "Respiratory ",
"chartdate": "2138-09-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 339058,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\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: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent non-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: Tolerated well\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue NIV 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 To ICU from ED\n 1100\n Radiology\n 1130\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339137,
"text": "67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Pneumonia, aspiration\n Assessment:\n Low grade fever temp100, LS ronchi diminished on left side, pt has\n productive cough. On NC pt c/o of SOB\n Action:\n Cont BIPAP, cont Zocyn IV, chest CT to r/o PE done\n Response:\n Chest CT neg for PE\n Plan:\n Cont ABX , cont BIPAP. Pt NPO for speech/swallow study\n Respiratory failure, chronic\n Assessment:\n Received on BPAP70%, sat 98-99%, put on NC 5L.pt has a few episodes of\n Apnea.\n Action:\n FIO down to 60%, sat 96-97%, given nebs tx\n Response:\n On NC c/o of SOB and desat to high 80%, tolerates nebs\n Plan:\n Cont BPAP.\n Pt c/o of pain on R leg ( no new for pt), given Ativan with good effect\n also ordering vicodin prn.\n After turning pt\ns BP drooped to 78-88, MD aware, after a few minutes\n BP up to 100\n K 3.8 repleted with 20meq, Mag 1.9 repleted with 2gm\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339051,
"text": "Admitted on @ 1000hrs.\n 67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339053,
"text": "Admitted on @ 1000hrs.\n 67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Respiratory failure, chronic\n Assessment:\n CXR revealed Rt LL PNA . Sats 90 % in ED with SOB.\n Action:\n Put on non invasive ventilation , as failed with non breather mask.\n BIPAP with PEEP / PS / FIO2 . CT chest done to R/O PE . on zosyn\n and vanco iv .\n Response:\n Sats 95-99% ,no SOB noted.comfortable with BIPAP . CT verbal report no\n PE,waiting for official report. Pt remains afebrile. VSS.\n Plan:\n Continue with BIPAP.\n Pt having h/o anxiety, requiring PRN po ativan. And having cough ,need\n guaifenessin.\n D5W with NaHCo3 150meq @ 200cc/hr is on progress .\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339054,
"text": "Admitted on @ 1000hrs.\n 67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Respiratory failure, chronic\n Assessment:\n CXR revealed Rt LL PNA . Sats 90 % in ED with SOB.\n Action:\n Put on non invasive ventilation , as failed with non breather mask.\n BIPAP with PEEP / PS / FIO2 . CT chest done to R/O PE . on zosyn\n and vanco iv .\n Response:\n Sats 95-99% ,no SOB noted.comfortable with BIPAP . CT verbal report no\n PE,waiting for official report. Pt remains afebrile. VSS.\n Plan:\n Continue with BIPAP.\n Pt having h/o anxiety, requiring PRN po ativan. And having cough ,need\n guaifenessin.\n D5W with NaHCo3 150meq @ 200cc/hr is on progress .\n Blood c/s tomorrow am. Sputum c/s pending. UA sent\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 339236,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 09:40 AM\n NON-INVASIVE VENTILATION - STOP 11:06 AM\n NON-INVASIVE VENTILATION - START 11:48 AM\n URINE CULTURE - At 06:26 PM\n BLOOD CULTURED - At 01:12 AM\n EKG - At 01:12 AM\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:02 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 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.4\nC (97.6\n HR: 96 (77 - 102) bpm\n BP: 104/54(65) {83/38(50) - 134/76(86)} mmHg\n RR: 19 (10 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,050 mL\n 505 mL\n PO:\n 460 mL\n TF:\n IVF:\n 1,590 mL\n 505 mL\n Blood products:\n Total out:\n 1,310 mL\n 495 mL\n Urine:\n 1,010 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 740 mL\n 10 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 510 (359 - 590) mL\n PS : 6 cmH2O\n PEEP: 6 cmH2O\n FiO2: 60%\n PIP: 12 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 11.1 g/dL\n 404 K/uL\n 168 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 101 mEq/L\n 141 mEq/L\n 30.5 %\n 10.3 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n WBC\n 13.1\n 10.3\n Hct\n 32.3\n 30.5\n Plt\n 443\n 404\n Cr\n 1.3\n 1.3\n TropT\n 0.03\n <0.01\n Glucose\n 70\n 168\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:92/6/<0.01, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.3 mmol/L, Ca++:9.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 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": "Physician ",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 339238,
"text": "Chief Complaint:\n HPI:\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Extubated , d/c'ed\n home on Bactrim DS presumptively for extended coverage of her MRSA\n pneumonia (despite having completed course of Vanc.) At ~1AM this\n morning she developed shortness of breath when she got up to go to the\n bathroom. No cough, fevers, chills. She went back to bed, slept for ~1\n hour on CPAP but awoke again with persistent shortness of breath and\n presented to the ER for further evaluation. Denies chest pain /\n pressure, orthopnea, PND. She feels that her volume overload is\n improving. She denies leg swelling or pain. Persistent cough productive\n of white sputum, no purulence noted. No wheezing or stridor.\n 24 Hour Events: Was on Bipap overnight. Received CTA here which was\n negative. RML and RLL PNA.\n NON-INVASIVE VENTILATION - START 09:40 AM\n NON-INVASIVE VENTILATION - STOP 11:06 AM\n NON-INVASIVE VENTILATION - START 11:48 AM\n URINE CULTURE - At 06:26 PM\n BLOOD CULTURED - At 01:12 AM\n EKG - At 01:12 AM\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Protonix\n Ducloax\n Senna\n Lamictal\n Simvistatin\n Asa\n Atrovent/albuterol nebs\n Cipro 500q24\n Zosun 2.25Q6\n Vancomycin 1g q24\n Seroquel\n Zoloft\n Dexamethasone d\ncd. (total 3 doses) for airway.\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.4\nC (97.6\n HR: 96 (77 - 102) bpm\n BP: 104/54(65) {83/38(50) - 134/76(86)} mmHg\n RR: 19 (10 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,050 mL\n 505 mL\n PO:\n 460 mL\n TF:\n IVF:\n 1,590 mL\n 505 mL\n Blood products:\n Total out:\n 1,310 mL\n 495 mL\n Urine:\n 1,010 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 740 mL\n 10 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 510 (359 - 590) mL\n PS : 6 cmH2O\n PEEP: 6 cmH2O\n FiO2: 60%\n PIP: 12 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 9 L/min\n Physical ExaminationGeneral: Chronically ill appearing. Breathing with\n mild accessory muscle use.\n HEENT: PERRL, anicteric, OP clear with dry MM. CV: S1S2 soft HS\n irreg irreg, +SEM apex no r/g\ns noted. No heave. JVP at ~8-10cm without\n HJR. Lungs: CTA bilaterally with right basilar crackles, upper airway\n wheezing.\n Ab: Obese, positive BS\ns, NT/ND. Ext: 1+ pitting edema, no c/c.\n Neuro: Awake, alert, answers questions appropriately. No gross motor\n deficits.\n Labs / Radiology\n 11.1 g/dL\n 404 K/uL\n 168 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 101 mEq/L\n 141 mEq/L\n 30.5 %\n 10.3 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n WBC\n 13.1\n 10.3\n Hct\n 32.3\n 30.5\n Plt\n 443\n 404\n Cr\n 1.3\n 1.3\n TropT\n 0.03\n <0.01\n Glucose\n 70\n 168\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:92/6/<0.01, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.3 mmol/L, Ca++:9.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Attempts were made in\n MICU to take her off NIPPV but her FiO2 requirement shot up to 100%-\n now back down on minimal PAP. So far her CXR and ENT eval do not appear\n acutely worsened from several days ago prior to hospital d/c . Her\n recent worsening appears most consistent with a multifactorial\n etiology: upper airway procedure (fistula repair) with upper airway\n edema, bronchospasm/COPD, recent MRSA pneumonia. No problems with the\n surgical site. Suspect mucus plug as the etilogy\n 1) ID: CTA demonstrated RLL and RML infiltrate when compared to CT back\n in was present then. Will complete a 8 day course of antibiotics.\n 2) Cardiac: She has a h/o diastolic CHF, however, her current\n presentation is not overly suggestive of a CHF exacerbation being her\n primary issue. Would aim for I/O to be euvolumic.\n 3) Renal: Creatinine 1.3. Follow in the setting of anticipate CTA.\n 4) COPD / tracheobronchiomalacia: Would provide standing nebs,\n Albuterol / Atrovent q4hr and q2hr PRN. Will hold steroids no evidenc\n of wheeze on exam, Guaifenesin and chest PT. NIPPV overnight and as\n needed during the day. Should she require intubation, would do it with\n fiberoptic guidance given her recent surgery. Would also follow with\n repeat CT scan once clear to evaluate for resolution of findinds\n otherwise would consider bronchoscopy to evaluate for obstruction.\n 5) F/E/N: Cardiac prudent diet. Speech and swallow evaluation for\n chronic aspiration. Follow / replete lytes as needed. Goal euvolumic\n for now.\n 6) Hosp: Access - pIV, code - full, proph - PPI and SCDs.\n 7) transfer to floor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 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": "2138-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339183,
"text": "67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Pneumonia, aspiration\n Assessment:\n Low grade fever temp100, LS ronchi diminished on left side, pt has\n productive cough. On NC pt c/o of SOB\n Action:\n Cont BIPAP, cont Zocyn IV, chest CT to r/o PE done\n Response:\n Chest CT neg for PE\n Plan:\n Cont ABX , cont BIPAP. Pt NPO for speech/swallow study\n Respiratory failure, chronic\n Assessment:\n Received on BPAP70%, sat 98-99%, put on NC 5L.pt has a few episodes of\n Apnea.\n Action:\n FIO down to 60%, sat 96-97%, given nebs tx\n Response:\n On NC c/o of SOB and desat to high 80%, tolerates nebs\n Plan:\n Cont BPAP.\n Pt c/o of pain on R leg ( no new for pt), given Ativan with good effect\n also ordering vicodin prn.\n After turning pt\ns BP drooped to 78-88, MD aware, after a few minutes\n BP up to 100\n K 3.8 repleted with 20meq, Mag 1.9 repleted with 2gm\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339126,
"text": "67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Pneumonia, aspiration\n Assessment:\n Low grade fever temp100, LS ronchi diminished on left side, pt has\n productive cough. On NC pt c/o of SOB\n Action:\n Cont BIPAP, cont Zocyn IV, chest CT to r/o PE done\n Response:\n Chest CT neg for PE\n Plan:\n Cont ABX , cont BIPAP. Pt NPO for speech/swallow study\n Respiratory failure, chronic\n Assessment:\n Received on BPAP70%, sat 98-99%, put on NC 5L\n Action:\n FIO down to 60%, sat 96-97%, given nebs tx\n Response:\n On NC c/o of SOB and desat to high 80%, tolerates nebs\n Plan:\n Cont BPAP.\n Pt c/o of pain on R leg ( no new for pt), given Ativan with good effect\n also ordering vicodin prn.\n After turning pt\ns BP drooped to 78-88, MD aware, after a few minutes\n BP up to 100\n K 3.8 repleted with 20meq, Mag 1.9 repleted with 2gm\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 339245,
"text": "67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Pneumonia, aspiration\n Assessment:\n Pt. maintains intact, gag and cough. But, from previous imaging, Pt. is\n to be r/o for aspiration PNA.\n Action:\n Pt. is scheduled for a speech and swallow study today.\n Response:\n No test performed as of yet. Pt. is noted to clear her own secretions.\n Plan:\n Obtain speech and swallow.\n Respiratory failure, chronic\n Assessment:\n Pt, continues to exhibit strong productive cough for moderate amt\ns of\n at times blood tinged tan sputum. Sputum culture sent this am .\n Pt. exhibits clear mid to upper lobes while diminished bibasilar.\n Action:\n Pt. has been ordered IV antibiotics of Zosyn, Vancomycin, and\n Ciprofloxin. Pt. has also been ordered chest PT which she tolerates\n fair. Pt. c/o back pain with this.\n Response:\n Pt. barely tolerates chest PT and\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 339246,
"text": "67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Pneumonia, aspiration\n Assessment:\n Pt. maintains intact, gag and cough. But, from previous imaging, Pt. is\n to be r/o for aspiration PNA.\n Action:\n Pt. is scheduled for a speech and swallow study today.\n Response:\n No test performed as of yet. Pt. is noted to clear her own secretions.\n Plan:\n Obtain speech and swallow.\n Respiratory failure, chronic\n Assessment:\n Pt, continues to exhibit strong productive cough for moderate amt\ns of\n at times blood tinged tan sputum. Sputum culture sent this am .\n Pt. exhibits clear mid to upper lobes while diminished bibasilar.\n Action:\n Pt. has been ordered IV antibiotics of Zosyn, Vancomycin, and\n Ciprofloxin. Pt. has also been ordered chest PT which she tolerates\n fair. Pt. c/o back pain with this.\n Response:\n Pt. barely tolerates chest PT and Pt. does obtain use of her BIPAP\n routinely throughout the day and full time during the night.\n Plan:\n To pre medicate pt. prior to chest PT.\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 339255,
"text": "67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Pneumonia, aspiration\n Assessment:\n Pt. maintains intact, gag and cough. But, from previous imaging, Pt. is\n to be r/o for aspiration PNA.\n Action:\n Pt. is scheduled for a speech and swallow study today.\n Response:\n No test performed as of yet. Pt. is noted to clear her own secretions.\n Plan:\n Obtain speech and swallow.\n Respiratory failure, chronic\n Assessment:\n Pt, continues to exhibit strong productive cough for moderate amt\ns of\n at times blood tinged tan sputum. Sputum culture sent this am .\n Pt. exhibits clear mid to upper lobes while diminished bibasilar.\n Action:\n Pt. has been ordered IV antibiotics of Zosyn, Vancomycin, and\n Ciprofloxin. Pt. has also been ordered chest PT which she tolerates\n fair. Pt. c/o back pain with this.\n Response:\n Pt. barely tolerates chest PT and Pt. does obtain use of her BIPAP\n routinely throughout the day and full time during the night.\n Plan:\n To pre medicate pt. prior to chest PT.\n Pt. is scheduled for a video swallow and Barium swallow to assess\n possible aspiration and or regurg. Pt. has remained A/A/O and c/o\n occasional right hip pain which she is treated with vicoden. Pt. has\n remained afebrile throughout this shift with TMAX 99.1. Pt. is aware\n and is able to state when she requires her BIPAP. Pt. has Allevyn\n dressing over old trach site. This was recently, surgically closed.\n This site remains D&I at this time. Pt. continues to have pending,\n blood, sputum, and urine cultures.\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 339265,
"text": "Chief Complaint:\n HPI:\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Extubated , d/c'ed\n home on Bactrim DS presumptively for extended coverage of her MRSA\n pneumonia (despite having completed course of Vanc.) At ~1AM this\n morning she developed shortness of breath when she got up to go to the\n bathroom. No cough, fevers, chills. She went back to bed, slept for ~1\n hour on CPAP but awoke again with persistent shortness of breath and\n presented to the ER for further evaluation. Denies chest pain /\n pressure, orthopnea, PND. She feels that her volume overload is\n improving. She denies leg swelling or pain. Persistent cough productive\n of white sputum, no purulence noted. No wheezing or stridor.\n 24 Hour Events: Was on Bipap overnight. Received CTA here which was\n negative. RML and RLL PNA.\n NON-INVASIVE VENTILATION - START 09:40 AM\n NON-INVASIVE VENTILATION - STOP 11:06 AM\n NON-INVASIVE VENTILATION - START 11:48 AM\n URINE CULTURE - At 06:26 PM\n BLOOD CULTURED - At 01:12 AM\n EKG - At 01:12 AM\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Protonix\n Ducloax\n Senna\n Lamictal\n Simvistatin\n Asa\n Atrovent/albuterol nebs\n Cipro 500q24\n Zosun 2.25Q6\n Vancomycin 1g q24\n Seroquel\n Zoloft\n Dexamethasone d\ncd. (total 3 doses) for airway.\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.4\nC (97.6\n HR: 96 (77 - 102) bpm\n BP: 104/54(65) {83/38(50) - 134/76(86)} mmHg\n RR: 19 (10 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,050 mL\n 505 mL\n PO:\n 460 mL\n TF:\n IVF:\n 1,590 mL\n 505 mL\n Blood products:\n Total out:\n 1,310 mL\n 495 mL\n Urine:\n 1,010 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 740 mL\n 10 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 510 (359 - 590) mL\n PS : 6 cmH2O\n PEEP: 6 cmH2O\n FiO2: 60%\n PIP: 12 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 9 L/min\n Physical ExaminationGeneral: Chronically ill appearing. Breathing with\n mild accessory muscle use.\n HEENT: PERRL, anicteric, OP clear with dry MM. CV: S1S2 soft HS\n irreg irreg, +SEM apex no r/g\ns noted. No heave. JVP at ~8-10cm without\n HJR. Lungs: CTA bilaterally with right basilar crackles, upper airway\n wheezing.\n Ab: Obese, positive BS\ns, NT/ND. Ext: 1+ pitting edema, no c/c.\n Neuro: Awake, alert, answers questions appropriately. No gross motor\n deficits.\n Labs / Radiology\n 11.1 g/dL\n 404 K/uL\n 168 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 101 mEq/L\n 141 mEq/L\n 30.5 %\n 10.3 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n WBC\n 13.1\n 10.3\n Hct\n 32.3\n 30.5\n Plt\n 443\n 404\n Cr\n 1.3\n 1.3\n TropT\n 0.03\n <0.01\n Glucose\n 70\n 168\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:92/6/<0.01, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.3 mmol/L, Ca++:9.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Attempts were made in\n MICU to take her off NIPPV but her FiO2 requirement shot up to 100%-\n now back down on minimal PAP. So far her CXR and ENT eval do not appear\n acutely worsened from several days ago prior to hospital d/c . Her\n recent worsening appears most consistent with a multifactorial\n etiology: upper airway procedure (fistula repair) with upper airway\n edema, bronchospasm/COPD, recent MRSA pneumonia. No problems with the\n surgical site. Suspect mucus plug as the etiology\n 1) ID: CTA demonstrated RLL and RML infiltrate when compared to CT back\n in was present then. Will complete a 8 day course of antibiotics.\n 2) Cardiac: She has a h/o diastolic CHF, however, her current\n presentation is not overly suggestive of a CHF exacerbation being her\n primary issue. Would aim for I/O to be euvolumic.\n 3) Renal: Creatinine 1.3. Follow in the setting of CTA.\n 4) COPD / tracheobronchiomalacia: Would provide standing nebs,\n Albuterol / Atrovent q4hr and q2hr PRN. Will hold steroids no evidenc\n of wheeze on exam, Guaifenesin and chest PT. NIPPV overnight and as\n needed during the day. Should she require intubation, would do it with\n fiberoptic guidance given her recent surgery. Would also follow with\n repeat CT scan once clear to evaluate for resolution of findings\n otherwise would consider bronchoscopy to evaluate for obstruction.\n 5) F/E/N: Cardiac prudent diet. Speech and swallow evaluation for\n chronic aspiration. Follow / replete lytes as needed. Goal euvolumic\n for now.\n 6) Hosp: Access - pIV, code - full, proph - PPI and SCDs.\n 7) transfer to floor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 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": "Physician ",
"chartdate": "2138-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339527,
"text": "Chief Complaint: 67F with complicated pulmonary history which began\n with prolonged post op course of intubation in after total hip\n replacement with associated pseudomonas PNA, trach/PEG with resultant\n supraglottic stenosis and tracheomalacia. Had laser treatment of\n granulation tissue in trachea in and trach decannulation in\n . Past year has been complicated by multiple admissions for both\n PNA and flash pulm edema. Hospitalized late for take down of\n tracheocutaneous fistula (), had postop MRSA PNA/bacteremia treated\n with vanc. Discharged home on on PO bactrim, represented in acute\n respiratory distress in despite home BIPAP. Working ddx was mucous\n plug vs recurrent PNA. Has received IV decadron x 3 for slight airway\n swelling seen on laryngoscope on admission.\n 24 Hour Events:\n PICC LINE - START 09:34 AM\n NON-INVASIVE VENTILATION - STOP 09:48 AM\n SPUTUM CULTURE - At 09:58 AM\n Pt. expectorated tan colored sputum. Culture sent to the lab.\n FLUOROSCOPY - At 02:22 PM\n Pt. transported down for both a barium and video swallow study. -- no\n evidence overt aspiration\n INVASIVE VENTILATION - START 05:10 AM\n EKG - At 05:20 AM\n BLOOD CULTURED - At 05:30 AM\n RESPIRATORY ARREST - At 04:45 AM\n pt in acute distress, desat to 50's, diaphoretic and mottled; intubated\n Pt did well all day off BiPap, reported feeling back to baseline. Was\n on her BiPap at night (uses this at home) when became acutely short of\n breath at 4am. Given chest PT, lasix 40mg IV and morphine. Pulse 0x\n in high 40s. Emergently intubated. Position confirmed\n fiberoptically. Continued to oxygenate poorly. Tachycardic to\n 130-140s, lots of ectopy, ecg didn't show overt ischemia, CEs\n negative. Blood cultures drawn. CXR c/w pulmonary edema. VBG with pH\n 6.98, lactate 6.6. PEEP increased to 12. Given 80mg IV lasix and\n started on nitro gtt. Became hypotensive to 70s, nitro gtt held.\n Neosynephrine started. Called husband and left message, called and\n spoke to son and informed him of events, he will relay to his father.\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:45 AM\n Furosemide (Lasix) - 05:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.9\n HR: 75 (46 - 134) bpm\n BP: 99/42(58) {70/32(44) - 156/84(100)} mmHg\n RR: 22 (12 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Mixed Venous O2% Sat: 80 - 80\n Total In:\n 567 mL\n 594 mL\n PO:\n TF:\n IVF:\n 567 mL\n 594 mL\n Blood products:\n Total out:\n 1,125 mL\n 940 mL\n Urine:\n 1,125 mL\n 940 mL\n NG:\n Stool:\n Drains:\n Balance:\n -559 mL\n -346 mL\n Respiratory support\n O2 Delivery Device: Other\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (500 - 550) mL\n Vt (Spontaneous): 580 (400 - 580) mL\n PS : 6 cmH2O\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10, FiO2 > 60%, Hemodynamic Instability, Agitated\n PIP: 35 cmH2O\n Plateau: 26 cmH2O\n SpO2: 100%\n ABG: ///31/\n Ve: 11.9 L/min\n Physical Examination\n General: Intubated woman, alert and able to answer questions, in no\n acute distress\n Head, Ears, Nose, Throat: Normocephalic, trach site healing, tiny\n fistula still present\n Pulmonary: No crackles. Decreased with rhonchi at right base.\n Cardiac: Distant. RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted\n Extremities: No edema, 2+ radial, DP pulses b/l\n Neurologic: Alert, able to follow simple commands and express wishes\n Labs / Radiology\n 380 K/uL\n 9.5 g/dL\n 120 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 27.7 %\n 8.0 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n WBC\n 13.1\n 10.3\n 8.0\n Hct\n 32.3\n 30.5\n 27.7\n Plt\n \n Cr\n 1.3\n 1.3\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n Glucose\n 70\n 168\n 120\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:67/6/0.03, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:6.6 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Imaging\n Barium swallow : Prelim report - No evidence for gastroesophageal\n reflux. Small-to-moderate hiatal hernia.\n Video swallow : Preliminary result of no overt aspiration\n Assessment and Plan\n 67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n .\n <I>PLAN:</I>\n .\n <I>## Acute respiratory failure:</I>Patient admitted with respiratory\n distress in setting of possible aspiration PNA vs mucous plugging in\n setting of recent upper airway procedure with airway edema. Patient was\n being weaned off BIPAP yesterday and was doing well until acute episode\n of respiratory distress and failure early this AM leading to\n intubation. Etiology of acute respiratory distress may be mucous\n plugging vs bronchospasm in setting of possible underlying tracheal\n stenosis/edema or granulation tissue in area of prior trach.\n - IP involved, contact them this am regarding possibility of trach\n today. Patient with 6.5 tube so cannot bronch through ETT\n - continue nebs and aggressive chest PT\n - continue tx for aspiration PNA with 8 day course Vanc/Cipro/Zosyn\n (day #3 today)\n -s/p 3 doses decadron per ENT for airway swelling, no stridor\n -f/u ENT and IP recs\n .\n <I>## Hypotension:</I>Requiring neosynephrine overnight with an\n elevated lactate to 6.6 in context of respiratory distress. No evidence\n of new infection or intraabdominal pathology.\n -wean down pressors as tolerated\n -recheck lactate\n -place a-line and recheck ABG today\n .\n <I>## CAD:</I> No evidence for ischemia on ecg. Ruled out with enzymes\n on admission. Patient\ns cardiac enzymes checked overnight in context of\n acute respiratory distress and hypotension. First set troponin <0.01,\n 2^nd set 0.03\n - cycle enzymes, third set of cardiac enzymes due at noon\n -continue ASA, BB. Hold ACEI as above\n .\n <I>## CHF:</I>Patient with pulmonary edema by CXR overnight. TTE\n recently done () showed preserved EF with some focal wall motion\n abnormality. Patient received two doses of IV lasix overnight, looks\n euvolemic currently\n -Will allow patient to autodiuresis, goal net even overnight\n -monitor I/Os\n -Continue BB\n -Holding ACEI as above for ARF\n .\n <I>## ARF:</I>Ddx includes pre-renal in setting of possible infection\n vs ATN/AIN from meds given during last hospitalization and in setting\n of CTA on . Cr decreased from 1.3 to 1.2 overnight.\n -hold on diuresis\n -hold lisinopril\n -renally dose abx\n -check urine lytes, eos\n .\n <I>## COPD:</I>Likely not etiology of acute respiratory distress\n overnight, patient without wheezing on exam\n -continue nebs\n .\n <I>## h/o bacteremia:</I>Last positive blood cx , was MRSA.\n received 8 days of IV vanc, sent home on PO bactrim.\n -Continue vancomycin to complete 14 day treatement for bacteremia\n -monitor for evidence of seeding especially in setting of leukocytosis\n and thrombocytosis which may be evidence for more chronic inflammation\n -PICC placement, continue vancomycin as above, additional 5 days will\n complete total 14 days of IV antibiotics.\n -monitor blood cultures\n .\n <I>## Depression/anxiety:</I>\n -ativan prn anxiety, caution not to oversedate\n -Continue home lamotrigine, quetiapine, sertraline\n .\n <I>## Hyperlipidemia:</I>\n -Continue statin\n .\n <I>## Leukocytosis:<I>White count decreased overnight. Concerning for\n infection although with normal diff. Possible sources include likely\n lungs and possibly bactermia. Pt also at risk for c. diff given recent\n antibiotic use.\n -f/u blood, sputum, stool and urine cultures\n ICU Care\n Nutrition: OG tube placed, CXR confirmed placement. Start tube feeds\n today\n Nutren pulmonary. On cardiac diet as tolerated\n Glycemic Control: Start on insulin sliding scale with initiation of\n tube feeds\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: aspirin and pneumoboots\n Stress ulcer: restart IV protonix 40mg daily\n VAP:\n Comments: increase bowel regimen\n goal for bowel movement today\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 339307,
"text": "Chief Complaint:\n HPI:\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Extubated , d/c'ed\n home on Bactrim DS presumptively for extended coverage of her MRSA\n pneumonia (despite having completed course of Vanc.) At ~1AM this\n morning she developed shortness of breath when she got up to go to the\n bathroom. No cough, fevers, chills. She went back to bed, slept for ~1\n hour on CPAP but awoke again with persistent shortness of breath and\n presented to the ER for further evaluation. Denies chest pain /\n pressure, orthopnea, PND. She feels that her volume overload is\n improving. She denies leg swelling or pain. Persistent cough productive\n of white sputum, no purulence noted. No wheezing or stridor.\n 24 Hour Events: Was on Bipap overnight. Received CTA here which was\n negative. RML and RLL PNA.\n NON-INVASIVE VENTILATION - START 09:40 AM\n NON-INVASIVE VENTILATION - STOP 11:06 AM\n NON-INVASIVE VENTILATION - START 11:48 AM\n URINE CULTURE - At 06:26 PM\n BLOOD CULTURED - At 01:12 AM\n EKG - At 01:12 AM\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Protonix\n Ducloax\n Senna\n Lamictal\n Simvistatin\n Asa\n Atrovent/albuterol nebs\n Cipro 500q24\n Zosun 2.25Q6\n Vancomycin 1g q24\n Seroquel\n Zoloft\n Dexamethasone d\ncd. (total 3 doses) for airway.\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.4\nC (97.6\n HR: 96 (77 - 102) bpm\n BP: 104/54(65) {83/38(50) - 134/76(86)} mmHg\n RR: 19 (10 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,050 mL\n 505 mL\n PO:\n 460 mL\n TF:\n IVF:\n 1,590 mL\n 505 mL\n Blood products:\n Total out:\n 1,310 mL\n 495 mL\n Urine:\n 1,010 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 740 mL\n 10 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 510 (359 - 590) mL\n PS : 6 cmH2O\n PEEP: 6 cmH2O\n FiO2: 60%\n PIP: 12 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 9 L/min\n Physical ExaminationGeneral: Chronically ill appearing. Breathing with\n mild accessory muscle use.\n HEENT: PERRL, anicteric, OP clear with dry MM. CV: S1S2 soft HS\n irreg irreg, +SEM apex no r/g\ns noted. No heave. JVP at ~8-10cm without\n HJR. Lungs: CTA bilaterally with right basilar crackles, upper airway\n wheezing.\n Ab: Obese, positive BS\ns, NT/ND. Ext: 1+ pitting edema, no c/c.\n Neuro: Awake, alert, answers questions appropriately. No gross motor\n deficits.\n Labs / Radiology\n 11.1 g/dL\n 404 K/uL\n 168 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 101 mEq/L\n 141 mEq/L\n 30.5 %\n 10.3 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n WBC\n 13.1\n 10.3\n Hct\n 32.3\n 30.5\n Plt\n 443\n 404\n Cr\n 1.3\n 1.3\n TropT\n 0.03\n <0.01\n Glucose\n 70\n 168\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:92/6/<0.01, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.3 mmol/L, Ca++:9.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Attempts were made in\n MICU to take her off NIPPV but her FiO2 requirement shot up to 100%-\n now back down on minimal PAP. So far her CXR and ENT eval do not appear\n acutely worsened from several days ago prior to hospital d/c . Her\n recent worsening appears most consistent with a multifactorial\n etiology: upper airway procedure (fistula repair) with upper airway\n edema, bronchospasm/COPD, recent MRSA pneumonia. No problems with the\n surgical site. Suspect mucus plug as the etiology\n 1) ID: CTA demonstrated RLL and RML infiltrate when compared to CT back\n in was present then. Will complete a 8 day course of antibiotics.\n 2) Cardiac: She has a h/o diastolic CHF, however, her current\n presentation is not overly suggestive of a CHF exacerbation being her\n primary issue. Would aim for I/O to be euvolumic.\n 3) Renal: Creatinine 1.3. Follow in the setting of CTA.\n 4) COPD / tracheobronchiomalacia: Would provide standing nebs,\n Albuterol / Atrovent q4hr and q2hr PRN. Will hold steroids no evidenc\n of wheeze on exam, Guaifenesin and chest PT. NIPPV overnight and as\n needed during the day. Should she require intubation, would do it with\n fiberoptic guidance given her recent surgery. Would also follow with\n repeat CT scan once clear to evaluate for resolution of findings\n otherwise would consider bronchoscopy to evaluate for obstruction.\n 5) F/E/N: Cardiac prudent diet. Speech and swallow evaluation for\n chronic aspiration. Follow / replete lytes as needed. Goal euvolumic\n for now.\n 6) Hosp: Access - pIV, code - full, proph - PPI and SCDs.\n 7) transfer to floor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU level of care\n Total time spent: 45 min\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 339312,
"text": "67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Pneumonia, aspiration\n Assessment:\n Pt. maintains intact, cough, with no gag noted.. But, from previous\n imaging, Pt. is to be r/o for aspiration PNA.\n Action:\n Pt. had video and barium swallow studies today. Outcome at present is\n to give pt. nectar thickened liquids.\n Response:\n Pt. is noted to clear her own secretions. Pt. is to have thickened\n liquids for precautions of aspiration potential.\n Plan:\n Thickened liquids.\n Respiratory failure, chronic\n Assessment:\n Pt, continues to exhibit strong productive cough for moderate amt\ns of\n at times blood tinged tan sputum. Sputum culture sent this am .\n Pt. exhibits clear mid to upper lobes while diminished bibasilar.\n Action:\n Pt. has been ordered IV antibiotics of Zosyn, Vancomycin, and\n Ciprofloxin. Pt. has also been ordered chest PT which she tolerates\n fair. Pt. c/o back pain with this.\n Response:\n Pt. barely tolerates chest PT and Pt. does obtain use of her BIPAP\n routinely throughout the day and full time during the night.\n Plan:\n To pre medicate pt. prior to chest PT.\n Pt. is scheduled for a video swallow and Barium swallow to assess\n possible aspiration and or regurg. Which has now been obtained. Pt. has\n remained A/A/O and c/o occasional right hip pain which she is treated\n with vicoden. Pt. also has received ativan po for slight anxiety. Pt.\n has remained afebrile throughout this shift with TMAX 99.1. Pt. is\n aware and is able to state when she requires her BIPAP. Pt. has\n Allevyn dressing over old trach site. This was recently, surgically\n closed. This site remains D&I at this time. Pt. continues to have\n pending, blood, sputum, and urine cultures.\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339196,
"text": "Chief Complaint:\n 24 Hour Events:\n On CPAP for much of day/night.\n - CTA done (was treated w/ mucomyst & bicarb), which, on prelim report,\n shows minimal subcutaneous emphysema along both anterior chest walls.\n No PE. Aspiration, with fluid in the right lower lobe and right middle\n lobe bronchi,\n with atelectasis and patchy consolidation suspicious for pneumonia.\n There are also findings suspicious for interstitial edema.\n - Put in for Speech & Swallow c/s given question of aspiration on CTA\n URINE CULTURE - At 06:26 PM\n BLOOD CULTURED - At 01:12 AM\n EKG - At 01:12 AM\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.7\nC (98.1\n HR: 93 (77 - 102) bpm\n BP: 107/53(67) {83/38(50) - 134/76(86)} mmHg\n RR: 21 (10 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,050 mL\n 469 mL\n PO:\n 460 mL\n TF:\n IVF:\n 1,590 mL\n 469 mL\n Blood products:\n Total out:\n 1,310 mL\n 355 mL\n Urine:\n 1,010 mL\n 355 mL\n NG:\n Stool:\n Drains:\n Balance:\n 740 mL\n 114 mL\n Respiratory support\n O2 Delivery Device: Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 510 (359 - 590) mL\n PS : 6 cmH2O\n PEEP: 6 cmH2O\n FiO2: 60%\n PIP: 12 cmH2O\n SpO2: 99%\n ABG: ///30/\n Ve: 9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 404 K/uL\n 11.1 g/dL\n 168 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 101 mEq/L\n 141 mEq/L\n 30.5 %\n 10.3 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n WBC\n 13.1\n 10.3\n Hct\n 32.3\n 30.5\n Plt\n 443\n 404\n Cr\n 1.3\n 1.3\n TropT\n 0.03\n <0.01\n Glucose\n 70\n 168\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:92/6/<0.01, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.3 mmol/L, Ca++:9.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 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": "2138-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339213,
"text": "Chief Complaint:\n 24 Hour Events:\n On CPAP for much of day/night.\n - CTA done (was treated w/ mucomyst & bicarb), which, on prelim report,\n shows minimal subcutaneous emphysema along both anterior chest walls.\n No PE. Aspiration, with fluid in the right lower lobe and right middle\n lobe bronchi,\n with atelectasis and patchy consolidation suspicious for pneumonia.\n There are also findings suspicious for interstitial edema.\n - Put in for Speech & Swallow c/s given question of aspiration on CTA,\n made NPO\n URINE CULTURE - At 06:26 PM\n BLOOD CULTURED - At 01:12 AM\n EKG - At 01:12 AM\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.7\nC (98.1\n HR: 93 (77 - 102) bpm\n BP: 107/53(67) {83/38(50) - 134/76(86)} mmHg\n RR: 21 (10 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,050 mL\n 469 mL\n PO:\n 460 mL\n TF:\n IVF:\n 1,590 mL\n 469 mL\n Blood products:\n Total out:\n 1,310 mL\n 355 mL\n Urine:\n 1,010 mL\n 355 mL\n NG:\n Stool:\n Drains:\n Balance:\n 740 mL\n 114 mL\n Respiratory support\n O2 Delivery Device: Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 510 (359 - 590) mL\n PS : 6 cmH2O\n PEEP: 6 cmH2O\n FiO2: 60%\n PIP: 12 cmH2O\n SpO2: 99%\n ABG: ///30/\n Ve: 9 L/min\n Physical Examination\n General: Awake, alert, mildly anxious, tachypneic.\n HEENT: NCAT, MM dry. Hoarse voice\n Neck: supple, inspiratory wheeze on ascultation of trachea (louder than\n in lungs), + JVD with HJR. s/p tracheocutaneous fistula repair with\n bandage c/d/i, incision still partially open with sm amount white\n drainage. No surrounding erythema. No crepitus.\n Pulmonary: No crackles, inspiratory wheeze. Decreased at right base.\n Cardiac: Distant. RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted\n Extremities: No edema, 2+ radial, DP pulses b/l\n Neurologic: Alert, oriented x 3. Able to relate history without\n difficulty. Cranial nerves II-XII intact. Normal bulk, strength and\n tone throughout. No abnormal movements noted. No deficits to light\n touch throughout.\n Labs / Radiology\n 404 K/uL\n 11.1 g/dL\n 168 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 101 mEq/L\n 141 mEq/L\n 30.5 %\n 10.3 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n WBC\n 13.1\n 10.3\n Hct\n 32.3\n 30.5\n Plt\n 443\n 404\n Cr\n 1.3\n 1.3\n TropT\n 0.03\n <0.01\n Glucose\n 70\n 168\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:92/6/<0.01, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.3 mmol/L, Ca++:9.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 67F with CAD, CHF, COPD and complicated pulmonary history w/p prolonged\n tracheostomy with recent decannulation and subsequent fistula closure\n with complicated MRSA PNA presenting with worsened respiratory\n distess.\n .\n <I>PLAN:</I>\n .\n <I>## Respiratory distress:</I>Ddx includes cardiac (CHF, MI), PE given\n recent hospitalization and immobility, VAP, COPD exacerbation, airway\n obstruction given recent surgery and airway instrumentation. Per ENT\n note there is moderate supraglottic edema.\n -Per ENT recs, 10mg IV decadron Q8 x 3.\n -After decadron completed with switch to PO prednisone for steroid\n taper to tx for COPD component of respiratory compromise.\n -Standing and PRN nebs\n -Tx for VAP pna with Vanc/Zosyn and Cipro for add'l coverage of GNRs.\n -PICC placement for anticipated prolonged abx course\n -sputum cultures\n -follor CXRs\n -BNP 1900, not significantly off baseline. Pt dose look slightly volume\n overloaded, but unclear if this is playing a significant role in her\n respiratory distress. Also in ARF so want to minimize diuresis for\n now. Will reserve lasix for now, may need after getting fluid/dye for\n CT.\n -Pt is moderate to high risk per criteria for PE given recent\n surgery and hospitalizion. CTA with pretreatment mucomyst and bicarb\n to r/o PE.\n -F/u IP recs.\n -Continue to ROMI with serial CEs\n -Pt refusing ABGs, will hold of for now, may need if becomes\n somnolent.\n -BiPap to maintain 02 sats >88% or for pt comfort. Wean down 02 as\n tolerated.\n .\n <I>## ARF:</I>Ddx includes pre-renal in setting of possible infection\n vs ATN/AIN from meds given during last hospitalization.\n -d/c bactrim\n -hold on diuresis\n -hold lisinopril\n -renally dose abx\n -check urine lytes, eos\n .\n <I>## CAD:</I> No evidence for ischemia on ecg.\n -continue ASA, BB. Hold ACEI as above\n -continue to cycle CEs for full ROMI\n .\n <I>## CHF:</I>Clinically and by CXR and BNP pt appears moderately\n volume overloaded. TTE recently done () showed preserved EF with\n some focal wall motion abnormality.\n -Caution with fluids\n -may require diuresis after CTA\n -monitor I/Os\n -Continue BB\n -Holding ACEI as above for ARF\n .\n <I>## COPD:</I>Treat for exacerbation\n -steroids\n -nebs\n -02 prn\n -watch for somnolence as indicatory of increased retention as pt\n refusing ABG.\n .\n <I>## h/o bacteremia:</I>Last positive blood cx , was MRSA.\n received 8 days of IV vanc, sent home on PO bactrim.\n -Continue vancomycin to complete 14 day treatement for bacteremia\n -monitor for evidence of seeding especially in setting of leukocytosis\n and thrombocytosis which may be evidence for more chronic inflammation\n -PICC placement\n -monitor blood cultures\n .\n <I>## Depression/anxiety:</I>\n -ativan prn anxiety, caution not to oversedate\n -Continue home lamotrigine, quetiapine, sertraline\n .\n <I>## OSA:</I>\n -BiPAP or CPAP at night\n .\n <I>## Hyperlipidemia:</I>\n -Continue statin\n .\n <I>## Leukocytosis:<I>Concerning for infection although with normal\n diff. Possible sources include likely lungs and possibly bactermia. Pt\n also at risk for c. diff given recent antibiotic use.\n -blood cultres\n -sputum cultures\n -stool and urine cultures\n ICU Care\n Nutrition:\n Comments: Cardiac heart healthy diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339403,
"text": "67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Video swallow & barium swallow study on to assess possible\n aspiration & regurgitation. Patient may have nectar thick liquids.\n Pneumonia, aspiration\n Assessment:\n Taking Po meds with apple sauce. No signs of aspiration noted. Appetite\n very poor.\n Action:\n Pt. had video and barium swallow studies . Outcome at present is\n to give pt. nectar thickened liquids.\n Response:\n Strong coughing, productive at times for moderate amounts of blood\n tinged tan sputum. Tolerates Po meds with apple sauce.\n Plan:\n Will cont to monitor her closely for aspiration. need Dietary\n consult for poor appetite/ improper nutrition.\n Respiratory failure, chronic\n Assessment:\n Patient on BIPAP overnight, C/O fatigueness. Denies any SOB. Strong\n productive cough at times. Lungs crackles bilaterally anterorly, while\n diminished at bases.\n Action:\n On BiPAP overnight. Tolearting well.\n Response:\n Pt. barely tolerates chest . tolerating BIPAP .\n Plan:\n To pre medicate pt. prior to chest PT. will cont on Abx ( zosyn,\n vancomycin & Cipro PO)\n Pt. has remained A/A/O and c/o occasional right hip pain which she is\n treated with vicoden PRN. Pt. also has received ativan po , PRN for\n anxiety. Pt C/O fatiguness. Uses BIPAP overnight.. Pt. has Allevyn\n dressing over old trach site. This was recently, surgically closed.\n This site remains D&I at this time. P ending, blood, sputum, and urine\n cultures.\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339519,
"text": "Chief Complaint: 67F with complicated pulmonary history. Initiated in\n when had THR, complicated post op course with prolonged\n intubation, with associated pseudomonas PNA, trach/PEG with resultant\n supraglottic stenosis and tracheomalacia. Had laser treatment of\n granulation tissue in trachea in and trach decannulation in\n . Past year has been complicated by multiple admissions for both\n PNA and flash pulm edema. Hospitalized late for take down of\n tracheocutaneous fistula (), had postop MRSA PNA/bacteremia treated\n with vanc. Discharged home on on PO bactrim, represented in acute\n respiratory distress in despite home BIPAP. Working ddx was mucous\n plug vs recurrent PNA. Has received IV decadron x 3 for slight airway\n swelling seen on laryngoscope on admission.\n 24 Hour Events:\n PICC LINE - START 09:34 AM\n NON-INVASIVE VENTILATION - STOP 09:48 AM\n SPUTUM CULTURE - At 09:58 AM\n Pt. expectorated tan colored sputum. Culture sent to the lab.\n FLUOROSCOPY - At 02:22 PM\n Pt. transported down for both a barium and video swallow study. -- no\n evidence overt aspiration\n INVASIVE VENTILATION - START 05:10 AM\n EKG - At 05:20 AM\n BLOOD CULTURED - At 05:30 AM\n RESPIRATORY ARREST - At 04:45 AM\n pt in acute distress, desat to 50's, diaphoretic and mottled; intubated\n Pt did well all day off BiPap, reported feeling back to baseline. Was\n on her BiPap at night (uses this at home) when became acutely short of\n breath at 4am. Given chest PT, lasix 40mg IV and morphine. Pulse 0x\n in high 40s. Emergently intubated. Position confirmed\n fiberoptically. Continued to oxygenate poorly. Tachycardic to\n 130-140s, lots of ectopy, ecg didn't show overt ischemia, CEs\n negative. Blood cultures drawn. CXR c/w pulmonary edema. VBG with pH\n 6.98, lactate 6.6. PEEP increased to 12. Given 80mg IV lasix and\n started on nitro gtt. Became hypotensive to 70s, nitro gtt held.\n Neosynephrine started. Called husband and left message, called and\n spoke to son and informed him of events, he will relay to his father.\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:45 AM\n Furosemide (Lasix) - 05:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.9\n HR: 75 (46 - 134) bpm\n BP: 99/42(58) {70/32(44) - 156/84(100)} mmHg\n RR: 22 (12 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Mixed Venous O2% Sat: 80 - 80\n Total In:\n 567 mL\n 594 mL\n PO:\n TF:\n IVF:\n 567 mL\n 594 mL\n Blood products:\n Total out:\n 1,125 mL\n 940 mL\n Urine:\n 1,125 mL\n 940 mL\n NG:\n Stool:\n Drains:\n Balance:\n -559 mL\n -346 mL\n Respiratory support\n O2 Delivery Device: Other\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (500 - 550) mL\n Vt (Spontaneous): 580 (400 - 580) mL\n PS : 6 cmH2O\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10, FiO2 > 60%, Hemodynamic Instability, Agitated\n PIP: 35 cmH2O\n Plateau: 26 cmH2O\n SpO2: 100%\n ABG: ///31/\n Ve: 11.9 L/min\n Physical Examination\n General: Intubated woman, alert and able to answer questions, in no\n acute distress\n Head, Ears, Nose, Throat: Normocephalic, trach site healing, tiny\n fistula still present\n Pulmonary: No crackles. Decreased with rhonchi at right base.\n Cardiac: Distant. RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted\n Extremities: No edema, 2+ radial, DP pulses b/l\n Neurologic: Alert, able to follow simple commands and express wishes\n Labs / Radiology\n 380 K/uL\n 9.5 g/dL\n 120 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 27.7 %\n 8.0 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n WBC\n 13.1\n 10.3\n 8.0\n Hct\n 32.3\n 30.5\n 27.7\n Plt\n \n Cr\n 1.3\n 1.3\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n Glucose\n 70\n 168\n 120\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:67/6/0.03, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:6.6 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Imaging\n Barium swallow : Prelim report - No evidence for gastroesophageal\n reflux. Small-to-moderate hiatal hernia.\n Video swallow : Preliminary result of no overt aspiration\n Assessment and Plan\n 67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n .\n <I>PLAN:</I>\n .\n <I>## Acute respiratory failure:</I>Patient admitted with respiratory\n distress in setting of possible aspiration PNA vs mucous plugging in\n setting of recent upper airway procedure with airway edema. Patient was\n being weaned off BIPAP yesterday and was doing well until acute episode\n of respiratory distress and failure early this AM leading to\n intubation. Etiology of acute respiratory distress may be mucous\n plugging vs bronchospasm in setting of possible underlying tracheal\n stenosis/edema or granulation tissue in area of prior trach.\n - IP involved, contact them this am regarding possibility of trach\n today. Patient with 6.5 tube so cannot bronch through ETT\n - continue nebs and aggressive chest PT\n - continue tx for aspiration PNA with 8 day course Vanc/Cipro/Zosyn\n (day #3 today)\n -s/p 3 doses decadron per ENT for airway swelling, no stridor\n -f/u ENT and IP recs\n .\n <I>## Hypotension:</I>Requiring neosynephrine overnight with an\n elevated lactate to 6.6 in context of respiratory distress. No evidence\n of new infection or intraabdominal pathology.\n -wean down pressors as tolerated\n -recheck lactate\n -place a-line and recheck ABG today\n .\n <I>## CAD:</I> No evidence for ischemia on ecg. Ruled out with enzymes\n on admission. Patient\ns cardiac enzymes checked overnight in context of\n acute respiratory distress and hypotension. First set troponin <0.01,\n 2^nd set 0.03\n - cycle enzymes, third set of cardiac enzymes due at noon\n -continue ASA, BB. Hold ACEI as above\n .\n <I>## CHF:</I>Patient with pulmonary edema by CXR overnight. TTE\n recently done () showed preserved EF with some focal wall motion\n abnormality. Patient received two doses of IV lasix overnight, looks\n euvolemic currently\n -Will allow patient to autodiuresis, goal net even overnight\n -monitor I/Os\n -Continue BB\n -Holding ACEI as above for ARF\n .\n <I>## ARF:</I>Ddx includes pre-renal in setting of possible infection\n vs ATN/AIN from meds given during last hospitalization and in setting\n of CTA on . Cr decreased from 1.3 to 1.2 overnight.\n -hold on diuresis\n -hold lisinopril\n -renally dose abx\n -check urine lytes, eos\n .\n <I>## COPD:</I>Likely not etiology of acute respiratory distress\n overnight, patient without wheezing on exam\n -continue nebs\n .\n <I>## h/o bacteremia:</I>Last positive blood cx , was MRSA.\n received 8 days of IV vanc, sent home on PO bactrim.\n -Continue vancomycin to complete 14 day treatement for bacteremia\n -monitor for evidence of seeding especially in setting of leukocytosis\n and thrombocytosis which may be evidence for more chronic inflammation\n -PICC placement, continue vancomycin as above, additional 8 days will\n complete total 14 days of IV antibiotics.\n -monitor blood cultures\n .\n <I>## Depression/anxiety:</I>\n -ativan prn anxiety, caution not to oversedate\n -Continue home lamotrigine, quetiapine, sertraline\n .\n <I>## Hyperlipidemia:</I>\n -Continue statin\n .\n <I>## Leukocytosis:<I>White count decreased overnight. Concerning for\n infection although with normal diff. Possible sources include likely\n lungs and possibly bactermia. Pt also at risk for c. diff given recent\n antibiotic use.\n -f/u blood, sputum, stool and urine cultures\n ICU Care\n Nutrition: OG tube placed, CXR confirmed placement. Start tube feeds\n today\n Nutren pulmonary. On cardiac diet as tolerated\n Glycemic Control: Start on insulin sliding scale with initiation of\n tube feeds\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: aspirin and pneumoboots\n Stress ulcer: restart IV protonix 40mg daily\n VAP:\n Comments: increase bowel regimen\n goal for bowel movement today\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339380,
"text": "Chief Complaint:\n 24 Hour Events:\n On CPAP for much of day/night.\n - CTA done (was treated w/ mucomyst & bicarb), which, on prelim report,\n shows minimal subcutaneous emphysema along both anterior chest walls.\n No PE. Aspiration, with fluid in the right lower lobe and right middle\n lobe bronchi,\n with atelectasis and patchy consolidation suspicious for pneumonia.\n There are also findings suspicious for interstitial edema.\n - Put in for Speech & Swallow c/s given question of aspiration on CTA,\n made NPO\n URINE CULTURE - At 06:26 PM\n BLOOD CULTURED - At 01:12 AM\n EKG - At 01:12 AM\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:02 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 Reports feeling back to baseline. + cough with white, blood tinged\n sptutum, not new.\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.7\nC (98.1\n HR: 93 (77 - 102) bpm\n BP: 107/53(67) {83/38(50) - 134/76(86)} mmHg\n RR: 21 (10 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,050 mL\n 469 mL\n PO:\n 460 mL\n TF:\n IVF:\n 1,590 mL\n 469 mL\n Blood products:\n Total out:\n 1,310 mL\n 355 mL\n Urine:\n 1,010 mL\n 355 mL\n NG:\n Stool:\n Drains:\n Balance:\n 740 mL\n 114 mL\n Respiratory support\n O2 Delivery Device: Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 510 (359 - 590) mL\n PS : 6 cmH2O\n PEEP: 6 cmH2O\n FiO2: 60%\n PIP: 12 cmH2O\n SpO2: 99%\n ABG: ///30/\n Ve: 9 L/min\n Physical Examination\n General: Awake, alert, appears comfortable\n HEENT: NCAT, MM dry. Hoarse voice\n Neck: supple + JVD with HJR. s/p tracheocutaneous fistula repair with\n bandage c/d/i, incision still partially open with sm amount white\n drainage. No surrounding erythema. No crepitus.\n Pulmonary: No crackles. Decreased at right base.\n Cardiac: Distant. RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted\n Extremities: No edema, 2+ radial, DP pulses b/l\n Neurologic: Alert, oriented x 3. Able to relate history without\n difficulty. Cranial nerves II-XII intact. Normal bulk, strength and\n tone throughout. No abnormal movements noted. No deficits to light\n touch throughout.\n Labs / Radiology\n 404 K/uL\n 11.1 g/dL\n 168 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 101 mEq/L\n 141 mEq/L\n 30.5 %\n 10.3 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n WBC\n 13.1\n 10.3\n Hct\n 32.3\n 30.5\n Plt\n 443\n 404\n Cr\n 1.3\n 1.3\n TropT\n 0.03\n <0.01\n Glucose\n 70\n 168\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:92/6/<0.01, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.3 mmol/L, Ca++:9.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 67F with CAD, CHF, COPD and complicated pulmonary history w/p prolonged\n tracheostomy with recent decannulation and subsequent fistula closure\n with complicated MRSA PNA presenting with worsened respiratory\n distress.\n .\n <I>PLAN:</I>\n .\n <I>## Respiratory distress:</I>No evidence MI or PE. Ddx includes PNA,\n CT imaging c/w lung collapse vs possible aspiration PNA. have\n mucous plugged resulting in acute resp distress now resolved.\n -tx for aspiration PNA with 8 day course Vanc/Cipro/Zosyn\n -Aggressive chest PT\n -SLP eval\n -barium swallow to eval if chronic reflux/aspiration\n -supplemental 02 as needed\n -BiPAP at night and PRN\n -s/p 3 doses decadron per ENT for airway swelling, no stridor\n -f/u ENT and IP recs\n -home nebs\n .\n <I>## ARF:</I>Ddx includes pre-renal in setting of possible infection\n vs ATN/AIN from meds given during last hospitalization.\n -d/c bactrim\n -hold on diuresis\n -hold lisinopril\n -renally dose abx\n -check urine lytes, eos\n .\n <I>## CAD:</I> No evidence for ischemia on ecg. Ruled out with enzymes\n -continue ASA, BB. Hold ACEI as above\n .\n <I>## CHF:</I>Clinically and by CXR and BNP pt appears moderately\n volume overloaded. TTE recently done () showed preserved EF with\n some focal wall motion abnormality.\n -Caution with fluids\n -may require diuresis after CTA\n -monitor I/Os\n -Continue BB\n -Holding ACEI as above for ARF\n .\n <I>## COPD:</I>Treat for exacerbation\n -nebs\n -02 prn\n -watch for somnolence as indicatory of increased retention as pt\n refusing ABG.\n .\n <I>## h/o bacteremia:</I>Last positive blood cx , was MRSA.\n received 8 days of IV vanc, sent home on PO bactrim.\n -Continue vancomycin to complete 14 day treatement for bacteremia\n -monitor for evidence of seeding especially in setting of leukocytosis\n and thrombocytosis which may be evidence for more chronic inflammation\n -PICC placement, continue vancomycin as above, additional 8 days will\n complete total 14 days of IV antibiotics.\n -monitor blood cultures\n .\n <I>## Depression/anxiety:</I>\n -ativan prn anxiety, caution not to oversedate\n -Continue home lamotrigine, quetiapine, sertraline\n .\n <I>## OSA:</I>\n -BiPAP or CPAP at night\n .\n <I>## Hyperlipidemia:</I>\n -Continue statin\n .\n <I>## Leukocytosis:<I>Concerning for infection although with normal\n diff. Possible sources include likely lungs and possibly bactermia. Pt\n also at risk for c. diff given recent antibiotic use.\n -blood cultres\n -sputum cultures\n -stool and urine cultures\n ICU Care\n Nutrition:\n Comments: Cardiac heart healthy diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU, consider call out in am if stable.\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 339494,
"text": "Chief Complaint: respiratory failure\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 67 y/o F w/CAD, TBM, tracheocutaneous fistula c/b MRSA pna, recently\n discharged & readmitted for respiratory failure.\n 24 Hour Events:\n PICC LINE - START 09:34 AM\n NON-INVASIVE VENTILATION - STOP 09:48 AM\n SPUTUM CULTURE - At 09:58 AM\n Pt. expectorated tan colored sputum. Culture sent to the lab.\n FLUOROSCOPY - At 02:22 PM\n Pt. transported down for both a barium and video swallow study.\n RESPIRATORY ARREST - At 04:45 AM\n pt in acute distress, desat to 50's, diaphoretic and mottled; intubated\n INVASIVE VENTILATION - START 05:10 AM\n EKG - At 05:20 AM\n BLOOD CULTURED - At 05:30 AM\n Overnight, had worsening hypoxemia & respiratory distress. Acute event\n where desaturated to high 40s, looked diaphoretic, and got intubated.\n EKG nonischemic, cardiac enzymes negative x1. Became hypotensive and\n now requiring neo.\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:45 AM\n Furosemide (Lasix) - 05:38 AM\n Other medications:\n colace, senna, lamictal, simvastatin, aspirin 81, albuterol/atrovent,\n ciprofloxacin, vancomycin q48h, seroquel, zoloft, peridex\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 Respiratory: Dyspnea, Tachypnea\n Flowsheet Data as of 10:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.9\n HR: 70 (46 - 134) bpm\n BP: 92/52(62) {70/32(44) - 156/84(100)} mmHg\n RR: 22 (12 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Mixed Venous O2% Sat: 80 - 80\n Total In:\n 567 mL\n 642 mL\n PO:\n TF:\n IVF:\n 567 mL\n 642 mL\n Blood products:\n Total out:\n 1,125 mL\n 1,180 mL\n Urine:\n 1,125 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n -559 mL\n -538 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (500 - 550) mL\n Vt (Spontaneous): 580 (400 - 580) mL\n PS : 6 cmH2O\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10, FiO2 > 60%, Hemodynamic Instability, Agitated\n PIP: 35 cmH2O\n Plateau: 26 cmH2O\n SpO2: 100%\n ABG: ///31/\n Ve: 11.9 L/min\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic, trach site healing, tiny\n fistula still present\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: at R base)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: 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 9.5 g/dL\n 380 K/uL\n 120 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 27.7 %\n 8.0 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n WBC\n 13.1\n 10.3\n 8.0\n Hct\n 32.3\n 30.5\n 27.7\n Plt\n \n Cr\n 1.3\n 1.3\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n Glucose\n 70\n 168\n 120\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:67/6/0.03, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:6.6 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n 1) ID: CTA demonstrated RLL and RML infiltrate when compared to CT back\n in was present then. Will complete a 8 day course of\n antibiotics. On vanc/cipro/zosyn for VAP.\n 2) Cardiac: She has a h/o diastolic CHF, however, her current\n presentation is not overly suggestive of a CHF exacerbation being her\n primary issue. Would aim for I/O to be euvolumic. Trend cardiac\n enzymes given event overnight.\n 3) Renal: Creatinine 1.2. Follow in the setting of CTA.\n 4) COPD / tracheobronchiomalacia: Acute event overnight appears to be\n due to a mucus plug, likely complicated by underlying airway\n pathology. have tracheal stenosis or granulation tissue at level\n of prior trach complicating the situation. Will discuss with IP\n possibility of bronch today (cannot bronch through ETT given 6.5\n tube). Continue nebs.\n 5) F/E/N: Cardiac prudent diet. Speech and swallow evaluation for\n chronic aspiration. Follow / replete lytes as needed. Goal euvolumic\n for now.\n 6) Shock: Requiring neosynephrine overnight with an elevated lactate.\n No evidence of intraabdominal pathology to explain the lactate. Will\n recheck.\n .\n ICU Care\n Nutrition:\n Comments: start tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339458,
"text": "Chief Complaint: 67F with complicated pulmonary history. Initiated in\n when had THR, complicated post op course with prolonged\n intubation, with associated pseudomonas PNA, trach/PEG with resultant\n supraglottic stenosis and tracheomalacia. Had laser treatment of\n granulation tissue in trachea in and trach decannulation in\n . Past year has been complicated by multiple admissions for both\n PNA and flash pulm edema. Hospitalized late for take down of\n tracheocutaneous fistula (), had MRSA PNA/bacteremia. Discharged on\n , represented in acute respiratory distress in . Working ddx was\n mucous plug vs recurrent PNA. Has received IV decadron x 3 for slight\n airway swelling seen on laryngoscope on admission.\n 24 Hour Events:\n PICC LINE - START 09:34 AM\n NON-INVASIVE VENTILATION - STOP 09:48 AM\n SPUTUM CULTURE - At 09:58 AM\n Pt. expectorated tan colored sputum. Culture sent to the lab.\n FLUOROSCOPY - At 02:22 PM\n Pt. transported down for both a barium and video swallow study. -- no\n evidence overt aspiration\n RESPIRATORY ARREST - At 04:45 AM\n pt in acute distress, desat to 50's, diaphoretic and mottled; intubated\n Pt did well all day off BiPap, reported feeling back to baseline. Was\n on her BiPap at night (uses this at home) when became acutely short of\n breath at 4am. Given chest PT, lasix 40mg IV and morphine. Pulse 0x\n in high 40s. Emergently intubated. Position confirmed\n fiberoptically. Continued to oxygenate poorly. Tachycardic to\n 130-140s, lots of ectopy, ecg didn't show overt ischemia, CEs\n negative. Blood cultures drawn. CXR c/w pulmonary edema. VBG with pH\n 6.98, lactate 6.6. PEEP increased to 12. Given 80mg IV lasix and\n started on nitro gtt. Became hypotensive to 70s, nitro gtt held.\n Neosynephrine started. Called husband and left message, called and\n spoke to son and informed him of events, he will relay to his father.\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:45 AM\n Furosemide (Lasix) - 05:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.4\nC (97.6\n HR: 133 (46 - 133) bpm\n BP: 156/83(100) {96/36(50) - 156/84(100)} mmHg\n RR: 26 (12 - 26) insp/min\n SpO2: 83%\n Heart rhythm: ST (Sinus Tachycardia)\n Mixed Venous O2% Sat: 80 - 80\n Total In:\n 567 mL\n 769 mL\n PO:\n TF:\n IVF:\n 567 mL\n 769 mL\n Blood products:\n Total out:\n 1,125 mL\n 230 mL\n Urine:\n 1,125 mL\n 230 mL\n NG:\n Stool:\n Drains:\n Balance:\n -559 mL\n 539 mL\n Respiratory support\n O2 Delivery Device: Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 580 (400 - 580) mL\n PS : 6 cmH2O\n PEEP: 6 cmH2O\n PIP: 12 cmH2O\n SpO2: 83%\n ABG: ///31/\n Ve: 9.3 L/min\n Physical Examination\n General: Awake, alert, appears comfortable\n HEENT: NCAT, MM dry. Hoarse voice\n Neck: supple + JVD with HJR. s/p tracheocutaneous fistula repair with\n bandage c/d/i, incision still partially open with sm amount white\n drainage. No surrounding erythema. No crepitus.\n Pulmonary: No crackles. Decreased at right base.\n Cardiac: Distant. RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted\n Extremities: No edema, 2+ radial, DP pulses b/l\n Neurologic: Alert, oriented x 3. Able to relate history without\n difficulty. Cranial nerves II-XII intact. Normal bulk, strength and\n tone throughout. No abnormal movements noted. No deficits to light\n touch throughout.\n Labs / Radiology\n 380 K/uL\n 9.5 g/dL\n 120 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 27.7 %\n 8.0 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n WBC\n 13.1\n 10.3\n 8.0\n Hct\n 32.3\n 30.5\n 27.7\n Plt\n \n Cr\n 1.3\n 1.3\n 1.2\n TropT\n 0.03\n <0.01\n Glucose\n 70\n 168\n 120\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:92/6/<0.01, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:6.6 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Imaging: CTA :\n IMPRESSION:\n 1. No PE.\n 2. Findings compatible with aspiration within the right lower and\n middle lobe\n bronchi, with atelectasis and airspace consolidation suspicious for\n pneumonia.\n Prelim report barium swallow:\n No evidence for gastroesophageal reflux. Small-to-moderate hiatal\n hernia.\n Videooropharyngeal swallow with no overt aspiration, may be slight\n silent aspiration, report pending.\n Microbiology: Blood, urine and sputum cultures pending.\n Assessment and Plan\n 67F with CAD, CHF, COPD and complicated pulmonary history w/p prolonged\n tracheostomy with recent decannulation and subsequent fistula closure\n with complicated MRSA PNA presenting with worsened respiratory\n distress.\n .\n <I>PLAN:</I>\n .\n <I>## Respiratory distress:</I>No evidence MI or PE. Ddx includes PNA,\n CT imaging c/w lung collapse vs possible aspiration PNA. have\n mucous plugged resulting in acute resp distress now resolved.\n -tx for aspiration PNA with 8 day course Vanc/Cipro/Zosyn\n -Aggressive chest PT\n -SLP eval\n -barium swallow to eval if chronic reflux/aspiration\n -supplemental 02 as needed\n -BiPAP at night and PRN\n -s/p 3 doses decadron per ENT for airway swelling, no stridor\n -f/u ENT and IP recs\n -home nebs\n .\n <I>## ARF:</I>Ddx includes pre-renal in setting of possible infection\n vs ATN/AIN from meds given during last hospitalization.\n -d/c bactrim\n -hold on diuresis\n -hold lisinopril\n -renally dose abx\n -check urine lytes, eos\n .\n <I>## CAD:</I> No evidence for ischemia on ecg. Ruled out with enzymes\n -continue ASA, BB. Hold ACEI as above\n .\n <I>## CHF:</I>Clinically and by CXR and BNP pt appears moderately\n volume overloaded. TTE recently done () showed preserved EF with\n some focal wall motion abnormality.\n -Caution with fluids\n -may require diuresis after CTA\n -monitor I/Os\n -Continue BB\n -Holding ACEI as above for ARF\n .\n <I>## COPD:</I>Treat for exacerbation\n -nebs\n -02 prn\n -watch for somnolence as indicatory of increased retention as pt\n refusing ABG.\n .\n <I>## h/o bacteremia:</I>Last positive blood cx , was MRSA.\n received 8 days of IV vanc, sent home on PO bactrim.\n -Continue vancomycin to complete 14 day treatement for bacteremia\n -monitor for evidence of seeding especially in setting of leukocytosis\n and thrombocytosis which may be evidence for more chronic inflammation\n -PICC placement, continue vancomycin as above, additional 8 days will\n complete total 14 days of IV antibiotics.\n -monitor blood cultures\n .\n <I>## Depression/anxiety:</I>\n -ativan prn anxiety, caution not to oversedate\n -Continue home lamotrigine, quetiapine, sertraline\n .\n <I>## OSA:</I>\n -BiPAP or CPAP at night\n .\n <I>## Hyperlipidemia:</I>\n -Continue statin\n .\n <I>## Leukocytosis:<I>Concerning for infection although with normal\n diff. Possible sources include likely lungs and possibly bactermia. Pt\n also at risk for c. diff given recent antibiotic use.\n -blood cultres\n -sputum cultures\n -stool and urine cultures\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 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": "2138-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339459,
"text": "67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Video swallow & barium swallow study on to assess possible\n aspiration & regurgitation. Patient may have nectar thick liquids.\n Significant events overnight on :\n ***** started desatting at low 60\ns on BIPAP at 0450 hrs, C/O SOB.\n Intubated electively at 0530 hrs.\n ***** started Propofol drip.\n ***** CXRdone, Nitro gtt started but stopped for hypotensive episode.\n ***** Neo gtt started .\n *** Blood culture sent.\n Pneumonia, aspiration\n Assessment:\n Taking Po meds with apple sauce. No signs of aspiration noted. Appetite\n very poor.\n Action:\n Pt. had video and barium swallow studies . Outcome at present is\n to give pt. nectar thickened liquids.\n Response:\n Strong coughing, productive at times for moderate amounts of blood\n tinged tan sputum. Tolerates Po meds with apple sauce.\n Plan:\n Will cont to monitor her closely for aspiration. need Dietary\n consult for poor appetite/ improper nutrition.\n Respiratory failure, chronic\n Assessment:\n Patient was on BIPAP overnight, C/O fatigueness.. Strong productive\n cough at times. Lungs crackles bilaterally anterorly, while diminished\n at bases. At 0500 hrs started desatting to mid 60\ns to low 50\ns. Lungs\n crackled & wheezing noted. C/O SOB at this time. Electively intubated\n with 6.5 ETT, 22 at lip. SBP dropped to mid 70\ns -60\n Action:\n On BiPAP till 0445 hrs. Intubated at 0510 hrs. Started on propofol\n gtt. CXR done. Nitro gtt started & stopped due to hypotensive episode.\n Fluid bolus 250 ml X1 IV given. Suctioned for blood tinged thin\n secretion moderate amount.. Magnesium 2 gm repleted.\n Response:\n Sat up to mid 90\ns . Heart rate down to 90\ns. SBP up to mid 90\ns to\n low 100\n Plan:\n Will cont to monitor her resp status.\n Pt. has remained A/A/O and c/o occasional right hip pain which she is\n treated with vicoden PRN. Pt. also has received ativan po , PRN for\n anxiety. Pt C/O fatiguness. Uses BIPAP overnight.. Pt. has Allevyn\n dressing over old trach site. This was recently, surgically closed.\n This site remains D&I at this time. P ending, blood, sputum, and urine\n cultures.\n"
},
{
"category": "Respiratory ",
"chartdate": "2138-09-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 339471,
"text": "Demographics\n Day of intubation: 1\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: ICU\n Reason: Emergent (1st time); Comments: pt had been on NIV for at least\n 2 days doing well\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments: Previous sx before 0700 yielded thin bloody fluid only. Pt\n may have plugs from known pneumonia\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Nasal flaring, Supra-sternal\n retractions, Accessory muscle use, Prolonged exhalation, Frequent\n desaturation episodes, Tachypneic (RR> 35 b/min), Gasping efforts,\n Intercostal retractions, Active exhalations, High flow demand\n Assessment of breathing comfort: Pt acknowledges dyspnea\n Non-invasive ventilation assessment: Tolerated well; Comments: pt had\n been very complient with NIV\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Vigorous inspiratory efforts, Possible air\n trapping\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated, Adjust Min. ventilation to control\n pH\n Reason for continuing current ventilatory support: Pending procedure /\n OR, Underlying illness not resolved; Comments: need to be bronched\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": "2138-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339474,
"text": "Chief Complaint: 67F with complicated pulmonary history. Initiated in\n when had THR, complicated post op course with prolonged\n intubation, with associated pseudomonas PNA, trach/PEG with resultant\n supraglottic stenosis and tracheomalacia. Had laser treatment of\n granulation tissue in trachea in and trach decannulation in\n . Past year has been complicated by multiple admissions for both\n PNA and flash pulm edema. Hospitalized late for take down of\n tracheocutaneous fistula (), had postop MRSA PNA/bacteremia treated\n with vanc. Discharged home on on PO bactrim, represented in acute\n respiratory distress in despite home BIPAP. Working ddx was mucous\n plug vs recurrent PNA. Has received IV decadron x 3 for slight airway\n swelling seen on laryngoscope on admission.\n 24 Hour Events:\n PICC LINE - START 09:34 AM\n NON-INVASIVE VENTILATION - STOP 09:48 AM\n SPUTUM CULTURE - At 09:58 AM\n Pt. expectorated tan colored sputum. Culture sent to the lab.\n FLUOROSCOPY - At 02:22 PM\n Pt. transported down for both a barium and video swallow study. -- no\n evidence overt aspiration\n RESPIRATORY ARREST - At 04:45 AM\n pt in acute distress, desat to 50's, diaphoretic and mottled; intubated\n Pt did well all day off BiPap, reported feeling back to baseline. Was\n on her BiPap at night (uses this at home) when became acutely short of\n breath at 4am. Given chest PT, lasix 40mg IV and morphine. Pulse 0x\n in high 40s. Emergently intubated. Position confirmed\n fiberoptically. Continued to oxygenate poorly. Tachycardic to\n 130-140s, lots of ectopy, ecg didn't show overt ischemia, CEs\n negative. Blood cultures drawn. CXR c/w pulmonary edema. VBG with pH\n 6.98, lactate 6.6. PEEP increased to 12. Given 80mg IV lasix and\n started on nitro gtt. Became hypotensive to 70s, nitro gtt held.\n Neosynephrine started. Called husband and left message, called and\n spoke to son and informed him of events, he will relay to his father.\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:45 AM\n Furosemide (Lasix) - 05:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.4\nC (97.6\n HR: 133 (46 - 133) bpm\n BP: 156/83(100) {96/36(50) - 156/84(100)} mmHg\n RR: 26 (12 - 26) insp/min\n SpO2: 83%\n Heart rhythm: ST (Sinus Tachycardia)\n Mixed Venous O2% Sat: 80 - 80\n Total In:\n 567 mL\n 769 mL\n PO:\n TF:\n IVF:\n 567 mL\n 769 mL\n Blood products:\n Total out:\n 1,125 mL\n 230 mL\n Urine:\n 1,125 mL\n 230 mL\n NG:\n Stool:\n Drains:\n Balance:\n -559 mL\n 539 mL\n Respiratory support\n O2 Delivery Device: Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 580 (400 - 580) mL\n PS : 6 cmH2O\n PEEP: 6 cmH2O\n PIP: 12 cmH2O\n SpO2: 83%\n ABG: ///31/\n Ve: 9.3 L/min\n Physical Examination\n General: Awake, alert, appears comfortable\n HEENT: NCAT, MM dry. Hoarse voice\n Neck: supple + JVD with HJR. s/p tracheocutaneous fistula repair with\n bandage c/d/i, incision still partially open with sm amount white\n drainage. No surrounding erythema. No crepitus.\n Pulmonary: No crackles. Decreased at right base.\n Cardiac: Distant. RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted\n Extremities: No edema, 2+ radial, DP pulses b/l\n Neurologic: Alert, oriented x 3. Able to relate history without\n difficulty. Cranial nerves II-XII intact. Normal bulk, strength and\n tone throughout. No abnormal movements noted. No deficits to light\n touch throughout.\n Labs / Radiology\n 380 K/uL\n 9.5 g/dL\n 120 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 27.7 %\n 8.0 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n WBC\n 13.1\n 10.3\n 8.0\n Hct\n 32.3\n 30.5\n 27.7\n Plt\n \n Cr\n 1.3\n 1.3\n 1.2\n TropT\n 0.03\n <0.01\n Glucose\n 70\n 168\n 120\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:92/6/<0.01, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:6.6 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Imaging: CTA :\n IMPRESSION:\n 1. No PE.\n 2. Findings compatible with aspiration within the right lower and\n middle lobe\n bronchi, with atelectasis and airspace consolidation suspicious for\n pneumonia.\n Prelim report barium swallow:\n No evidence for gastroesophageal reflux. Small-to-moderate hiatal\n hernia.\n Videooropharyngeal swallow with no overt aspiration, may be slight\n silent aspiration, report pending.\n Microbiology: Blood, urine and sputum cultures pending.\n Assessment and Plan\n 67F with CAD, CHF, COPD and complicated pulmonary history w/p prolonged\n tracheostomy with recent decannulation and subsequent fistula closure\n with complicated MRSA PNA presenting with worsened respiratory\n distress.\n .\n <I>PLAN:</I>\n .\n <I>## Respiratory distress:</I>No evidence MI or PE. Ddx includes PNA,\n CT imaging c/w lung collapse vs possible aspiration PNA. have\n mucous plugged resulting in acute resp distress now resolved.\n -patient intubated, ENT aware of events overnight\n -tx for aspiration PNA with 8 day course Vanc/Cipro/Zosyn (day#3 today)\n -Aggressive chest PT\n -f/u final results of swallow eval\n -barium swallow to eval if chronic reflux/aspiration\n -BiPAP at night and PRN\n -s/p 3 doses decadron per ENT for airway swelling, no stridor\n -f/u ENT and IP recs\n -home nebs\n - cycle enzymes, last set due at noon today\n .\n <I>## ARF:</I>Ddx includes pre-renal in setting of possible infection\n vs ATN/AIN from meds given during last hospitalization.\n -d/c bactrim\n -hold on diuresis\n -hold lisinopril\n -renally dose abx\n -check urine lytes, eos\n .\n <I>## CAD:</I> No evidence for ischemia on ecg. Ruled out with enzymes\n -continue ASA, BB. Hold ACEI as above\n .\n <I>## CHF:</I>Clinically and by CXR and BNP pt appears moderately\n volume overloaded. TTE recently done () showed preserved EF with\n some focal wall motion abnormality.\n -Caution with fluids\n -may require diuresis after CTA\n -monitor I/Os\n -Continue BB\n -Holding ACEI as above for ARF\n .\n <I>## COPD:</I>Treat for exacerbation\n -nebs\n -02 prn\n -watch for somnolence as indicatory of increased retention as pt\n refusing ABG.\n .\n <I>## h/o bacteremia:</I>Last positive blood cx , was MRSA.\n received 8 days of IV vanc, sent home on PO bactrim.\n -Continue vancomycin to complete 14 day treatement for bacteremia\n -monitor for evidence of seeding especially in setting of leukocytosis\n and thrombocytosis which may be evidence for more chronic inflammation\n -PICC placement, continue vancomycin as above, additional 8 days will\n complete total 14 days of IV antibiotics.\n -monitor blood cultures\n .\n <I>## Depression/anxiety:</I>\n -ativan prn anxiety, caution not to oversedate\n -Continue home lamotrigine, quetiapine, sertraline\n .\n <I>## OSA:</I>\n -BiPAP or CPAP at night\n .\n <I>## Hyperlipidemia:</I>\n -Continue statin\n .\n <I>## Leukocytosis:<I>Concerning for infection although with normal\n diff. Possible sources include likely lungs and possibly bactermia. Pt\n also at risk for c. diff given recent antibiotic use.\n -blood cultres\n -sputum cultures\n -stool and urine cultures\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 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": "2138-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339483,
"text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 09:34 AM\n NON-INVASIVE VENTILATION - STOP 09:48 AM\n SPUTUM CULTURE - At 09:58 AM\n Pt. expectorated tan colored sputum. Culture sent to the lab.\n FLUOROSCOPY - At 02:22 PM\n Pt. transported down for both a barium and video swallow study.\n RESPIRATORY ARREST - At 04:45 AM\n pt in acute distress, desat to 50's, diaphoretic and mottled; intubated\n INVASIVE VENTILATION - START 05:10 AM\n EKG - At 05:20 AM\n BLOOD CULTURED - At 05:30 AM\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:45 AM\n Furosemide (Lasix) - 05:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.9\n HR: 75 (46 - 134) bpm\n BP: 99/42(58) {70/32(44) - 156/84(100)} mmHg\n RR: 22 (12 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Mixed Venous O2% Sat: 80 - 80\n Total In:\n 567 mL\n 594 mL\n PO:\n TF:\n IVF:\n 567 mL\n 594 mL\n Blood products:\n Total out:\n 1,125 mL\n 940 mL\n Urine:\n 1,125 mL\n 940 mL\n NG:\n Stool:\n Drains:\n Balance:\n -559 mL\n -346 mL\n Respiratory support\n O2 Delivery Device: Other\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (500 - 550) mL\n Vt (Spontaneous): 580 (400 - 580) mL\n PS : 6 cmH2O\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10, FiO2 > 60%, Hemodynamic Instability, Agitated\n PIP: 35 cmH2O\n Plateau: 26 cmH2O\n SpO2: 100%\n ABG: ///31/\n Ve: 11.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 380 K/uL\n 9.5 g/dL\n 120 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 27.7 %\n 8.0 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n WBC\n 13.1\n 10.3\n 8.0\n Hct\n 32.3\n 30.5\n 27.7\n Plt\n \n Cr\n 1.3\n 1.3\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n Glucose\n 70\n 168\n 120\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:67/6/0.03, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:6.6 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 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": "2138-09-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 339561,
"text": "Chief Complaint: respiratory failure\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 67 y/o F w/CAD, TBM, tracheocutaneous fistula c/b MRSA pna, recently\n discharged & readmitted for respiratory failure.\n 24 Hour Events:\n PICC LINE - START 09:34 AM\n NON-INVASIVE VENTILATION - STOP 09:48 AM\n SPUTUM CULTURE - At 09:58 AM\n Pt. expectorated tan colored sputum. Culture sent to the lab.\n FLUOROSCOPY - At 02:22 PM\n Pt. transported down for both a barium and video swallow study.\n RESPIRATORY ARREST - At 04:45 AM\n pt in acute distress, desat to 50's, diaphoretic and mottled; intubated\n INVASIVE VENTILATION - START 05:10 AM\n EKG - At 05:20 AM\n BLOOD CULTURED - At 05:30 AM\n Overnight, had worsening hypoxemia & respiratory distress. Acute event\n where desaturated to high 40s, looked diaphoretic, and got intubated.\n EKG nonischemic, cardiac enzymes negative x1. Became hypotensive and\n now requiring neo.\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:45 AM\n Furosemide (Lasix) - 05:38 AM\n Other medications:\n colace, senna, lamictal, simvastatin, aspirin 81, albuterol/atrovent,\n ciprofloxacin, vancomycin q48h, seroquel, zoloft, peridex\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 Respiratory: Dyspnea, Tachypnea\n Flowsheet Data as of 10:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.6\nC (97.9\n HR: 70 (46 - 134) bpm\n BP: 92/52(62) {70/32(44) - 156/84(100)} mmHg\n RR: 22 (12 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Mixed Venous O2% Sat: 80 - 80\n Total In:\n 567 mL\n 642 mL\n PO:\n TF:\n IVF:\n 567 mL\n 642 mL\n Blood products:\n Total out:\n 1,125 mL\n 1,180 mL\n Urine:\n 1,125 mL\n 1,180 mL\n NG:\n Stool:\n Drains:\n Balance:\n -559 mL\n -538 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (500 - 550) mL\n Vt (Spontaneous): 580 (400 - 580) mL\n PS : 6 cmH2O\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10, FiO2 > 60%, Hemodynamic Instability, Agitated\n PIP: 35 cmH2O\n Plateau: 26 cmH2O\n SpO2: 100%\n ABG: ///31/\n Ve: 11.9 L/min\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic, trach site healing, tiny\n fistula still present\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: at R base)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: 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 9.5 g/dL\n 380 K/uL\n 120 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 27.7 %\n 8.0 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n WBC\n 13.1\n 10.3\n 8.0\n Hct\n 32.3\n 30.5\n 27.7\n Plt\n \n Cr\n 1.3\n 1.3\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n Glucose\n 70\n 168\n 120\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:67/6/0.03, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:6.6 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n 1) ID: CTA demonstrated RLL and RML infiltrate when compared to CT back\n in was present then. Will complete a 8 day course of\n antibiotics. On vanc/cipro/zosyn for VAP.\n 2) Cardiac: She has a h/o diastolic CHF, however, her current\n presentation is not overly suggestive of a CHF exacerbation being her\n primary issue. Would aim for I/O to be euvolumic. Trend cardiac\n enzymes given event overnight.\n 3) Renal: Creatinine 1.2. Follow in the setting of CTA.\n 4) COPD / tracheobronchiomalacia: Acute event overnight appears to be\n due to a mucus plug, likely complicated by underlying airway\n pathology. have tracheal stenosis or granulation tissue at level\n of prior trach complicating the situation. Will discuss with IP\n possibility of bronch today (cannot bronch through ETT given 6.5\n tube). Continue nebs.\n 5) F/E/N: Cardiac prudent diet. Speech and swallow evaluation for\n chronic aspiration. Follow / replete lytes as needed. Goal euvolumic\n for now.\n 6) Shock: Requiring neosynephrine overnight with an elevated lactate.\n No evidence of intraabdominal pathology to explain the lactate. Will\n recheck.\n .\n ICU Care\n Nutrition:\n Comments: start tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 60 min\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2138-09-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 339583,
"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: ICU\n Reason: Emergent (1st time); Comments: acute dyspnea/desaturation\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Lung sounds\n RLL Lung Sounds: 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 Comments: Pt weaned from A/C to PSV this shift, tolerating well.\n Currently on +10PSV/+8PEEP w/ Vt ~500 RR mid teens, Ve ~9L/M. Unable to\n obtain ABG after multiple attempts by team, weaning PEEP/FiO2 based on\n SpO2 which has stayed high 90s to 100%.\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: Pending procedure /\n OR; Comments: To have bronchoscopy by IP possibly tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339604,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Pulmonary edema\n Assessment:\n Pt. had noted crackles from mid to upper lobes.\n Action:\n Lasix I.V. given prior to this shift. With pt. putting out moderate to\n large amt\ns of clear yellow urine.\n Response:\n Lungs cleared with pt\ns diuresing.\n Plan:\n To monitor lung status frequently and U.O.\n Hypotension (not Shock)\n Assessment:\n Pt. dropped B/P following intubation and with medications utilized\n with the episode of acute resp. distress.\n Action:\n Pt. placed on Neo gtt to maintain map\ns >60.\n Response:\n Pt. rermains on Neo gtt but this has been weaned down form 1.5 mcg to\n 0.75 mcg/kg/min.\n Plan:\n Plan to keep weaning Neo gtt until off.\n Respiratory failure, chronic\n Assessment:\n Pt. acutely decompensated during am care. Pt. was intubated as a\n result. Pt. has been suctioned for moderate amt\ns of thick/tenacious\n tan/blood tinged secretions.\n Action:\n Pt. has been successfully weaned down from full support to pressure\n support. Plan is to Hold tube feeds at midnight and plan for SBT in the\n am. Plan is for probable bronch with I.P. tomorrow with extubation.\n Response:\n Pt. has tolerated wean from full support to pressure support.\n Plan:\n Albuterol/attrovent MDI\ns along with frequent suctioning. Plan to\n bronchoscopy to evaluate airway following possible extubation in the am\n hours tomorrow.\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 339808,
"text": "Chief Complaint: respiratory failure\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 67 y/o F w/TBM, trach s/p decannulation and fistula repair, admitted\n with respiratory failure.\n 24 Hour Events:\n -troponin peaked at 0.13 and trended down overnight\n -lactate trended down\n -bolused with NS 250 x2\n -IP does not feel needs bronch as there is nothing they would offer her\n at this point.\n History obtained from Medical records\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Other medications:\n senna, lamictal, simvastatin, aspirin 81 mg daily, ciprofloxacin,\n seroquel, zoloft, propofol at 15, lactulose, colace, atrovent and\n albuterol MDIs, ativan prn, vicodin prn, guaifenesin prn\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.4\nC (99.4\n HR: 69 (54 - 72) bpm\n BP: 94/48(60) {87/25(39) - 126/61(72)} mmHg\n RR: 17 (14 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,004 mL\n 876 mL\n PO:\n TF:\n 162 mL\n IVF:\n 1,721 mL\n 756 mL\n Blood products:\n Total out:\n 2,164 mL\n 429 mL\n Urine:\n 2,164 mL\n 429 mL\n NG:\n Stool:\n Drains:\n Balance:\n -160 mL\n 447 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 428 (428 - 428) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 16\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 54\n PIP: 32 cmH2O\n Plateau: 25 cmH2O\n SpO2: 99%\n ABG: ///30/\n Ve: 7.3 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious, tearful\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.6 g/dL\n 474 K/uL\n 161 mg/dL\n 1.2 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 101 mEq/L\n 139 mEq/L\n 28.3 %\n 10.4 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n Plt\n 74\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.1 mg/dL\n Imaging: Video swallow: Moderate penetration of nectar thick and thin\n liquids.\n CXR: Increased interstitial markings c/w yesterday but no obvious\n infiltrate.\n Microbiology: Blood cx NGTD\n Sputum OP flora\n CDiff pending\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology +/- aspiration.\n 1) Respiratory failure: Acute event the other night appears to be due\n to a mucus plug, likely complicated by underlying airway pathology.\n have tracheal stenosis or granulation tissue at level of prior\n trach complicating the situation. Will discuss need for bronch or\n visualization of airway with both IP and ENT. If neither want to scope\n her, can likely extubate today given how well she looks on current\n settings.\n - PSV 5/5, SBT\n - Has received 10 days of abx, sputum was non-purulent . Will d/c\n abx and follow fever curve, WBC count.\n 2) Shock: Neo requirement decreased, appears related to propofol.\n Lactate normalized.\n -wean neo\n 3) Elevated troponin: Likely demand in setting of hypotension, now\n resolving. No ECG changes. Goal euvolemic.\n 4) Renal: Creatinine 1.2. Follow in the setting of CTA.\n 5) F/E/N: Cardiac prudent diet. Follow / replete lytes as needed. Goal\n euvolemic for now.\n ICU Care\n Nutrition:\n Comments: holding tube feeds pending extubation\n Glycemic Control: Blood sugar well controlled\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: SQ UF Heparin\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:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 339810,
"text": "Chief Complaint: respiratory failure\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 67 y/o F w/TBM, trach s/p decannulation and fistula repair, admitted\n with respiratory failure.\n 24 Hour Events:\n -troponin peaked at 0.13 and trended down overnight\n -lactate trended down\n -bolused with NS 250 x2\n -IP does not feel needs bronch as there is nothing they would offer her\n at this point.\n History obtained from Medical records\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Other medications:\n senna, lamictal, simvastatin, aspirin 81 mg daily, ciprofloxacin,\n seroquel, zoloft, propofol at 15, lactulose, colace, atrovent and\n albuterol MDIs, ativan prn, vicodin prn, guaifenesin prn\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.4\nC (99.4\n HR: 69 (54 - 72) bpm\n BP: 94/48(60) {87/25(39) - 126/61(72)} mmHg\n RR: 17 (14 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,004 mL\n 876 mL\n PO:\n TF:\n 162 mL\n IVF:\n 1,721 mL\n 756 mL\n Blood products:\n Total out:\n 2,164 mL\n 429 mL\n Urine:\n 2,164 mL\n 429 mL\n NG:\n Stool:\n Drains:\n Balance:\n -160 mL\n 447 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 428 (428 - 428) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 16\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 54\n PIP: 32 cmH2O\n Plateau: 25 cmH2O\n SpO2: 99%\n ABG: ///30/\n Ve: 7.3 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious, tearful\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.6 g/dL\n 474 K/uL\n 161 mg/dL\n 1.2 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 101 mEq/L\n 139 mEq/L\n 28.3 %\n 10.4 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n Plt\n 74\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.1 mg/dL\n Imaging: Video swallow: Moderate penetration of nectar thick and thin\n liquids.\n CXR: Increased interstitial markings c/w yesterday but no obvious\n infiltrate.\n Microbiology: Blood cx NGTD\n Sputum OP flora\n CDiff pending\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology +/- aspiration.\n 1) Respiratory failure: Acute event the other night appears to be due\n to a mucus plug, likely complicated by underlying airway pathology.\n have tracheal stenosis or granulation tissue at level of prior\n trach complicating the situation. Will discuss need for bronch or\n visualization of airway with both IP and ENT. If neither want to scope\n her, can likely extubate today given how well she looks on current\n settings.\n - PSV 5/5, SBT\n - Has received 10 days of abx, sputum was non-purulent . Will d/c\n abx and follow fever curve, WBC count.\n 2) Shock: Neo requirement decreased, appears related to propofol.\n Lactate normalized.\n -wean neo\n 3) Elevated troponin: Likely demand in setting of hypotension, now\n resolving. No ECG changes. Goal euvolemic.\n 4) Renal: Creatinine 1.2. Follow in the setting of CTA.\n 5) F/E/N: Cardiac prudent diet. Follow / replete lytes as needed. Goal\n euvolemic for now.\n ICU Care\n Nutrition:\n Comments: holding tube feeds pending extubation\n Glycemic Control: Blood sugar well controlled\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: SQ UF Heparin\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:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339812,
"text": "Chief Complaint:\n 67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress.\n 24 Hour Events:\n -Yesterday patient\ns troponin increased to 0.13, CK decreased at 60.\n EKG done showing no ischemic changes so thought to be demand\n ischemia in setting of respiratory distress on AM of . This AM\n cardiac enzymes trending downwards at trop 0.08, CK 39.\n -Overnight had decreased BP with MAP in low 50s, given 250ml NS bolus x\n 2 with increase of pressure to MAP in 60s and increase in UOP (30 to\n 70cc/hr)\n -Lactate decreased to normal\n -Vancomycin dose changed from Q48 to Q24 dosing as Cr improving\n -A-line placement attempted but unsuccessful\n -Had BM overnight on increased bowel reg\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin 1gm Q24hr\n Ciprofloxacin 500mg PO Q24\n Zosyn 2.25gm IV Q6h\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 10:51 AM\n Other medications:\n Lamotrigine 25mg PO BID\n Seroquel\n Sertraline 100mg PO daily\n Simvastatin 40mg PO daily\n Colace\n Albuterol/Ipratroprium\n Ativan prn\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 63 (57 - 80) bpm\n BP: 91/52(61) {80/25(39) - 126/61(72)} mmHg\n RR: 18 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,004 mL\n 540 mL\n PO:\n TF:\n 162 mL\n IVF:\n 1,721 mL\n 480 mL\n Blood products:\n Total out:\n 2,164 mL\n 290 mL\n Urine:\n 2,164 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n -160 mL\n 250 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 22\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 54\n PIP: 32 cmH2O\n Plateau: 25 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 9.1 L/min\n Physical Examination\n General: Intubated woman, alert and able to answer questions, in no\n acute distress\n Head, Ears, Nose, Throat: Normocephalic, trach site healing, tiny\n fistula still present\n Pulmonary: No crackles. Decreased with rhonchi at right base.\n Cardiac: Distant. RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted\n Extremities: No edema, 2+ radial, DP pulses b/l\n Neurologic: Alert, able to follow simple commands and express wishes\n Labs / Radiology\n 474 K/uL\n 9.6 g/dL\n 161 mg/dL\n 1.2 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 101 mEq/L\n 139 mEq/L\n 28.3 %\n 10.4 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n Plt\n 74\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.1 mg/dL\n INR 1.2, PTT 30.1\n Micro:\n All BCx NGTD, Sputum Cx with oropharyngeal contamination, stool cdiff\n from this AM pending\n Imaging\n : Video swallow final results: Mild to moderate oropharyngeal\n dysphagia with episodes of penetration on nectar thick and thin liquids\n Assessment and Plan\n 67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight on requiring intubation with plan\n for bronchoscopy to evaluate.\n .\n <I>PLAN:</I>\n .\n <I>## Acute respiratory failure:</I>Patient intubated after acute\n respiratory failure on AM of . Likely mucous plugging vs\n bronchospasm in setting of possible underlying tracheal stenosis/edema\n or granulation tissue in area of prior trach. Patient still intubated\n in the case there is need for bronch or visualization of airway by\n either IP or ENT. Given patient\ns history of multiple episodes of\n respiratory distress, worrisome that patient would have future episodes\n and would benefit for visualization and possible intervention.\n - follow up with final IP and ENT recommendations\n - if no bronch or airway visualization today, can likely extubate\n patient today\n - trial patient on pressure support with SBT\n - patient has received 10 days of broad spectrum abx for staph in\n sputum from prior BAL. CXR with no evidence of infiltrate, last BCx and\n sputum unremarkable. Discontinue antibiotics today and follow fever\n curve, white count\n - touch base with speech and swallow regarding recommendations for diet\n to decrease chance of aspiration\n - continue nebs and aggressive chest PT\n .\n <I>## Hypotension:</I>Lactate decreased, has been weaned down on neo\n but unable to completely wean off while intubated and on propofol.\n Patient\ns BP is fluid responsive and has been stable over last 8 hours.\n A-line attempted but unable to place, no need for monitoring currently\n - wean down neo as tolerated\n .\n <I>## CAD:</I> Patient with some troponin elevation to peak of 0.13 in\n setting of acute respiratory distress from two nights prior. Most\n recent troponin trending down at 0.08 and EKG with no acute ischemic\n changes\n -continue ASA, BB. Hold ACEI as above\n .\n <I>## CHF:</I>Patient with pulmonary edema by CXR overnight. TTE\n recently done () showed preserved EF with some focal wall motion\n abnormality. Patient euvolemic and net even overnight without any\n additional diuretics\n -Will allow patient to autodiuresis, goal net even overnight\n -monitor I/Os\n -Continue BB\n -Holding ACEI as above for ARF\n .\n <I>## ARF:</I>Ddx includes pre-renal in setting of possible infection\n vs ATN/AIN from meds given during last hospitalization and in setting\n of CTA on . Cr stable at 1.2\n -hold on diuresis\n -hold lisinopril\n -renally dose abx\n -check urine lytes, eos\n .\n <I>## COPD:</I>Likely not etiology of acute respiratory distress\n overnight, patient without wheezing on exam\n -continue nebs\n .\n <I>## Depression/anxiety:</I>\n -ativan prn anxiety, caution not to oversedate\n -Continue home lamotrigine, quetiapine, sertraline\n .\n <I>## Hyperlipidemia:</I>\n -Continue statin\n .\n <I>## Leukocytosis:<I>White count decreased overnight. Concerning for\n infection although with normal diff. Possible sources include likely\n lungs and possibly bactermia. Pt also at risk for c. diff given recent\n antibiotic use.\n -f/u blood, sputum, stool and urine cultures\n ICU Care\n Nutrition: Continue on tube feeds\n Nutren pulmonary. On cardiac diet\n with aspiration precautions as tolerated\n Glycemic Control: Continue on insulin sliding scale with initiation of\n tube feeds\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: aspirin and pneumoboots\n Stress ulcer: restart IV protonix 40mg daily\n VAP: Mouth care, HOB elevated\n Comments: Can decrease Lactulose to prn as patient with 2 large BMs\n overnight\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340018,
"text": "Pulmonary edema\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340019,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Pulmonary edema\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340478,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient Extubated. Initially on face tent, but patient requested CPAP\n overnight.\n Asymptomatic hypotension of 80s/40 that resolved without intervention.\n INVASIVE VENTILATION - STOP 11:18 AM\n PICC LINE - STOP 12:48 AM\n PICC LINE - START 12:52 AM\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Other medications:\n Morphine 1 mg IV prn hip pain\n Ativan PO/ IV prn anxiety\n Lasix 40 mg daily\n Lactulose 30 mg daily\n Albuterol q4 hr\n Atrovent\n Colace 100 \n Pantoprazole 40 IV daily\n Chlorhexidine mouthwash\n Senna\n Lamotrigine 25 mg \n Simvastatin 40 mg daily\n Aspirin 81 daily\n Seroquel\n Sertraline 100 daily\n Albuterol/ipratroprium nebs\n Insuline sliding scale\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:39 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: 36.3\nC (97.4\n HR: 79 (66 - 91) bpm\n BP: 121/55(72) {82/40(51) - 143/73(98)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 523 mL\n 60 mL\n PO:\n TF:\n IVF:\n 223 mL\n Blood products:\n Total out:\n 1,620 mL\n 135 mL\n Urine:\n 1,620 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,097 mL\n -75 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n Ventilator mode: Standby\n Vt (Spontaneous): 73 (73 - 432) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 17 cmH2O\n SpO2: 93%\n ABG: ///28/\n Ve: 8.9 L/min\n Physical Examination\n Gen: Comfortable, pleasant, in NAD\n HEENT: PERRL, EOMI, MMM, area of prior trach c/d/i\n Lungs: Trace rhonchi, no wheezes\n CV: RRR, no m/r/g\n Ext: WWP\n Labs / Radiology\n 369 K/uL\n 10.5 g/dL\n 87 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 104 mEq/L\n 142 mEq/L\n 30.3 %\n 7.7 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n Plt\n 74\n 423\n 369\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.1 mg/dL,\n Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n Ms. is a 67F with CAD s/p CABG, CHF, COPD and complicated\n pulmonary history with prolonged tracheostomy with recent decannulation\n and subsequent fistula closure (on ENT service at on ) with\n complicated MRSA PNA presented with worsened respiratory distress. Now\n s/p bronchoscopy which did not reveal significant upper airway\n stenosis.\n .\n 1. Respiratory failure. Patient was intubated on after episode of\n flash pulmonary edema while being bathed and concern for upper airway\n obstruction due to previous intubations/trach. Patient also has\n history of trace aspiration. Completed 10 day course for aspiration\n pneumonia on . Rigid bronchoscopy on showed no significant upper\n airway stenosis. Extubated successfully on . No episodes of\n respiratory distress overnight, but given history, will watch closely\n today as patient is advanced on her diet with aspiration precautions.\n - IP and ENT following, appreciate recs\n - watch patient closely overnight as we advance her diet today\n - strict aspiration precautions with PO intake\n regular food with thin\n liquids with aspiration precautions, but pills must be taken with\n thickened liquids\n - continue nebs\n - continue home lasix for interstial edema\n - ativan prn for anxiety\n .\n 2.Hypotension. Patient off pressors, still with some low BP overnight,\n but asymptomatic\n - monitor BP and fluid boluses prn\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\n edema/HTN. Troponins have trended down.\n -continue ASA, BB\n - consider resuming ACEI tomorrow if hemodynamically stable\n .\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\n on . CXR yesterday showed mild interstitial edema. Currently\n euvolemic, but will continue home lasix dose. TTE recently done\n () showed preserved EF with some focal wall motion abnormality.\n Patient euvolemic and net even overnight without any additional\n diuretics\n -continue home lasix\n -monitor I/Os\n -Continue BB\n - holding ACEI until blood pressure stable for 24 hours off pressors\n .\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\n - consider resuming lisinopril in AM\n 6. COPD.\n -continue nebs\n .\n 7. Depression/anxiety. Patient has significant anxiety.\n -ativan prn anxiety, caution not to oversedate\n -Continue home lamotrigine, quetiapine, sertraline\n .\n 8. Hyperlipidemia:\n -Continue statin\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: pantoprazole\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU care for now\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340482,
"text": "Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340483,
"text": "67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology required reintubation on had rigid\n bronch on resulted as WNL now s/p extubation on .\n Respiratory failure, chronic\n Assessment:\n Pt AO X 3 received on face tent 70 %,weaned to NC 5L, LS are clear,O2\n sats are maintained 92-95% denies any SOB or related discomfort.\n Action:\n OOB to chair tolerated well,Nebs as ordered,Diet advanced to regular on\n asp precautions,pills to crushed and not to use thin liquids.\n Response:\n Pt was comfortable,able to cough and expectorate thick yellow\n secretions\n Plan:\n Continue to monitor resp status,nebs as ordered, PRN ---CPAP overnight,\n can be called to floor tomorrow if remains stable.\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340485,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient Extubated. Initially on face tent, but patient requested CPAP\n overnight. This morning back on face tent breathing comfortably with\n good O2 sat\n Asymptomatic hypotension of 80s/40 that resolved without intervention.\n INVASIVE VENTILATION - STOP 11:18 AM\n PICC LINE - STOP 12:48 AM\n PICC LINE - START 12:52 AM\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Now off all antibiotics\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Other medications:\n Morphine 1 mg IV prn hip pain\n Ativan PO/ IV prn anxiety\n Lasix 40 mg daily\n Lactulose 30 mg daily\n Albuterol q4 hr\n Atrovent\n Colace 100 \n Pantoprazole 40 IV daily\n Chlorhexidine mouthwash\n Senna\n Lamotrigine 25 mg \n Simvastatin 40 mg daily\n Aspirin 81 daily\n Seroquel\n Sertraline 100 daily\n Albuterol/ipratroprium nebs\n Insuline sliding scale\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:39 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: 36.3\nC (97.4\n HR: 79 (66 - 91) bpm\n BP: 121/55(72) {82/40(51) - 143/73(98)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 523 mL\n 60 mL\n PO:\n TF:\n IVF:\n 223 mL\n Blood products:\n Total out:\n 1,620 mL\n 135 mL\n Urine:\n 1,620 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,097 mL\n -75 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n Ventilator mode: Standby\n Vt (Spontaneous): 73 (73 - 432) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 17 cmH2O\n SpO2: 93%\n ABG: ///28/\n Ve: 8.9 L/min\n Physical Examination\n Gen: Comfortable, pleasant, in NAD\n HEENT: PERRL, EOMI, MMM, area of prior trach c/d/i\n Lungs: Trace rhonchi, no wheezes\n CV: RRR, no m/r/g\n Ext: WWP\n Labs / Radiology\n 369 K/uL\n 10.5 g/dL\n 87 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 104 mEq/L\n 142 mEq/L\n 30.3 %\n 7.7 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n Plt\n 74\n 423\n 369\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.1 mg/dL,\n Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n Ms. is a 67F with CAD s/p CABG, CHF, COPD and complicated\n pulmonary history with prolonged tracheostomy with recent decannulation\n and subsequent fistula closure (on ENT service at on ) with\n complicated MRSA PNA presented with worsened respiratory distress. Now\n s/p bronchoscopy which did not reveal significant upper airway\n stenosis.\n .\n 1. Respiratory failure. Patient was intubated on after episode of\n flash pulmonary edema while being bathed and concern for upper airway\n obstruction due to previous intubations/trach. Patient also has\n history of trace aspiration. Completed 10 day course for aspiration\n pneumonia on . Rigid bronchoscopy on showed no significant upper\n airway stenosis. Extubated successfully on . No episodes of\n respiratory distress overnight, but given history, will watch closely\n today as patient is advanced on her diet with aspiration precautions.\n - IP and ENT following, appreciate recs\n - watch patient closely overnight as we advance her diet today\n - strict aspiration precautions with PO intake\n regular food with thin\n liquids with aspiration precautions, but pills must be taken with\n thickened liquids\n - continue nebs\n - continue home lasix for interstial edema\n - ativan prn for anxiety\n .\n 2.Hypotension. Patient off pressors, still with some low BP overnight,\n but asymptomatic\n - monitor BP and fluid boluses prn\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\n edema/HTN. Troponins have trended down.\n -continue ASA, BB\n - consider resuming ACEI when BP tolerates and if renal function\n continues to improve\n .\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\n on . CXR yesterday showed mild interstitial edema. Currently\n euvolemic, but will continue home lasix dose. TTE recently done\n () showed preserved EF with some focal wall motion abnormality.\n Patient euvolemic and net even overnight without any additional\n diuretics\n -continue home lasix\n -monitor I/Os\n -Continue BB\n - holding ACEI until blood pressure stable\n .\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\n - consider resuming lisinopril when BP tolerates, Cr improved\n 6. COPD.\n -continue nebs\n .\n 7. Depression/anxiety. Patient has significant anxiety.\n -ativan prn anxiety, caution not to oversedate. Can change Ativan from\n IV to PO\n -Continue home lamotrigine, quetiapine, sertraline\n .\n 8. Hyperlipidemia:\n -Continue statin\n ICU Care\n Nutrition: Advance diet to regular diet with aspiration precautions,\n pills with thickened liquids\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: pantoprazole\n VAP: Extubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU care for now\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340489,
"text": "67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology required reintubation on had rigid\n bronch on resulted as WNL now s/p extubation on .\n *** foley catheter d/cd since pt was c/o burning sensation.\n Respiratory failure, chronic\n Assessment:\n Pt AO X 3 received on face tent 70 %,weaned to NC 5L, LS are clear,O2\n sats are maintained 92-95% denies any SOB or related discomfort.\n Action:\n OOB to chair tolerated well,Nebs as ordered,Diet advanced to regular on\n asp precautions,pills to crushed and not to use thin liquids.\n Response:\n Pt was comfortable,able to cough and expectorate thick yellow\n secretions robitussin X 2 dose\n Plan:\n Continue to monitor resp status,nebs as ordered, PRN ---CPAP overnight,\n can be called to floor tomorrow if remains stable. Ativan PO/PRN for\n anxiety.\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-22 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 339021,
"text": "Chief Complaint: Respiratory distress x 1 day\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Extubated , d/c'ed\n home on Bactrim DS presumptively for extended coverage of her MRSA\n pneumonia (despite having completed course of Vanc.) At ~1AM this\n morning she developed shortness of breath when she got up to go to the\n bathroom. No cough, fevers, chills. She went back to bed, slept for ~1\n hour on CPAP but awoke again with persistent shortness of breath and\n presented to the ER for further evaluation. Denies chest pain /\n pressure, orthopnea, PND. She feels that her volume overload is\n improving. She denies leg swelling or pain. Persistent cough productive\n of white sputum, no purulence noted. No wheezing or stridor.\n Seen in Malborough ER where she received Ceftriaxone, Azithromycin,\n Lasix and IVF for presumptive RLL CAP. She was placed on BiPAP. At\n her ABG was 7.28 / 52 / 74 (? FiO2.) Cardiac enzymes were\n negative, BNP 344. Transferred to where her vitals were notable\n for 98.5, 80s, SBP 90s, 98-100% (FiO2 100%.) She received a dose of\n Levaquin and is admitted to the MICU on PAP.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n HOME medications (from d/c):\n Lactulose prn\n Sertraline 100 mg daily\n Docusate\n Senna\n Lamotrigine 25 mg Tablet \n Quetiapine 25 mg TID & 100 mg QHS\n Albuterol Sulfate Q 6 hours prn\n Ipratropium-Albuterol Q4 prn\n Aspirin 81 mg Tablet daily\n Simvastatin 40 mg daily\n Lisinopril 5 mg Tablet daily\n Furosemide 40 mg daily\n Potassium Chloride 20 mEq daily\n Metoprolol Tartrate 12.5mg daily\n Vicodin 5-500 mg Tablet\n Guaifenesin\n Bactroban 2 % Ointment Sig\n 1Bactrim DS 160-800 mg \n Past medical history:\n Family history:\n Social History:\n 1) Pseudomonas pneumonia in c/b tracheobronchiomalacia and\n subglottic stenosis; had been trached and decannulated (.) On \n she had repair of a chronic fistula by ENT c/b MRSA pneumonia.\n 2) HIT.\n 3) COPD.\n 4) S/p THR c/b pseudomonas pneumonia in .\n 5) Paroxysmal A fib.\n 6) Depression / bipolar disorder.\n 7) CAD s/p CABG in .\n 8) Hyperlipidemia.\n 9) Constipation.\n 10) GERD.\n Depression\n Occupation:\n Drugs: None.\n Tobacco: Quit in , ~35 pack-year history.\n Alcohol: No significant EtOH\n Other:\n Review of systems:\n General: Denies fevers, chills, night sweats.\n CV: Denies chest pain, palpitations, orthopnea, PND.\n Lungs: As per HPI.\n GI: Denies nausea, vomiting, diarrhea, constipation, brbpr.\n Derm: No new rashes, bruising or lesions.\n Neuro: No focal deficits, headaches, seizures.\n Flowsheet Data as of 11:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.3\n Tcurrent: 35.7\nC (96.3\n HR: 83 (83 - 85) bpm\n BP: 94/51(63) {90/51(63) - 94/55(64)} mmHg\n RR: 17 (14 - 17) insp/min\n SpO2: 99%\n CPAP 6, FIO2 40-50$\n Total In:\n 156 mL\n PO:\n TF:\n IVF:\n 156 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -144 mL\n Respiratory\n O2 Delivery Device: Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 414 (414 - 414) mL\n PS : 6 cmH2O\n PEEP: 6 cmH2O\n FiO2: 100%\n SpO2: 99%\n ABG: ///27/\n Ve: 8.3 L/min\n Physical Examination\n General: Chronically ill appearing. Breathing with mild accessory\n muscle use.\n HEENT: PERRL, anicteric, OP clear with dry MM.\n CV: S1S2 soft HS\ns irreg irreg, no m/r/g\ns noted. No heave. JVP at\n ~8-10cm without HJR.\n Lungs: CTA bilaterally with right basilar crackles, upper airway\n wheezing.\n Ab: Obese, positive BS\ns, NT/ND.\n Ext: 1+ pitting edema, no c/c.\n Neuro: Awake, alert, answers questions appropriately. No gross motor\n deficits.\n Labs / Radiology\n 443 K/uL\n 32.3 %\n 10.8 g/dL\n 70 mg/dL\n 1.3 mg/dL\n 19 mg/dL\n 27 mEq/L\n 106 mEq/L\n 4.4 mEq/L\n 142 mEq/L\n 13.1 K/uL\n [image002.jpg]\n 09:05 AM\n WBC\n 13.1\n Hct\n 32.3\n Plt\n 443\n Cr\n 1.3\n Glucose\n 70\n Other labs: Lactic Acid:1.3 mmol/L\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Attempts were made in\n MICU to take her off NIPPV but her FiO2 requirement shot up to 100%-\n now back down on minimal PAP. So far her CXR and ENT eval do not appear\n acutely worsened from several days ago prior to hospital d/c . Her\n recent worsening appears most consistent with a multifactorial\n etiology: upper airway procedure (fistula repair) with upper airway\n edema, bronchospasm/COPD, recent MRSA pneumonia. No problems with the\n surgical site.\n 1) ID: Pneumonia is a possible explanation of her hypoxia and acute\n presentation; she had MRSA bacteremia that was treated with a course of\n Vancomycin during her recent hospitalization and d/c'ed on Bactrim. She\n has a h/o Pseudomonas pneumonia. Therefore empiric treatment for MRSA\n pneumonia is reasonable especially in the setting of her elevated WBC.\n Broadening coverage to gram negative pathogens is reasonable as well.\n Would recommend Zosyn and Cipro initially with a plan for rapid\n de-escalation as culture results become available and her clinical\n course is clarified.\n 2) Pulmonary: PE is a possibility especially in the setting of a recent\n hospitalization, recent surgery and her HIT positive status. Would\n pursue CTA with pre-treatment to minimize any renal toxicity. Would not\n pursue empiric anti-coagulation given h/o HIT and other potential\n causes of hypoxia. PE, however, is important to rule out given her\n clinical circumstances.\n 3) Cardiac: She has a h/o diastolic CHF, however, her current\n presentation is not overly suggestive of a CHF exacerbation being her\n primary issue. Would aim for I/O to be euvolumic.\n 4) Renal: Creatinine 1.3. Follow in the setting of anticipate CTA.\n 5) COPD / tracheobronchiomalacia: Would provide standing nebs,\n Albuterol / Atrovent q4hr and q2hr PRN. Decadron initially with plan\n for transition to Prednisone. Guaifenesin. NIPPV overnight and as\n needed during the day. Should she require intubation, would do it with\n fiberoptic guidance given her recent surgery.\n 6) F/E/N: Cardiac prudent diet. Follow / replete 'lytes as needed. Goal\n euvolumic for now.\n 7) Hosp: Access - pIV, code - full, proph - PPI and SCDs.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 10:15 AM\n Comments:\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: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340618,
"text": "67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology required reintubation on had rigid\n bronch on resulted as WNL now s/p extubation on .\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p left hip replacement and states she always has discomfort in her\n right hip but will never get\nthis one done\n. Pt did c/o constant\n pain in right hip. She takes vicodin at home for the pain.\n Action:\n Pt given 1 tab vicodin x2 in addition to repositioning and emotional\n support.\n Response:\n Pt stated pain tolerable at 4/10 after interventions. Pt stated\nThis\n hip always hurts\n Plan:\n Continue to assess for pain, medicate as needed, emotional support and\n repositioning.\n Anxiety\n Assessment:\n Pt states she is anxious a lot and takes Ativan at home for anxiety.\n When pt was first assessed she asked this RN to let her sleep for the\n night because she had not gotten sleep in the past few nights. Pt also\n expressed her anxiety about not being able to breath overnight and the\n possible need to be reintubated.\n Action:\n Pt given 0.5mg Ativan x2. One dose given per PRN order and pt did\n require a 1x order for additional 0.5mg. Pt also reassured about the\n close monitoring on the ICU.\n Response:\n After Ativan admin pt slept for 2-3 hours each time.\n Plan:\n Continue to assess pt\ns anxiety level. Provide emotional support and\n reassurance. Ativan PRN.\n Respiratory failure, chronic\n Assessment:\n Pt received on face tent at 35% and soon after initial assessment and\n PM meds she was put on her CPAP machine per her request. RR 15-19 with\n sats 90-98%. LS with exp wheezes noted in upper lobes and clear in\n lower lobes. Pt with occasional non-productive cough.\n Action:\n Pt tolerating and is comfortable on her CPAP. She did request 10cc\n robitussin PO per pt\ns request.\n Response:\n Pt\ns respiratory status remained stable throughout shift.\n Plan:\n Continue to monitor resp status, CPAP and robitussin PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340626,
"text": "67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology required reintubation on had rigid\n bronch on resulted as WNL now s/p extubation on .\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p left hip replacement and states she always has discomfort in her\n right hip but will never get\nthis one done\n. Pt did c/o constant\n pain in right hip. She takes vicodin at home for the pain.\n Action:\n Pt given 1 tab vicodin x2 in addition to repositioning and emotional\n support.\n Response:\n Pt stated pain tolerable at 4/10 after interventions. Pt stated\nThis\n hip always hurts\n Plan:\n Continue to assess for pain, medicate as needed, emotional support and\n repositioning.\n Anxiety\n Assessment:\n Pt states she is anxious a lot and takes Ativan at home for anxiety.\n When pt was first assessed she asked this RN to let her sleep for the\n night because she had not gotten sleep in the past few nights. Pt also\n expressed her anxiety about not being able to breath overnight and the\n possible need to be reintubated.\n Action:\n Pt given 0.5mg Ativan x2. One dose given per PRN order and pt did\n require a 1x order for additional 0.5mg. Pt also reassured about the\n close monitoring on the ICU.\n Response:\n After Ativan admin pt slept for 2-3 hours each time.\n Plan:\n Continue to assess pt\ns anxiety level. Provide emotional support and\n reassurance. Ativan PRN.\n Respiratory failure, chronic\n Assessment:\n Pt received on face tent at 35% and soon after initial assessment and\n PM meds she was put on her CPAP machine per her request. RR 15-19 with\n sats 90-98%. LS with exp wheezes noted in upper lobes and clear in\n lower lobes. Pt with occasional non-productive cough.\n Action:\n Pt tolerating and is comfortable on her CPAP. She did request 10cc\n robitussin PO per pt\ns request.\n Response:\n Pt\ns respiratory status remained stable throughout shift.\n Plan:\n Continue to monitor resp status, CPAP and robitussin PRN.\n GU: Pt has voided approximately 260cc clear amber urine. Cr 0.9. Dr.\n aware. Will just continue to monitor UOP at this time.\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340101,
"text": "Chief Complaint:\n 24 Hour Events:\n Antibiotics discontinued.\n Home Lasix regimen restarted.\n Rigid BRONCHOSCOPY (- At 07:00 PM) performed in OR with\n anesthesia present; with essentially normal findings and nothing to\n explain her recurrent respiratory failure.\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsHeparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37\nC (98.6\n HR: 58 (54 - 77) bpm\n BP: 123/57(74) {91/44(55) - 130/63(79)} mmHg\n RR: 14 (13 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,242 mL\n 366 mL\n PO:\n TF:\n IVF:\n 942 mL\n 186 mL\n Blood products:\n Total out:\n 1,660 mL\n 325 mL\n Urine:\n 1,660 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -418 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 458 (407 - 541) mL\n PS : 10 cmH2O\n RR (Set): 8\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 43\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: ///29/\n Ve: 7.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 423 K/uL\n 9.1 g/dL\n 205 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 14 mg/dL\n 100 mEq/L\n 137 mEq/L\n 26.9 %\n 8.2 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n Plt\n 74\n 423\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-22 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 339023,
"text": "Chief Complaint: Respiratory distress requiring BiPAP\n HPI:\n 67F with extensive cardiac history and COPD with\n post-intubation tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an our, awoke again with severe SOB and presented to OSH ED. Reports\n jaw pain is her anginal equivalent but did not experience this during\n the episode. No chest pain. Has been coughing, producing white sputum,\n though no more than prior to last discharge. Subjective fevers this\n afternoon. No chills. Slight right hip pain although not new. On 2L 02\n at home, able to ambulate and climb stairs without difficulty. No note\n of LE swelling or recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, transfered to ED. In our ED, tried off\n BiPap, desatted to 80s on NRB. Got CTX, azithromycin lasix and 500NS\n at OSH at was flown here. In our ED, initial VS 98.5 HR 80s BP\n 95/44 20 98% BiPAP, given 1 dose of levaquin.\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Piperacillin/Tazobactam (Zosyn) - 12:54 PM\n Vancomycin - 12:55 PM\n Infusions:\n Other ICU medications:\n Other medications:\n 1. Lactulose prn\n 2. Sertraline 100 mg daily\n 3. Docusate\n 4. Senna\n 5. Lamotrigine 25 mg Tablet \n 6. Quetiapine 25 mg TID\n 7. Quetiapine 100 mg QHS\n 8. Albuterol Sulfate Q 6 hours prn\n 9. Ipratropium-Albuterol Q4 prn\n 10. Aspirin 81 mg Tablet daily\n 11. Simvastatin 40 mg daily\n 12. Lisinopril 5 mg Tablet daily\n 13. Furosemide 40 mg daily\n 14. Potassium Chloride 20 mEq daily\n 15. Metoprolol Tartrate 12.5mg daily\n 16. Vicodin 5-500 mg Tablet\n 17. Guaifenesin\n 18. Bactroban 2 % Ointment Sig\n 19. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a\n day for 7 days: please take all pills on time and finish entire\n course.\n Disp:*14 Tablet(s)* Refills:*0*\n Past medical history:\n Family history:\n Social History:\n -Coronary artery disease s/p CABG in and \"recent\" PCI\n -CHF, last TTE EF 60% with mild LVH and some focal hypokinesis\n at base.\n -OSA\n -Dyslipidemia\n -HTN\n -Left total hip replacement-, elective. Complicated\n postoperative course with post-operative atrial fibrillation\n wtih RVR requiring cardioversion, sepsis, Pseudomonas VAP, VRE\n UT, and prolonged intubation leading to trach/PEG. Discharged to\n chronic wean facility but unable to decannulate. Bronchoscopy\n revealed tracheomalacia of subglottic region.\n -Supraglottic edema from GERD\n -Bipolar disorder\n -Depression\n -chronic atrial fibrillation, developed postop from THR, not\n anticoagulated\n -Chronic constipation\n -HIT during Fragmin therapy\n Depression\n Married. Very supportive husband. When she is not\n hospitalized/in rehab, she lives with him. No ETOH or current smoking.\n Has 35 pack year smoking history, quit 13 years ago.\n Review of systems: See HPI\n Flowsheet Data as of 01:29 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.7\nC (96.3\n Tcurrent: 35.7\nC (96.3\n HR: 86 (83 - 90) bpm\n BP: 96/48(60) {90/48(60) - 110/57(71)} mmHg\n RR: 16 (14 - 18) insp/min\n SpO2: 99%\n Total In:\n 808 mL\n PO:\n 240 mL\n TF:\n IVF:\n 568 mL\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 311 mL\n Respiratory\n O2 Delivery Device: Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 359 (359 - 414) mL\n PS : 6 cmH2O\n PEEP: 6 cmH2O\n FiO2: 100%\n SpO2: 99%\n ABG: ///27/\n Ve: 8.4 L/min\n Physical Examination\n Vitals: T:96.3 BP:94/51 P:83 R:17 SaO2: 100 BiPap 100% Fi02, Peep/PS\n TVs 400s.\n General: Awake, alert, mildly anxious, tachypneic.\n HEENT: NCAT, MM dry. Hoarse voice\n Neck: supple, inspiratory wheeze on ascultation of trachea (louder than\n in lungs), + JVD with HJR. s/p tracheocutaneous fistula repair with\n bandage c/d/i, incision still partially open with sm amount white\n drainage. No surrounding erythema. No crepitus.\n Pulmonary: No crackles, inspiratory wheeze. Decreased at right base.\n Cardiac: Distant. RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted\n Extremities: No edema, 2+ radial, DP pulses b/l\n Neurologic: Alert, oriented x 3. Able to relate history without\n difficulty. Cranial nerves II-XII intact. Normal bulk, strength and\n tone throughout. No abnormal movements noted. No deficits to light\n touch throughout.\n Labs / Radiology\n 443 K/uL\n 10.8 g/dL\n 70 mg/dL\n 1.3 mg/dL\n 19 mg/dL\n 27 mEq/L\n 106 mEq/L\n 4.4 mEq/L\n 142 mEq/L\n 32.3 %\n 13.1 K/uL\n [image002.jpg]\n \n 2:33 A9/1/ 09:05 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 13.1\n Hct\n 32.3\n Plt\n 443\n Cr\n 1.3\n Glucose\n 70\n Other labs: Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9 %,\n Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.3 mmol/L\n Fluid analysis / Other labs: From :\n WBC 19.3\n normal diff (52% neutrophils, no bands)\n Hct 41.8\n Platelets 631\n Na 140 K 5.3 Cl 101 CO2 26 BUN 14 Cr 1.34 Glucose 276\n CPK 135\n 7.28/52/74\n UA negative\n BNP 340 (nl <100)\n Trop I 0.05\n Imaging: CXR: Persistent RLL infiltrate. Fluid overload worse than\n prior ()\n .\n TTE : The left atrium is moderately dilated. There is mild\n symmetric left ventricular hypertrophy. The left ventricular cavity\n size is normal. Due to suboptimal technical quality, a focal wall\n motion abnormality cannot be fully excluded. Overall left ventricular\n systolic function is grossly normal (LVEF 60%). However, the basal\n inferior wall is dyskinetic and tha posterior wall is hypokinetic.\n Right ventricular chamber size and free wall motion are normal. The\n number of aortic valve leaflets cannot be determined. The aortic valve\n is not well seen. There is no aortic valve stenosis. No aortic\n regurgitation is seen. The mitral valve leaflets are mildly thickened.\n There is no mitral valve prolapse. Mild (1+) mitral regurgitation is\n seen. [Due to acoustic shadowing, the severity of mitral regurgitation\n may be significantly UNDERestimated.] The left ventricular inflow\n pattern suggests impaired relaxation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n ECG: Sinus rhythm at 92 nl axis, nl intervals. Q waves in II, III,\n aVF. TWI V4-V6. Early r-wave progression. No change from prior.\n Assessment and Plan\n 67F with CAD, CHF, COPD and complicated pulmonary history w/p prolonged\n tracheostomy with recent decannulation and subsequent fistula closure\n with complicated MRSA PNA presenting with worsened respiratory\n distess.\n .\n <I>PLAN:</I>\n .\n <I>## Respiratory distress:</I>Ddx includes cardiac (CHF, MI), PE given\n recent hospitalization and immobility, VAP, COPD exacerbation, airway\n obstruction given recent surgery and airway instrumentation. Per ENT\n note there is moderate supraglottic edema.\n -Per ENT recs, 10mg IV decadron Q8 x 3.\n -After decadron completed with switch to PO prednisone for steroid\n taper to tx for COPD component of respiratory compromise.\n -Standing and PRN nebs\n -Tx for VAP pna with Vanc/Zosyn and Cipro for add'l coverage of GNRs.\n -PICC placement for anticipated prolonged abx course\n -sputum cultures\n -follor CXRs\n -BNP 1900, not significantly off baseline. Pt dose look slightly volume\n overloaded, but unclear if this is playing a significant role in her\n respiratory distress. Also in ARF so want to minimize diuresis for\n now. Will reserve lasix for now, may need after getting fluid/dye for\n CT.\n -Pt is moderate to high risk per criteria for PE given recent\n surgery and hospitalizion. CTA with pretreatment mucomyst and bicarb\n to r/o PE.\n -F/u IP recs.\n -Continue to ROMI with serial CEs\n -Pt refusing ABGs, will hold of for now, may need if becomes\n somnolent.\n -BiPap to maintain 02 sats >88% or for pt comfort. Wean down 02 as\n tolerated.\n .\n <I>## ARF:</I>Ddx includes pre-renal in setting of possible infection\n vs ATN/AIN from meds given during last hospitalization.\n -d/c bactrim\n -hold on diuresis\n -hold lisinopril\n -renally dose abx\n -check urine lytes, eos\n .\n <I>## CAD:</I> No evidence for ischemia on ecg.\n -continue ASA, BB. Hold ACEI as above\n -continue to cycle CEs for full ROMI\n .\n <I>## CHF:</I>Clinically and by CXR and BNP pt appears moderately\n volume overloaded. TTE recently done () showed preserved EF with\n some focal wall motion abnormality.\n -Caution with fluids\n -may require diuresis after CTA\n -monitor I/Os\n -Continue BB\n -Holding ACEI as above for ARF\n .\n <I>## COPD:</I>Treat for exacerbation\n -steroids\n -nebs\n -02 prn\n -watch for somnolence as indicatory of increased retention as pt\n refusing ABG.\n .\n <I>## h/o bacteremia:</I>Last positive blood cx , was MRSA.\n received 8 days of IV vanc, sent home on PO bactrim.\n -Continue vancomycin to complete 14 day treatement for bacteremia\n -monitor for evidence of seeding especially in setting of leukocytosis\n and thrombocytosis which may be evidence for more chronic inflammation\n -PICC placement\n -monitor blood cultures\n .\n <I>## Depression/anxiety:</I>\n -ativan prn anxiety, caution not to oversedate\n -Continue home lamotrigine, quetiapine, sertraline\n .\n <I>## OSA:</I>\n -BiPAP or CPAP at night\n .\n <I>## Hyperlipidemia:</I>\n -Continue statin\n .\n <I>## Leukocytosis:<I>Concerning for infection although with normal\n diff. Possible sources include likely lungs and possibly bactermia. Pt\n also at risk for c. diff given recent antibiotic use.\n -blood cultres\n -sputum cultures\n -stool and urine cultures\n ICU Care\n Nutrition:\n Comments: Cardiac heart healthy diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339108,
"text": "Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339109,
"text": "67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339110,
"text": "67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Pneumonia, aspiration\n Assessment:\n Low grade fever temp100, LS ronchi diminished on left side, pt has\n productive cough. On NC pt c/o of SOB\n Action:\n Cont BIPAP, cont Zocyn IV, chest CT to r/o PE done\n Response:\n Chest CT neg for PE\n Plan:\n Cont ABX , cont BIPAP. Pt NPO for speech/swallow study\n Respiratory failure, chronic\n Assessment:\n Received on BPAP70%, sat 98-99%, put on NC 5L\n Action:\n FIO down to 60%, sat 96-97%, given nebs tx\n Response:\n On NC c/o of SOB and desat to high 80%, tolerates nebs\n Plan:\n Cont BPAP.\n Pt c/o of pain on R leg ( no new for pt), given Ativan with good effect\n also ordering vicodin prn.\n After turning pt\ns BP drooped to 78-88, MD aware, after a few minutes\n BP up to 100\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340594,
"text": "67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology required reintubation on had rigid\n bronch on resulted as WNL now s/p extubation on .\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p left hip replacement and states she always has discomfort in her\n right hip but will never get\nthis one done\n. Pt did c/o constant\n pain in right hip. She takes vicodin at home for the pain.\n Action:\n Pt given 1 tab vicodin x2 in addition to repositioning and emotional\n support.\n Response:\n Pt stated pain tolerable at 4/10 after interventions. Pt stated\nThis\n hip always hurts\n Plan:\n Continue to assess for pain, medicate as needed, emotional support and\n repositioning.\n Anxiety\n Assessment:\n Pt states she is anxious a lot and takes Ativan at home for anxiety.\n When pt was first assessed she asked this RN to let her sleep for the\n night because she had not gotten sleep in the past few nights. Pt also\n expressed her anxiety about not being able to breath overnight and the\n possible need to be reintubated.\n Action:\n Pt given 0.5mg Ativan x2. One dose given per PRN order and pt did\n require a 1x order for additional 0.5mg. Pt also reassured about the\n close monitoring on the ICU.\n Response:\n After Ativan admin pt slept for 2-3 hours each time.\n Plan:\n Continue to assess pt\ns anxiety level. Provide emotional support and\n reassurance. Ativan PRN.\n Respiratory failure, chronic\n Assessment:\n Pt received on face tent at 35% and soon after initial assessment and\n PM meds she was put on her CPAP machine per her request. RR 15-19 with\n sats 90-98%. LS with exp wheezes noted in upper lobes and clear in\n lower lobes. Pt with occasional non-productive cough.\n Action:\n Pt tolerating and is comfortable on her CPAP. She did request 10cc\n robitussin PO per pt\ns request.\n Response:\n Pt\ns respiratory status remained stable throughout shift.\n Plan:\n Continue to monitor resp status, CPAP and robitussin PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339090,
"text": "Admitted on @ 1000hrs.\n 67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Respiratory failure, chronic\n Assessment:\n CXR revealed Rt LL PNA . Sats 90 % in ED with SOB.\n Action:\n Put on non invasive ventilation , as failed with non breather mask.\n BIPAP with PEEP / PS / FIO2 . CT chest done to R/O PE . on zosyn\n and vanco iv .\n Response:\n Sats 95-99% ,no SOB noted.comfortable with BIPAP . CT verbal report no\n PE,waiting for official report. Pt remains afebrile. VSS.\n Plan:\n Continue with BIPAP.\n Pt having h/o anxiety, requiring PRN po ativan. And having cough ,need\n guaifenessin.\n D5W with NaHCo3 150meq @ 200cc/hr given\n Blood c/s tomorrow am. Sputum c/s pending. UA sent\n NPO now for speech and swallow eval in view of her ? ASPIRATION PNA\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339091,
"text": "Admitted on @ 1000hrs.\n 67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Respiratory failure, chronic\n Assessment:\n CXR revealed Rt LL PNA . Sats 90 % in ED with SOB.\n Action:\n Put on non invasive ventilation , as failed with non breather mask.\n BIPAP with PEEP / PS / FIO2 . CT chest done to R/O PE . on zosyn\n and vanco iv .\n Response:\n Sats 95-99% ,no SOB noted.comfortable with BIPAP . CT verbal report no\n PE,waiting for official report. Pt remains afebrile. VSS.\n Plan:\n Continue with BIPAP.\n Pt having h/o anxiety, requiring PRN po ativan. And having cough ,need\n guaifenessin.\n D5W with NaHCo3 150meq @ 200cc/hr given\n Blood c/s tomorrow am. Sputum c/s pending. UA sent\n NPO now for speech and swallow eval in view of her ? ASPIRATION PNA\n PM labs trop not send, unable to draw. team aware.\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 340741,
"text": "67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology required reintubation on had rigid\n bronch on resulted as WNL now s/p extubation on .\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p left hip replacement and states she always has discomfort in her\n right hip but will never get\nthis one done\n. Pt did c/o constant pain\n in right hip. She takes vicodin at home for the pain.\n Action:\n Pt given last dose of 1 tab vicodin at 1200 in addition to\n repositioning and emotional support.\n Response:\n Pt stated pain tolerable at 4/10 after interventions. Pt stated\nThis\n hip always hurts\n Plan:\n Continue to assess for pain, medicate as needed, emotional support and\n repositioning.\n Respiratory failure, chronic\n Assessment:\n AO X 3,appears comfortable,CPAP overnight then on and off Cool mist 70%\n and NC 5L, sats are maintained 92-95% currently on NC 5L since\n AM,denies any SOB. Has strong productive cough robitussin 10 ml X\n idose.\n Action:\n On and off NC and cool mist as mentioned above\n Response:\n Pt remains comfortable\n Plan:\n Continue to monitor resp status,BIPAP at night for OSA.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 67.8 kg\n Daily weight:\n Allergies/Reactions:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Precautions: Contact\n PMH:\n CV-PMH: Arrhythmias, CAD, CHF\n Additional history: CAD, resp failure ,s/p trache\n s/p CABG in ,\n left total hip replacement ,\n Afib,\n VAP,\n VRE,\n bipolar disorder,\n depression.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:123\n D:78\n Temperature:\n 99\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 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 91% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 210 mL\n 24h total out:\n 615 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:12 AM\n Potassium:\n 3.7 mEq/L\n 04:12 AM\n Chloride:\n 103 mEq/L\n 04:12 AM\n CO2:\n 29 mEq/L\n 04:12 AM\n BUN:\n 13 mg/dL\n 04:12 AM\n Creatinine:\n 0.9 mg/dL\n 04:12 AM\n Glucose:\n 115 mg/dL\n 04:12 AM\n Hematocrit:\n 30.5 %\n 04:12 AM\n Finger Stick Glucose:\n 116\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: BIPAP machine\n Clothes: Sent home with:pt\n / Money:\n No money / \n Cash / Credit cards sent home with: none\n Jewelry: worn by pt\n Transferred from: MICU 787\n Transferred to: cc612\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339780,
"text": "Chief Complaint:\n 24 Hour Events:\n -Yesterday patient\ns troponin increased to 0.13, CK decreased at 60.\n EKG done showing no ischemic changes so thought to be demand\n ischemia in setting of respiratory distress on AM of . This AM\n cardiac enzymes trending downwards at trop 0.08, CK 39.\n -Vancomycin dose changed from Q48 to Q24 dosing as Cr improving\n -Overnight had decreased BP with MAP in low 50s, given 250ml NS bolus x\n 2 with increase of pressure to MAP in 60s and increase in UOP (30 to\n 70cc/hr)\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 09:10 AM\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 10:51 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 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 63 (57 - 80) bpm\n BP: 91/52(61) {80/25(39) - 126/61(72)} mmHg\n RR: 18 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,004 mL\n 540 mL\n PO:\n TF:\n 162 mL\n IVF:\n 1,721 mL\n 480 mL\n Blood products:\n Total out:\n 2,164 mL\n 290 mL\n Urine:\n 2,164 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n -160 mL\n 250 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 22\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 54\n PIP: 32 cmH2O\n Plateau: 25 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 9.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 474 K/uL\n 9.6 g/dL\n 161 mg/dL\n 1.2 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 101 mEq/L\n 139 mEq/L\n 28.3 %\n 10.4 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n Plt\n 74\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 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": "2138-09-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339781,
"text": "Chief Complaint:\n 67F with complicated pulmonary history which began with prolonged post\n op course of intubation in after total hip replacement with\n associated pseudomonas PNA, trach/PEG with resultant supraglottic\n stenosis and tracheomalacia. Had laser treatment of granulation tissue\n in trachea in and trach decannulation in . Past year has\n been complicated by multiple admissions for both PNA and flash pulm\n edema. Hospitalized late for take down of tracheocutaneous\n fistula (), had postop MRSA PNA/bacteremia treated with vanc.\n Discharged home on on PO bactrim, represented in acute respiratory\n distress in despite home BIPAP. Working ddx was mucous plug vs\n recurrent PNA. Has received IV decadron x 3 for slight airway swelling\n seen on laryngoscope on admission.\n 24 Hour Events:\n -Yesterday patient\ns troponin increased to 0.13, CK decreased at 60.\n EKG done showing no ischemic changes so thought to be demand\n ischemia in setting of respiratory distress on AM of . This AM\n cardiac enzymes trending downwards at trop 0.08, CK 39.\n -Vancomycin dose changed from Q48 to Q24 dosing as Cr improving\n -Overnight had decreased BP with MAP in low 50s, given 250ml NS bolus x\n 2 with increase of pressure to MAP in 60s and increase in UOP (30 to\n 70cc/hr)\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 09:10 AM\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 10:51 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 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 63 (57 - 80) bpm\n BP: 91/52(61) {80/25(39) - 126/61(72)} mmHg\n RR: 18 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,004 mL\n 540 mL\n PO:\n TF:\n 162 mL\n IVF:\n 1,721 mL\n 480 mL\n Blood products:\n Total out:\n 2,164 mL\n 290 mL\n Urine:\n 2,164 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n -160 mL\n 250 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 22\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 54\n PIP: 32 cmH2O\n Plateau: 25 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 9.1 L/min\n Physical Examination\n General: Intubated woman, alert and able to answer questions, in no\n acute distress\n Head, Ears, Nose, Throat: Normocephalic, trach site healing, tiny\n fistula still present\n Pulmonary: No crackles. Decreased with rhonchi at right base.\n Cardiac: Distant. RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted\n Extremities: No edema, 2+ radial, DP pulses b/l\n Neurologic: Alert, able to follow simple commands and express wishes\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 474 K/uL\n 9.6 g/dL\n 161 mg/dL\n 1.2 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 101 mEq/L\n 139 mEq/L\n 28.3 %\n 10.4 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n Plt\n 74\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 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": "2138-09-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339790,
"text": "Chief Complaint:\n 67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress.\n 24 Hour Events:\n -Yesterday patient\ns troponin increased to 0.13, CK decreased at 60.\n EKG done showing no ischemic changes so thought to be demand\n ischemia in setting of respiratory distress on AM of . This AM\n cardiac enzymes trending downwards at trop 0.08, CK 39.\n -Vancomycin dose changed from Q48 to Q24 dosing as Cr improving\n -Overnight had decreased BP with MAP in low 50s, given 250ml NS bolus x\n 2 with increase of pressure to MAP in 60s and increase in UOP (30 to\n 70cc/hr)\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin 1gm Q24hr\n Ciprofloxacin 500mg PO Q24\n Zosyn 2.25gm IV Q6h\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 10:51 AM\n Other medications:\n Lamotrigine 25mg PO BID\n Seroquel\n Sertraline 100mg PO daily\n Simvastatin 40mg PO daily\n Colace\n Albuterol/Ipratroprium\n Ativan prn\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 63 (57 - 80) bpm\n BP: 91/52(61) {80/25(39) - 126/61(72)} mmHg\n RR: 18 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,004 mL\n 540 mL\n PO:\n TF:\n 162 mL\n IVF:\n 1,721 mL\n 480 mL\n Blood products:\n Total out:\n 2,164 mL\n 290 mL\n Urine:\n 2,164 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n -160 mL\n 250 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 22\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 54\n PIP: 32 cmH2O\n Plateau: 25 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 9.1 L/min\n Physical Examination\n General: Intubated woman, alert and able to answer questions, in no\n acute distress\n Head, Ears, Nose, Throat: Normocephalic, trach site healing, tiny\n fistula still present\n Pulmonary: No crackles. Decreased with rhonchi at right base.\n Cardiac: Distant. RR, nl S1 S2, no murmurs, rubs or gallops appreciated\n Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or\n organomegaly noted\n Extremities: No edema, 2+ radial, DP pulses b/l\n Neurologic: Alert, able to follow simple commands and express wishes\n Labs / Radiology\n 474 K/uL\n 9.6 g/dL\n 161 mg/dL\n 1.2 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 101 mEq/L\n 139 mEq/L\n 28.3 %\n 10.4 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n Plt\n 74\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.1 mg/dL\n INR 1.2, PTT 30.1\n Micro:\n All BCx NGTD, Sputum Cx with oropharyngeal contamination, stool cdiff\n from this AM pending\n Imaging\n : Video swallow final results: Mild to moderate oropharyngeal\n dysphagia with episodes of penetration on nectar thick and thin liquids\n Assessment and Plan\n 67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight on requiring intubation with plan\n for bronchoscopy to evaluate.\n .\n <I>PLAN:</I>\n .\n <I>## Acute respiratory failure:</I>Patient intubated after acute\n respiratory failure on AM of . Likely mucous plugging vs\n bronchospasm in setting of possible underlying tracheal stenosis/edema\n or granulation tissue in area of prior trach. Patient still intubated\n with\n - IP involved, contact them this am regarding possibility of trach\n today. Patient with 6.5 tube so cannot bronch through ETT\n - continue nebs and aggressive chest PT\n - continue tx for aspiration PNA with 8 day course Vanc/Cipro/Zosyn\n (day #3 today)\n -s/p 3 doses decadron per ENT for airway swelling, no stridor\n -f/u ENT and IP recs\n .\n <I>## Hypotension:</I>Requiring neosynephrine overnight with an\n elevated lactate to 6.6 in context of respiratory distress. No evidence\n of new infection or intraabdominal pathology.\n -wean down pressors as tolerated\n -recheck lactate\n -place a-line and recheck ABG today\n .\n <I>## CAD:</I> No evidence for ischemia on ecg. Ruled out with enzymes\n on admission. Patient\ns cardiac enzymes checked overnight in context of\n acute respiratory distress and hypotension. First set troponin <0.01,\n 2^nd set 0.03\n - cycle enzymes, third set of cardiac enzymes due at noon\n -continue ASA, BB. Hold ACEI as above\n .\n <I>## CHF:</I>Patient with pulmonary edema by CXR overnight. TTE\n recently done () showed preserved EF with some focal wall motion\n abnormality. Patient received two doses of IV lasix overnight, looks\n euvolemic currently\n -Will allow patient to autodiuresis, goal net even overnight\n -monitor I/Os\n -Continue BB\n -Holding ACEI as above for ARF\n .\n <I>## ARF:</I>Ddx includes pre-renal in setting of possible infection\n vs ATN/AIN from meds given during last hospitalization and in setting\n of CTA on . Cr decreased from 1.3 to 1.2 overnight.\n -hold on diuresis\n -hold lisinopril\n -renally dose abx\n -check urine lytes, eos\n .\n <I>## COPD:</I>Likely not etiology of acute respiratory distress\n overnight, patient without wheezing on exam\n -continue nebs\n .\n <I>## h/o bacteremia:</I>Last positive blood cx , was MRSA.\n received 8 days of IV vanc, sent home on PO bactrim.\n -Continue vancomycin to complete 14 day treatement for bacteremia\n -monitor for evidence of seeding especially in setting of leukocytosis\n and thrombocytosis which may be evidence for more chronic inflammation\n -PICC placement, continue vancomycin as above, additional 5 days will\n complete total 14 days of IV antibiotics.\n -monitor blood cultures\n .\n <I>## Depression/anxiety:</I>\n -ativan prn anxiety, caution not to oversedate\n -Continue home lamotrigine, quetiapine, sertraline\n .\n <I>## Hyperlipidemia:</I>\n -Continue statin\n .\n <I>## Leukocytosis:<I>White count decreased overnight. Concerning for\n infection although with normal diff. Possible sources include likely\n lungs and possibly bactermia. Pt also at risk for c. diff given recent\n antibiotic use.\n -f/u blood, sputum, stool and urine cultures\n ICU Care\n Nutrition: Continue on tube feeds\n Nutren pulmonary. On cardiac diet\n with aspiration precautions as tolerated\n Glycemic Control: Start on insulin sliding scale with initiation of\n tube feeds\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: aspirin and pneumoboots\n Stress ulcer: restart IV protonix 40mg daily\n VAP:\n Comments: increase bowel regimen\n goal for bowel movement today\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340082,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Pt to OR for Rigid bronch; official report not yet available.\n According to a verbal report, the condition of the airway should not\n interfere with a successful extubation.\n The patient was awake and alert on return from OR; Pt became agitation\n when she learned that the tube would stay in until morning. Propofol\n was resumed then held for low Blood Pressure; Pt did not tolerate;\n Propofol resumed at 30mcg; Ativan 0.5mg adm x2 ~midnight. Neo added.\n Frequent runs PVCs. Sm-mod amt thick ET secr. OG placed for oral med\n adm. Foley output 30-60/hour.\n Ativan 0.5 adm at 0630. (Last doses were 0.5 mg at 2200 and 0100)\n Potassium 40 meq for K+ of 3.5 adm at 0630.\n Husband called this am; plans to arrive ~0930.\n ENT intern called; updated.\n Respiratory failure, chronic\n Assessment:\n Rigid Bronch; Pt somnolent after procedure; Re-intubated until a.m.\n Action:\n Provided sedation for comfort; Resp support increased to MVV\n Response:\n Pt required more Propofol than previously; increased to 30mcg then\n tapered back to 15mcg). HR low 50s on 30mcg.\n Plan:\n Wean Propofol and Neo in preparation for extubation in am.\n Hypotension (not Shock)\n Assessment:\n Hypotensive during Propofol administration\n Action:\n Neo re-started for BP support\n Response:\n BP 100s-1teens and MAPS >60\n Plan:\n Wan Neo off when sedation lightened/DCd.\n"
},
{
"category": "Respiratory ",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 339686,
"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: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt is stable on vent\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: Pt is stable on vent\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning; Comments: With good RSBI outcome, pt\n should be assessed for weaning/extubation\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved; Comments: Pt to con't current\n support, wean as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339773,
"text": "Chief Complaint:\n 24 Hour Events:\n -Yesterday patient\ns troponin increased to 0.13, CK decreased at 60.\n EKG done showing no ischemic changes so thought to be demand\n ischemia in setting of respiratory distress on AM of . This AM\n cardiac enzymes trending downwards at trop 0.08, CK 39.\n -\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 09:10 AM\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 10:51 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 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 63 (57 - 80) bpm\n BP: 91/52(61) {80/25(39) - 126/61(72)} mmHg\n RR: 18 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,004 mL\n 540 mL\n PO:\n TF:\n 162 mL\n IVF:\n 1,721 mL\n 480 mL\n Blood products:\n Total out:\n 2,164 mL\n 290 mL\n Urine:\n 2,164 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n -160 mL\n 250 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 22\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 54\n PIP: 32 cmH2O\n Plateau: 25 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 9.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 474 K/uL\n 9.6 g/dL\n 161 mg/dL\n 1.2 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 101 mEq/L\n 139 mEq/L\n 28.3 %\n 10.4 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n Plt\n 74\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 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": "2138-09-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 339881,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: ICU\n Reason: Emergent (1st time); Comments: acute desaturation/dyspnea\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 6.5mm\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: Normal quiet breathing;\n Comments: weaned to +5PSV/+5PEEP tolerating well. O/C for OR for rigid\n bronch. ?extubate\n Assessment of breathing comfort: No claim of dyspnea)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: ?extubate after rigid bronch\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 339884,
"text": "Chief Complaint: respiratory failure\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 67 y/o F w/TBM, trach s/p decannulation and fistula repair, admitted\n with respiratory failure.\n 24 Hour Events:\n -troponin peaked at 0.13 and trended down overnight\n -lactate trended down\n -bolused with NS 250 x2\n -IP does not feel needs bronch as there is nothing they would offer her\n at this point.\n History obtained from Medical records\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Other medications:\n senna, lamictal, simvastatin, aspirin 81 mg daily, ciprofloxacin,\n seroquel, zoloft, propofol at 15, lactulose, colace, atrovent and\n albuterol MDIs, ativan prn, vicodin prn, guaifenesin prn\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.4\nC (99.4\n HR: 69 (54 - 72) bpm\n BP: 94/48(60) {87/25(39) - 126/61(72)} mmHg\n RR: 17 (14 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,004 mL\n 876 mL\n PO:\n TF:\n 162 mL\n IVF:\n 1,721 mL\n 756 mL\n Blood products:\n Total out:\n 2,164 mL\n 429 mL\n Urine:\n 2,164 mL\n 429 mL\n NG:\n Stool:\n Drains:\n Balance:\n -160 mL\n 447 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 428 (428 - 428) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 16\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 54\n PIP: 32 cmH2O\n Plateau: 25 cmH2O\n SpO2: 99%\n ABG: ///30/\n Ve: 7.3 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious, tearful\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.6 g/dL\n 474 K/uL\n 161 mg/dL\n 1.2 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 101 mEq/L\n 139 mEq/L\n 28.3 %\n 10.4 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n Plt\n 74\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.1 mg/dL\n Imaging: Video swallow: Moderate penetration of nectar thick and thin\n liquids.\n CXR: Increased interstitial markings c/w yesterday but no obvious\n infiltrate.\n Microbiology: Blood cx NGTD\n Sputum OP flora\n CDiff pending\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology +/- aspiration.\n 1) Respiratory failure: Acute event the other night appears to be due\n to a mucus plug, likely complicated by underlying airway pathology.\n have tracheal stenosis or granulation tissue at level of prior\n trach complicating the situation. Will discuss need for bronch or\n visualization of airway with both IP and ENT. If neither want to scope\n her, can likely extubate today given how well she looks on current\n settings.\n - PSV 5/5, SBT\n - Has received 10 days of abx, sputum was non-purulent . Will d/c\n abx and follow fever curve, WBC count.\n 2) Shock: Neo requirement decreased, appears related to propofol.\n Lactate normalized.\n -wean neo\n 3) Elevated troponin: Likely demand in setting of hypotension, now\n resolving. No ECG changes. Goal euvolemic.\n 4) Renal: Creatinine 1.2. Follow in the setting of CTA.\n 5) F/E/N: Cardiac prudent diet. Follow / replete lytes as needed. Goal\n euvolemic for now.\n ICU Care\n Nutrition:\n Comments: holding tube feeds pending extubation\n Glycemic Control: Blood sugar well controlled\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: SQ UF Heparin\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: 30\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339362,
"text": "67F with extensive cardiac history and COPD with post-intubation\n tracheal stenosis, s/p tracheal decannulation\n and tracheocutaneous fistula. Discharged from ENT service after\n tracheocutaneous fistula closure; her hospital course was complicated\n by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA\n completed a course of vancomycin, discharged home with BiPap at night\n on a course of bactrim. Has history of pseudomonas PNA. Overnight on\n evening of admission had acute SOB after getting up OOB to use\n bathroom. Reports feeling very anxious, put on CPAP, able to sleep for\n an hour, woke again with severe SOB and presented to OSH ED. No chest\n pain. Has been coughing, producing white sputum, though no more than\n prior to last discharge. Subjective fevers this afternoon. No chills.\n Slight right hip pain although not new. On 2L 02 at home, able to\n ambulate and climb stairs without difficulty. No note of LE swelling or\n recent weight gain.\n Initially presented to hospital, found to have RLL PNA on CXR\n and new leukocytosis, Got CTX, azithromycin lasix and 500NS at OSH at\n was flown to ED\n In our ED, tried off BiPap, desatted to 80s on NRB. . initial VS 98.5\n HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin\n And transffered to MICU for further management.\n Pneumonia, aspiration\n Assessment:\n Pt. maintains intact, cough, with no gag noted.. But, from previous\n imaging, Pt. is to be r/o for aspiration PNA.\n Action:\n Pt. had video and barium swallow studies today. Outcome at present is\n to give pt. nectar thickened liquids.\n Response:\n Pt. is noted to clear her own secretions. Pt. is to have thickened\n liquids for precautions of aspiration potential.\n Plan:\n Thickened liquids.\n Respiratory failure, chronic\n Assessment:\n Pt, continues to exhibit strong productive cough for moderate amt\ns of\n at times blood tinged tan sputum. Sputum culture sent this am .\n Pt. exhibits clear mid to upper lobes while diminished bibasilar.\n Action:\n Pt. has been ordered IV antibiotics of Zosyn, Vancomycin, and\n Ciprofloxin. Pt. has also been ordered chest PT which she tolerates\n fair. Pt. c/o back pain with this.\n Response:\n Pt. barely tolerates chest PT and Pt. does obtain use of her BIPAP\n routinely throughout the day and full time during the night.\n Plan:\n To pre medicate pt. prior to chest PT.\n Pt. is scheduled for a video swallow and Barium swallow to assess\n possible aspiration and or regurg. Which has now been obtained. Pt. has\n remained A/A/O and c/o occasional right hip pain which she is treated\n with vicoden. Pt. also has received ativan po for slight anxiety. Pt.\n has remained afebrile throughout this shift with TMAX 99.1. Pt. is\n aware and is able to state when she requires her BIPAP. Pt. has\n Allevyn dressing over old trach site. This was recently, surgically\n closed. This site remains D&I at this time. Pt. continues to have\n pending, blood, sputum, and urine cultures.\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 340201,
"text": "Chief Complaint: respiratory failure\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia.\n 24 Hour Events:\n BRONCHOSCOPY - At 07:00 PM\n Rigid bronchoscopy reportedly normal. Extubated in OR but became\n hypoxic, felt related to sedation so reintubated.\n Given lasix for pulmonary edema on CXR.\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Infusions:\n Other ICU medications:\n Other medications:\n senna, lamictal, simvastatin, aspirin 81 mg daily, seroquel, zoloft,\n peridex, colace, protonix, insulin SQ, atrovent, albuterol, lasix 40 mg\n daily, propofol is off\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 11:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.4\nC (99.3\n HR: 86 (54 - 86) bpm\n BP: 127/73(86) {92/44(55) - 130/73(86)} mmHg\n RR: 21 (13 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,242 mL\n 493 mL\n PO:\n TF:\n IVF:\n 942 mL\n 223 mL\n Blood products:\n Total out:\n 1,660 mL\n 905 mL\n Urine:\n 1,660 mL\n 905 mL\n NG:\n Stool:\n Drains:\n Balance:\n -418 mL\n -412 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): 73 (73 - 541) mL\n PS : 10 cmH2O\n RR (Set): 8\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 43\n PIP: 17 cmH2O\n SpO2: 98%\n ABG: ///29/\n Ve: 11.1 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic, trach site healing well\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.1 g/dL\n 423 K/uL\n 205 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 14 mg/dL\n 100 mEq/L\n 137 mEq/L\n 26.9 %\n 8.2 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n Plt\n 74\n 423\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR: bilateral LL infiltrates, minimal.\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology +/- aspiration.\n 1) Respiratory failure: Acute event the other night appears to be due\n to a mucus plug vs aspiration. No airway pathology seen on rigid\n bronch which would limit extubation.\n - good RSBI this AM, comfortable on , so will proceed with\n extubation.\n - no evidence of pneumonia, off antibiotics\n 2) Hypotension: Resolved. off neo. Likely related to propofol.\n 3) Elevated troponin/Hx CHF: Likely demand in setting of hypotension,\n now resolving. No ECG changes. Goal euvolemic. Restart\n antihypertensives in AM if stable today.\n 4) ARF: Resolved. Creatinine improved.\n 5) F/E/N: NPO, restart clear liquids tonight if she does well. Follow /\n replete lytes as needed. Goal euvolemic for now.\n ICU Care\n Nutrition:\n Comments: holding TF for extubation\n Glycemic Control: Regular insulin sliding scale\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 min\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340204,
"text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n Antibiotics discontinued.\n Home Lasix regimen restarted.\n Rigid BRONCHOSCOPY (- At 07:00 PM) performed in OR with\n anesthesia present; with essentially normal findings and nothing to\n explain her recurrent respiratory failure.\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsHeparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Other medications:\n Morphine 1 mg IV prn hip pain\n Ativan 0.5 mg IV prn anxiety\n Lasix 40 mg daily\n Lactulose 30 mg daily\n Albuterol q4 hr\n Atrovent\n Colace 100 \n Pantoprazole 40 IV daily\n Chlorhexidine mouthwash\n Senna\n Lamotrigine 25 mg \n Simvastatin 40 mg daily\n Aspirin 81 daily\n Seroquel\n Sertraline 100 daily\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37\nC (98.6\n HR: 58 (54 - 77) bpm\n BP: 123/57(74) {91/44(55) - 130/63(79)} mmHg\n RR: 14 (13 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,242 mL\n 366 mL\n PO:\n TF:\n IVF:\n 942 mL\n 186 mL\n Blood products:\n Total out:\n 1,660 mL\n 325 mL\n Urine:\n 1,660 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -418 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 458 (407 - 541) mL\n PS : 10 cmH2O\n RR (Set): 8\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 43\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: ///29/\n Ve: 7.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 423 K/uL\n 9.1 g/dL\n 205 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 14 mg/dL\n 100 mEq/L\n 137 mEq/L\n 26.9 %\n 8.2 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n Plt\n 74\n 423\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.8 mg/dL\n Micro: No new micro.\n CXR. Unchanged.\n Assessment and Plan\n In Summary, Ms. is a 67F with CAD s/p CABG, CHF, COPD and\n complicated pulmonary history with prolonged tracheostomy with recent\n decannulation and subsequent fistula closure (on ENT service at \n on ) with complicated MRSA PNA presented with worsened respiratory\n distress. Now s/p bronchoscopy which did not reveal significant upper\n airway stenosis.\n .\n 1. Respiratory failure. Patient was intubated on after episode of\n flash pulmonary edema while being bathed and concern for upper airway\n obstruction due to previous intubations/trach. Patient also has\n history of trace aspiration. Copmleted 10 day course for aspiration\n pneumonia on . Anxiety also contributes to patient\ns respiratory\n distress. Bronchoscopy on showed no significant upper airway\n stenosis. Will need permanent trach if extubation is unsuccessful\n today.\n - extubate today\n - continue nebs\n - continue home lasix for interstial edema\n - ativan prn\n - transition to PO meds if successfully extubated\n .\n 2. Hypotension. Patient required pressors while on propofol for\n sedation. Will wean neo and extubate today. Hopeful that patient will\n not require pressors when not on sedation.\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\n edema/HTN. Troponins have trended down.\n -continue ASA, BB\n - consider resuming ACEI tomorrow if hemodynamically stable\n .\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\n on . CXR yesterday showed mild interstitial edema. Currently\n euvolemic, but will continue home lasix dose. TTE recently done\n () showed preserved EF with some focal wall motion abnormality.\n Patient euvolemic and net even overnight without any additional\n diuretics\n -continue home lasix\n -monitor I/Os\n -Continue BB\n - holding ACEI until blood pressure stable for 24 hours off pressors\n .\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\n - consider resuming lisinopril in AM\n 6. COPD.\n -continue nebs\n .\n 7. Depression/anxiety. Patient has significant anxiety.\n -ativan prn anxiety, caution not to oversedate\n -Continue home lamotrigine, quetiapine, sertraline\n .\n 8. Hyperlipidemia:\n -Continue statin\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: pantoprazole\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU care for now\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339456,
"text": "Chief Complaint: 67F with complicated pulmonary history. Initiated in\n when had THR, complicated post op course with prolonged\n intubation, with associated pseudomonas PNA, trach/PEG with resultant\n supraglottic stenosis and tracheomalacia. Had laser treatment of\n granulation tissue in trachea in and trach decannulation in\n . Past year has been complicated by multiple admissions for both\n PNA and flash pulm edema. Hospitalized late for take down of\n tracheocutaneous fistula (), had MRSA PNA/bacteremia. Discharged on\n , represented in acute respiratory distress in . Working ddx was\n mucous plug vs recurrent PNA. Has received IV decadron x 3 for slight\n airway swelling seen on laryngoscope on admission.\n 24 Hour Events:\n PICC LINE - START 09:34 AM\n NON-INVASIVE VENTILATION - STOP 09:48 AM\n SPUTUM CULTURE - At 09:58 AM\n Pt. expectorated tan colored sputum. Culture sent to the lab.\n FLUOROSCOPY - At 02:22 PM\n Pt. transported down for both a barium and video swallow study. -- no\n evidence overt aspiration\n RESPIRATORY ARREST - At 04:45 AM\n pt in acute distress, desat to 50's, diaphoretic and mottled; intubated\n Pt did well all day off BiPap, reported feeling back to baseline. Was\n on her BiPap at night (uses this at home) when became acutely short of\n breath at 4am. Given chest PT, lasix 40mg IV and morphine. Pulse 0x\n in high 40s. Emergently intubated. Position confirmed\n fiberoptically. Continued to oxygenate poorly. Tachycardic to\n 130-140s, lots of ectopy, ecg didn't show overt ischemia, CEs\n negative. Blood cultures drawn. CXR c/w pulmonary edema. VBG with pH\n 6.98, lactate 6.6. PEEP increased to 12. Given 80mg IV lasix and\n started on nitro gtt. Became hypotensive to 70s, nitro gtt held.\n Neosynephrine started. Called husband and left message, called and\n spoke to son and informed him of events, he will relay to his father.\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 12:55 PM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 04:45 AM\n Furosemide (Lasix) - 05:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.4\nC (97.6\n HR: 133 (46 - 133) bpm\n BP: 156/83(100) {96/36(50) - 156/84(100)} mmHg\n RR: 26 (12 - 26) insp/min\n SpO2: 83%\n Heart rhythm: ST (Sinus Tachycardia)\n Mixed Venous O2% Sat: 80 - 80\n Total In:\n 567 mL\n 769 mL\n PO:\n TF:\n IVF:\n 567 mL\n 769 mL\n Blood products:\n Total out:\n 1,125 mL\n 230 mL\n Urine:\n 1,125 mL\n 230 mL\n NG:\n Stool:\n Drains:\n Balance:\n -559 mL\n 539 mL\n Respiratory support\n O2 Delivery Device: Other\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 580 (400 - 580) mL\n PS : 6 cmH2O\n PEEP: 6 cmH2O\n PIP: 12 cmH2O\n SpO2: 83%\n ABG: ///31/\n Ve: 9.3 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 380 K/uL\n 9.5 g/dL\n 120 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 105 mEq/L\n 143 mEq/L\n 27.7 %\n 8.0 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n WBC\n 13.1\n 10.3\n 8.0\n Hct\n 32.3\n 30.5\n 27.7\n Plt\n \n Cr\n 1.3\n 1.3\n 1.2\n TropT\n 0.03\n <0.01\n Glucose\n 70\n 168\n 120\n Other labs: PT / PTT / INR:15.2/31.1/1.3, CK / CKMB /\n Troponin-T:92/6/<0.01, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:6.6 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Imaging: CTA :\n IMPRESSION:\n 1. No PE.\n 2. Findings compatible with aspiration within the right lower and\n middle lobe\n bronchi, with atelectasis and airspace consolidation suspicious for\n pneumonia.\n Prelim report barium swallow:\n No evidence for gastroesophageal reflux. Small-to-moderate hiatal\n hernia.\n Videooropharyngeal swallow with no overt aspiration, may be slight\n silent aspiration, report pending.\n Microbiology: Blood, urine and sputum cultures pending.\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n 18 Gauge - 10:15 AM\n PICC Line - 09:34 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": "2138-09-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339760,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Levofloxacin - 10:05 AM\n Vancomycin - 09:10 AM\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 10:51 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 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 63 (57 - 80) bpm\n BP: 91/52(61) {80/25(39) - 126/61(72)} mmHg\n RR: 18 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,004 mL\n 540 mL\n PO:\n TF:\n 162 mL\n IVF:\n 1,721 mL\n 480 mL\n Blood products:\n Total out:\n 2,164 mL\n 290 mL\n Urine:\n 2,164 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n -160 mL\n 250 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 22\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 54\n PIP: 32 cmH2O\n Plateau: 25 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 9.1 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 474 K/uL\n 9.6 g/dL\n 161 mg/dL\n 1.2 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 15 mg/dL\n 101 mEq/L\n 139 mEq/L\n 28.3 %\n 10.4 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n Plt\n 74\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 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": "2138-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339864,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Pt. has been evaluated and is presently a\nadd on\n case for the O.R. to\n perform a rigid bronchoscopy, by M.D.\n Pulmonary edema\n Assessment:\n Pt\ns am CXR shows slight congestion.\n Action:\n Lasix 40mg po via OGT administered.\n Response:\n Pt. has diuresed appropriately with this. Lungs are clear mid to upper\n lobes and remain diminished bibasilar.\n Plan:\n Daily CXR along with lasix 40mg po qd order.\n Hypotension (not Shock)\n Assessment:\n Pt\ns B/P remains labile. Map\ns occasionally drop below 60.\n Action:\n Pt. remains on Neo gtt at 0.75mcq/kg/min.\n Response:\n Pt.\ns map\ns have been better controlled with Neo support.\n Plan:\n To wean Neo gtt when able, while maintaining map\ns >60.\n Respiratory failure, chronic\n Assessment:\n Pt. remains intubated and is presently on P.S. settings of . Resp\n rate is controlled and pt. voices no complaints of SOB.\n Action:\n Pt. is\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340713,
"text": "Chief Complaint:\n 24 Hour Events:\n - patient weaned to nasal cannula during day, CPAP at night. No events\n of respiratory distress overnight.\n - diet advanced following speech/swallow guidelines. Patient tolerating\n regular diet with aspiration precautions. Pills with thickened liquids\n - Patient received one extra dose of PO ativan 0.5mg overnight for\n anxiety\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 09:03 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Morphine 1 mg IV prn hip pain\n Ativan PO/ IV prn anxiety\n Lasix 40 mg daily\n Lactulose 30 mg daily\n Albuterol q4 hr\n Atrovent\n Colace 100 \n Pantoprazole 40 IV daily\n Chlorhexidine mouthwash\n Senna\n Lamotrigine 25 mg \n Simvastatin 40 mg daily\n Aspirin 81 daily\n Seroquel\n Sertraline 100 daily\n Albuterol/ipratroprium nebs\n Insuline sliding scale\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.1\nC (97\n HR: 75 (71 - 94) bpm\n BP: 98/54(64) {83/38(53) - 138/79(91)} mmHg\n RR: 16 (8 - 21) insp/min\n SpO2: 94%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 60 Inch\n Total In:\n 660 mL\n 112 mL\n PO:\n 460 mL\n TF:\n IVF:\n 40 mL\n 112 mL\n Blood products:\n Total out:\n 1,325 mL\n 15 mL\n Urine:\n 1,325 mL\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n -665 mL\n 97 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n GEN: NAD, sleeping, easily aroused\n HEENT: MMM\n CV: RRR\n Pulm: bibasilr rales, occ scattered rhonchi\n Abd: obese, soft, nt/nd\n Ext: no c/c.e\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 420 K/uL\n 10.6 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 103 mEq/L\n 142 mEq/L\n 30.5 %\n 6.8 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n 04:12 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n 6.8\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n 30.5\n Plt\n 74\n 423\n 369\n 420\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n 115\n Other labs: PT / PTT / INR:13.8/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Ms. is a 67F with CAD s/p CABG, CHF, COPD and complicated\n pulmonary history with prolonged tracheostomy with recent decannulation\n and subsequent fistula closure (on ENT service at on ) with\n complicated MRSA PNA presented with worsened respiratory distress. Now\n s/p bronchoscopy which did not reveal significant upper airway\n stenosis.\n .\n 1. Respiratory failure. Patient was intubated on after episode of\n flash pulmonary edema while being bathed and concern for upper airway\n obstruction due to previous intubations/trach. Patient also has\n history of trace aspiration. Completed 10 day course for aspiration\n pneumonia on . Rigid bronchoscopy on showed no significant upper\n airway stenosis. Extubated successfully on . No episodes of\n respiratory distress overnight, but given history, will watch closely\n today as patient is advanced on her diet with aspiration precautions.\n - IP and ENT following, appreciate recs\n - strict aspiration precautions with PO intake\n regular food with thin\n liquids with aspiration precautions, but pills must be taken with\n thickened liquids\n - continue nebs\n - continue home lasix for interstial edema\n - ativan prn for anxiety\n .\n 2.Hypotension. resolved.\n - monitor BP\n -will need to add back ace I in next 1-2 days\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\n edema/HTN. Troponins have trended down.\n -continue ASA, BB\n - consider resuming ACEI when BP tolerates and if renal function\n continues to improve\n .\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\n on . CXR yesterday showed mild interstitial edema. Currently\n euvolemic, but will continue home lasix dose. TTE recently done\n () showed preserved EF with some focal wall motion abnormality.\n Patient euvolemic and net even overnight without any additional\n diuretics\n -continue home lasix\n -monitor I/Os\n -Continue BB\n - holding ACEI until blood pressure stable\n .\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\n - consider resuming lisinopril when BP tolerates, Cr improved\n 6. COPD.\n -continue nebs\n .\n 7. Depression/anxiety. Patient has significant anxiety.\n -ativan prn anxiety, caution not to oversedate. Can change Ativan from\n IV to PO\n -Continue home lamotrigine, quetiapine, sertraline\n .\n 8. Hyperlipidemia:\n -Continue statin\n ICU Care\n Nutrition: Advance diet to regular diet with aspiration precautions,\n pills with thickened liquids\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: pantoprazole\n VAP: Extubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU care for now\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339679,
"text": "Chief Complaint: 67F with complicated pulmonary history which began\n with prolonged post op course of intubation in after total hip\n replacement with associated pseudomonas PNA, trach/PEG with resultant\n supraglottic stenosis and tracheomalacia. Had laser treatment of\n granulation tissue in trachea in and trach decannulation in\n . Past year has been complicated by multiple admissions for both\n PNA and flash pulm edema. Hospitalized late for take down of\n tracheocutaneous fistula (), had postop MRSA PNA/bacteremia treated\n with vanc. Discharged home on on PO bactrim, represented in acute\n respiratory distress in despite home BIPAP. Working dx was mucous\n plug vs recurrent PNA. Has received IV decadron x 3 for slight airway\n swelling seen on laryngoscope on admission.\n Hypotension (not Shock)\n Assessment:\n Propofol contributing to hypotension;\n Action:\n Titrated phenylephrine to 1.5 mcg/kg/min; Bolus 250cc x2; Decreased\n Propofol from 20 mcg to 10mcg/kg/min with significant increase in MAP\n to 74\n Response:\n Increase MAP; Increased UOP\n Plan:\n Wean Propofol in am; Wean Phenylephrine in preparation for\n extubation/bronchoscopy\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary edema\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339625,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Pulmonary edema\n Assessment:\n Pt. had noted crackles from mid to upper lobes.\n Action:\n Lasix I.V. given prior to this shift. With pt. putting out moderate to\n large amt\ns of clear yellow urine.\n Response:\n Lungs cleared with pt\ns diuresing.\n Plan:\n To monitor lung status frequently and U.O.\n Hypotension (not Shock)\n Assessment:\n Pt. dropped B/P following intubation and with medications utilized\n with the episode of acute resp. distress.\n Action:\n Pt. placed on Neo gtt to maintain map\ns >60.\n Response:\n Pt. rermains on Neo gtt but this has been weaned down form 1.5 mcg to\n 0.75 mcg/kg/min.\n Plan:\n Plan to keep weaning Neo gtt until off.\n Respiratory failure, chronic\n Assessment:\n Pt. acutely decompensated during am care. Pt. was intubated as a\n result. Pt. has been suctioned for moderate amt\ns of thick/tenacious\n tan/blood tinged secretions.\n Action:\n Pt. has been successfully weaned down from full support to pressure\n support. Plan is to Hold tube feeds at midnight and plan for SBT in the\n am. Plan is for probable bronch with I.P. tomorrow with extubation.\n Response:\n Pt. has tolerated wean from full support to pressure support.\n Plan:\n Albuterol/attrovent MDI\ns along with frequent suctioning. Plan to\n bronchoscopy to evaluate airway following possible extubation in the am\n hours tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339680,
"text": "Chief Complaint: 67F with complicated pulmonary history which began\n with prolonged post op course of intubation in after total hip\n replacement with associated pseudomonas PNA, trach/PEG with resultant\n supraglottic stenosis and tracheomalacia. Had laser treatment of\n granulation tissue in trachea in and trach decannulation in\n . Past year has been complicated by multiple admissions for both\n PNA and flash pulm edema. Hospitalized late for take down of\n tracheocutaneous fistula (), had postop MRSA PNA/bacteremia treated\n with vanc. Discharged home on on PO bactrim, represented in acute\n respiratory distress in despite home BIPAP. Working dx was mucous\n plug vs recurrent PNA. Has received IV decadron x 3 for slight airway\n swelling seen on laryngoscope on admission.\n Hypotension (not Shock)\n Assessment:\n Propofol contributing to hypotension;\n Action:\n Titrated phenylephrine to 1.5 mcg/kg/min; Bolus 250cc x2; Decreased\n Propofol from 20 mcg to 10mcg/kg/min with significant increase in MAP\n to 74\n Response:\n Increase MAP; Increased UOP\n Plan:\n Wean Propofol in am; Wean Phenylephrine in preparation for\n extubation/bronchoscopy\n Respiratory failure, chronic\n Assessment:\n Lungs clear, diminished at bases;\n Action:\n Suction prod for thick off white and blood tinged secretions\n Response:\n Tolerates well; improved aeration\n Plan:\n Continue pulm toilet.\n Pulmonary edema\n Assessment:\n BP and UOP dropped overnight; Bolus 250 cc x2; LS remained\n clear\n Action:\n Monitored LS; UOP\n Response:\n LS clear; UOP improved with boluses\n Plan:\n Continue to monitor; obtain order for Lasix if indicated.\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340027,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Pt to OR for Rigid bronch; official report not yet available.\n According to a verbal report, the condition of the airway should not\n interfere with a successful extubation.\n The patient was awake and alert on return from OR; Propofol was\n resumed then held for low Blood Pressure; Pt did not tolerate; Propofol\n resumed at 30mcg; Ativan 0.5mg adm x2 ~midnight. Neo added. Frequent\n runs PVCs. Sm-mod amt thick ET secr. OG placed for oral med adm.\n Foley output 30-60/hour.\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340028,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Pt to OR for Rigid bronch; official report not yet available.\n According to a verbal report, the condition of the airway should not\n interfere with a successful extubation.\n The patient was awake and alert on return from OR; Propofol was\n resumed then held for low Blood Pressure; Pt did not tolerate; Propofol\n resumed at 30mcg; Ativan 0.5mg adm x2 ~midnight. Neo added. Frequent\n runs PVCs. Sm-mod amt thick ET secr. OG placed for oral med adm.\n Foley output 30-60/hour.\n Respiratory failure, chronic\n Assessment:\n Rigid Bronch; Pt somnolent after procedure; Re-intubated until a.m.\n Action:\n Provided sedation for comfort; Resp support increased to MVV\n Response:\n Pt required more Propofol than last night;\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340116,
"text": "Chief Complaint:\n 24 Hour Events:\n Antibiotics discontinued.\n Home Lasix regimen restarted.\n Rigid BRONCHOSCOPY (- At 07:00 PM) performed in OR with\n anesthesia present; with essentially normal findings and nothing to\n explain her recurrent respiratory failure.\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsHeparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37\nC (98.6\n HR: 58 (54 - 77) bpm\n BP: 123/57(74) {91/44(55) - 130/63(79)} mmHg\n RR: 14 (13 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,242 mL\n 366 mL\n PO:\n TF:\n IVF:\n 942 mL\n 186 mL\n Blood products:\n Total out:\n 1,660 mL\n 325 mL\n Urine:\n 1,660 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n -418 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 458 (407 - 541) mL\n PS : 10 cmH2O\n RR (Set): 8\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 43\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: ///29/\n Ve: 7.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 423 K/uL\n 9.1 g/dL\n 205 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 14 mg/dL\n 100 mEq/L\n 137 mEq/L\n 26.9 %\n 8.2 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n Plt\n 74\n 423\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.8 mg/dL\n Micro: No new micro.\n CXR.\n Assessment and Plan\n 67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight on requiring intubation with plan\n for bronchoscopy to evaluate.\n .\n <I>PLAN:</I>\n .\n <I>## Acute respiratory failure:</I>Patient intubated after acute\n respiratory failure on AM of . Likely mucous plugging vs\n bronchospasm in setting of possible underlying tracheal stenosis/edema\n or granulation tissue in area of prior trach. Patient still intubated\n in the case there is need for bronch or visualization of airway by\n either IP or ENT. Given patient\ns history of multiple episodes of\n respiratory distress, worrisome that patient would have future episodes\n and would benefit for visualization and possible intervention.\n - follow up with final IP and ENT recommendations\n - if no bronch or airway visualization today, can likely extubate\n patient today\n - trial patient on pressure support with SBT\n - patient has received 10 days of broad spectrum abx for staph in\n sputum from prior BAL. CXR with no evidence of infiltrate, last BCx and\n sputum unremarkable. Discontinue antibiotics today and follow fever\n curve, white count\n - touch base with speech and swallow regarding recommendations for diet\n to decrease chance of aspiration\n - continue nebs and aggressive chest PT\n .\n <I>## Hypotension:</I>Lactate decreased, has been weaned down on neo\n but unable to completely wean off while intubated and on propofol.\n Patient\ns BP is fluid responsive and has been stable over last 8 hours.\n A-line attempted but unable to place, no need for monitoring currently\n - wean down neo as tolerated\n .\n <I>## CAD:</I> Patient with some troponin elevation to peak of 0.13 in\n setting of acute respiratory distress from two nights prior. Most\n recent troponin trending down at 0.08 and EKG with no acute ischemic\n changes\n -continue ASA, BB. Hold ACEI as above\n .\n <I>## CHF:</I>Patient with pulmonary edema by CXR overnight. TTE\n recently done () showed preserved EF with some focal wall motion\n abnormality. Patient euvolemic and net even overnight without any\n additional diuretics\n -Will allow patient to autodiuresis, goal net even overnight\n -monitor I/Os\n -Continue BB\n -Holding ACEI as above for ARF\n .\n <I>## ARF:</I>Ddx includes pre-renal in setting of possible infection\n vs ATN/AIN from meds given during last hospitalization and in setting\n of CTA on . Cr stable at 1.2\n -hold on diuresis\n -hold lisinopril\n -renally dose abx\n -check urine lytes, eos\n .\n <I>## COPD:</I>Likely not etiology of acute respiratory distress\n overnight, patient without wheezing on exam\n -continue nebs\n .\n <I>## Depression/anxiety:</I>\n -ativan prn anxiety, caution not to oversedate\n -Continue home lamotrigine, quetiapine, sertraline\n .\n <I>## Hyperlipidemia:</I>\n -Continue statin\n .\n <I>## Leukocytosis:<I>White count decreased overnight. Concerning for\n infection although with normal diff. Possible sources include likely\n lungs and possibly bactermia. Pt also at risk for c. diff given recent\n antibiotic use.\n -f/u blood, sputum, stool and urine cultures\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 340676,
"text": "Chief Complaint: respiratory failure\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress.\n 24 Hour Events:\n No events. Feeling better. Tolerating regular diet.\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n zoloft, seroquel, aspirin, simvastatin, lamictal, senna, colace,\n bupropion, albuterol\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.3\nC (97.4\n HR: 78 (71 - 85) bpm\n BP: 106/55(67) {83/38(53) - 138/79(91)} mmHg\n RR: 14 (8 - 19) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 660 mL\n 153 mL\n PO:\n 460 mL\n TF:\n IVF:\n 40 mL\n 153 mL\n Blood products:\n Total out:\n 1,325 mL\n 115 mL\n Urine:\n 1,325 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n -665 mL\n 38 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 5L NC\n SpO2: 92%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress, breathing\n comfortably\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: No(t)\n Crackles : , Wheezes : at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.6 g/dL\n 420 K/uL\n 115 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 103 mEq/L\n 142 mEq/L\n 30.5 %\n 6.8 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n 04:12 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n 6.8\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n 30.5\n Plt\n 74\n 423\n 369\n 420\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n 115\n Other labs: PT / PTT / INR:13.8/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Suspect mucus plug as\n the etiology +/- aspiration. Now much improved, s/p extubation .\n 1) Respiratory failure: Acute event the other night appears to be due\n to a mucus plug with aspiration in RLL. No airway pathology seen on\n rigid bronch.\n - aspiration precautions\n - no evidence of pneumonia, off antibiotics\n - standing inhalers/nebs\n - CPAP prn per home regimen\n - appreciate ENT & IP input\n 2) Elevated troponin/Hx CHF: Likely demand in setting of hypotension,\n now resolving. No ECG changes.\n - on home dose of lasix\n - bp stable off antihypertensives\n 3) F/E/N: Diet per speech/swallow recommendations.\n 4) Anxiety: ativan prn (home regimen.)\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 12:52 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339674,
"text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary edema\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339905,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Pt. has been evaluated and is presently a\nadd on\n case for the O.R. to\n perform a rigid bronchoscopy, by A. M.D.\n Pulmonary edema\n Assessment:\n Pt\ns am CXR shows slight congestion.\n Action:\n Lasix 40mg po via OGT administered.\n Response:\n Pt. has diuresed appropriately with this. Lungs are clear mid to upper\n lobes and remain diminished bibasilar.\n Plan:\n Daily CXR along with lasix 40mg po qd order.\n Hypotension (not Shock)\n Assessment:\n Pt\ns B/P remains labile. Map\ns occasionally drop below 60.\n Action:\n Pt. remains on Neo gtt at 0.75mcq/kg/min.\n Response:\n Pt.\ns map\ns have been better controlled with Neo support.\n Plan:\n To wean Neo gtt when able, while maintaining map\ns >60. Neo has been\n weaned off as of 1630\n Respiratory failure, chronic\n Assessment:\n Pt. remains intubated and is presently on P.S. settings of . Resp\n rate is controlled and pt. voices no complaints of SOB.\n Action:\n Pt. is scheduled for rigid bronch, with expected time to O.R. around\n 1800.\n Response:\n O2 sats remain >97%. Pt. denies any SOB.\n Plan:\n Extubate pt. post bronch.\n Pt. has received Vicoden one tab, twice. And, Ativan 1.5 mg throughout\n this shift. Last dose for both was 1740.\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339678,
"text": "Chief Complaint: 67F with complicated pulmonary history which began\n with prolonged post op course of intubation in after total hip\n replacement with associated pseudomonas PNA, trach/PEG with resultant\n supraglottic stenosis and tracheomalacia. Had laser treatment of\n granulation tissue in trachea in and trach decannulation in\n . Past year has been complicated by multiple admissions for both\n PNA and flash pulm edema. Hospitalized late for take down of\n tracheocutaneous fistula (), had postop MRSA PNA/bacteremia treated\n with vanc. Discharged home on on PO bactrim, represented in acute\n respiratory distress in despite home BIPAP. Working dx was mucous\n plug vs recurrent PNA. Has received IV decadron x 3 for slight airway\n swelling seen on laryngoscope on admission.\n Hypotension (not Shock)\n Assessment:\n Propofol contributing to hypotension;\n Action:\n Titrated phenylephrine to 1.5 mcg/kg/min; Bolus 250cc x2; Decreased\n Propofol from 20 mcg to 10mcg/kg/min with significant increase in MAP\n to 74\n Response:\n Increase MAP; Increased UOP\n Plan:\n Wean Propofol in am; Wean Phenylephrine\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary edema\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 340020,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n 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: Sedated / Paralyzed\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340171,
"text": "Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340173,
"text": "Respiratory failure, chronic\n Assessment:\n Received on vent MMV weaned to CPAP and then successfully extubated\n at 1115,AO X 3,Afebrile neo weaned off at 1000 NBP maintained since\n then.LS are clear diminished bibasilar.Appears to be comfortable but\n needs to be attended frequently for O2 requirements,initially placed\n on Cool mist 50%,changed to CPAP\npt,s own as requested by pt followed\n by hospital CPAP machine.\n Action:\n Ativan 0.5 X 1dose Successfully extubated O2 requirements as mentioned\n above and neo weaned off.\n Response:\n Heamodinamically remained stable\n Plan:\n Monitor resp status,NPO for now ,Ativan 0.5mg Q6H for anxiety.\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340174,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Respiratory failure, chronic\n Assessment:\n Received on vent MMV weaned to CPAP and then successfully extubated\n at 1115,AO X 3,Afebrile neo weaned off at 1000 NBP maintained since\n then.LS are clear diminished bibasilar.Appears to be comfortable but\n needs to be attended frequently for O2 requirements,initially placed\n on Cool mist 50%,changed to CPAP\npt,s own as requested by pt followed\n by hospital CPAP machine.\n Action:\n Ativan 0.5 X 1dose Successfully extubated O2 requirements as mentioned\n above and neo weaned off.\n Response:\n Heamodinamically remained stable\n Plan:\n Monitor resp status,NPO for now ,Ativan 0.5mg Q6H for anxiety.\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340175,
"text": ".\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology required reintubation on had rigid\n bronch on resulted as WNL now s/p extubation.\n Respiratory failure, chronic\n Assessment:\n Received on vent MMV weaned to CPAP and then successfully extubated\n at 1115,AO X 3,Afebrile neo weaned off at 1000 NBP maintained since\n then.LS are clear diminished bibasilar.Appears to be comfortable but\n needs to be attended frequently for O2 requirements,initially placed\n on Cool mist 50%,changed to CPAP\npt,s own as requested by pt followed\n by hospital CPAP machine.\n Action:\n Ativan 0.5 X 1dose Successfully extubated O2 requirements as mentioned\n above and neo weaned off.\n Response:\n Heamodinamically remained stable\n Plan:\n Monitor resp status,NPO for now ,Ativan 0.5mg Q6H for anxiety.\n"
},
{
"category": "Nutrition",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 339829,
"text": "Subjective\n unable to assess; per report was tolerating soft diet PTA; also h/o\n constipation\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 67.8 kg\n 29.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 149\n 51 kg\n 63.5 kg ()\n Diagnosis: PNA\n PMH : CAD s/p CABG, left THR c/b Afib, sepsis, resulting in\n PEG/trach, depression, chronic constipation, chronic A-fib, h/o PNA,\n supraglottic edema from GERD, COPD, recent tracheal decannulation,\n recent closure of tracheocutaneous fistula\n Food allergies and intolerances: NKFA\n Pertinent medications: HISS, Colace, Senna, Abx, Pantoprazole, ppf gtt,\n phenylephrine gtt\n Labs:\n Value\n Date\n Glucose\n 161 mg/dL\n 04:25 AM\n Glucose Finger Stick\n 118\n 05:30 AM\n BUN\n 15 mg/dL\n 04:25 AM\n Creatinine\n 1.2 mg/dL\n 04:25 AM\n Sodium\n 139 mEq/L\n 04:25 AM\n Potassium\n 3.4 mEq/L\n 04:25 AM\n Chloride\n 101 mEq/L\n 04:25 AM\n TCO2\n 30 mEq/L\n 04:25 AM\n pH (venous)\n 6.98 units\n 05:11 AM\n pH (urine)\n 6.5 units\n 04:05 PM\n Calcium non-ionized\n 8.8 mg/dL\n 04:25 AM\n Phosphorus\n 3.1 mg/dL\n 04:25 AM\n Magnesium\n 2.2 mg/dL\n 04:25 AM\n WBC\n 10.4 K/uL\n 04:25 AM\n Hgb\n 9.6 g/dL\n 04:25 AM\n Hematocrit\n 28.3 %\n 04:25 AM\n Current diet order / nutrition support: Diet: heart healthy regular,\n thin liquids; pills with thickened liquids or pureed\n TF: Nutren Pulmonary @ 35ml/hr (OFF)\n GI: soft/distended; (+) bs; (+) bm\n Assessment of Nutritional Status\n Adequately nourished, At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1275-1530 (BEE x or / 25-30 cal/kg)\n Protein: 61-92 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate NPO\n Specifics:\n Pt was recently d/c\nd home on Bipap and soft diet after admission for\n tracheal fistula repair c/b MRSA PNA. Pt presented to OSH for SOB then\n transferred to . CXR showed LLL PNA. SLP saw pt for video\n swallow evaluation for ?aspiration. SLP recommended regular solids and\n single sips of thin liquids w/ asp precautions including pills w/\n pureeds or nectar thick liquids, small bites of food and single sips of\n liquids. Pt w/ poor appetite on above diet RN note. Pt\n emergently intubated w/w respiratory distress; CXR c/w pulmonary\n edema. OGT placed and TF started. Currently pt remains\n intubated/sedated, TF off at MN for possible extubation. Anticipate\n extubation today per d/w MD. If pt able to tolerate po, concerned w/\n ability to take adequate po\ns given respiratory status, asp\n precautions.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If unable to extubate pt today, rec resume TF: Nutren\n Pulmonary @ 20ml/hr; adv as tolerated to goal of 35ml/hr (1260calories\n and 57g pro)\n 2. If pt extubated, rec re-evaluation by SLP before initiating\n po\n 3. Continue BS, lytes mgmt\n 4. Will continue to follow to check extubation status\n"
},
{
"category": "Nutrition",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 339830,
"text": "Subjective\n unable to assess; per report was tolerating soft diet PTA; also h/o\n constipation\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 67.8 kg\n 29.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 149\n 51 kg\n 63.5 kg ()\n Diagnosis: PNA\n PMH : CAD s/p CABG, left THR c/b Afib, sepsis, resulting in\n PEG/trach, depression, chronic constipation, chronic A-fib, h/o PNA,\n supraglottic edema from GERD, COPD, recent tracheal decannulation,\n recent closure of tracheocutaneous fistula\n Food allergies and intolerances: NKFA\n Pertinent medications: HISS, Colace, Senna, Abx, Pantoprazole, ppf gtt,\n phenylephrine gtt\n Labs:\n Value\n Date\n Glucose\n 161 mg/dL\n 04:25 AM\n Glucose Finger Stick\n 118\n 05:30 AM\n BUN\n 15 mg/dL\n 04:25 AM\n Creatinine\n 1.2 mg/dL\n 04:25 AM\n Sodium\n 139 mEq/L\n 04:25 AM\n Potassium\n 3.4 mEq/L\n 04:25 AM\n Chloride\n 101 mEq/L\n 04:25 AM\n TCO2\n 30 mEq/L\n 04:25 AM\n pH (venous)\n 6.98 units\n 05:11 AM\n pH (urine)\n 6.5 units\n 04:05 PM\n Calcium non-ionized\n 8.8 mg/dL\n 04:25 AM\n Phosphorus\n 3.1 mg/dL\n 04:25 AM\n Magnesium\n 2.2 mg/dL\n 04:25 AM\n WBC\n 10.4 K/uL\n 04:25 AM\n Hgb\n 9.6 g/dL\n 04:25 AM\n Hematocrit\n 28.3 %\n 04:25 AM\n Current diet order / nutrition support: Diet: heart healthy regular,\n thin liquids; pills with thickened liquids or pureed\n TF: Nutren Pulmonary @ 35ml/hr (OFF)\n GI: soft/distended; (+) bs; (+) bm\n Assessment of Nutritional Status\n Adequately nourished, At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1275-1530 (BEE x or / 25-30 cal/kg)\n Protein: 61-92 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate NPO\n Specifics:\n Pt was recently d/c\nd home on Bipap and soft diet after admission for\n tracheal fistula repair c/b MRSA PNA. Pt presented to OSH for SOB then\n transferred to . CXR showed LLL PNA. SLP saw pt for video\n swallow evaluation for ?aspiration. SLP recommended regular solids and\n single sips of thin liquids w/ asp precautions including pills w/\n pureeds or nectar thick liquids, small bites of food and single sips of\n liquids. Pt w/ poor appetite on above diet RN note. Pt\n emergently intubated w/w respiratory distress; CXR c/w pulmonary\n edema. OGT placed and TF started. Currently pt remains\n intubated/sedated, TF off at MN for possible extubation. Anticipate\n extubation today per d/w MD. If pt able to tolerate po, concerned w/\n ability to take adequate po\ns given respiratory status, asp\n precautions.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If unable to extubate pt today, rec resume TF: Nutren\n Pulmonary @ 20ml/hr; adv as tolerated to goal of 35ml/hr (1260calories\n and 57g pro)\n 2. If pt extubated, rec re-evaluation by SLP before initiating\n po\n 3. Continue BS, lytes mgmt\n 4. Will continue to follow to check extubation status\n ------ Protected Section ------\n Ppf providing 160calories at current rate. Above TF will still be\n appropriate if ppf remains on.\n ------ Protected Section Addendum Entered By: , RD,\n on: 12:08 ------\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340024,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Pt to OR for Rigid bronch; official report not yet available.\n According to a verbal report, the condition of the airway should not\n interfere with a successful extubation.\n The patient was awake and alert on return from OR; Propofol was\n resumed then held for low Blood Pressure; Pt did not tolerate; Propofol\n resumed at 30mcg; Ativan 0.5mg adm x2 ~midnight. Neo added. Frequent\n runs PVCs. Sm-mod amt thick ET secr. OG placed for oral med adm.\n Foley output 30-60/hour.\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340393,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient Extubated. Initially on face tent, but patient requested\n CPAP.\n Asymptomatic hypotension of 80s/40 that resolved without intervention.\n Patient is hungry and requring advancement of her diet\n INVASIVE VENTILATION - STOP 11:18 AM\n PICC LINE - STOP 12:48 AM\n PICC LINE - START 12:52 AM\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 07:50 PM\n Morphine Sulfate - 08:08 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 06:39 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: 36.3\nC (97.4\n HR: 79 (66 - 91) bpm\n BP: 121/55(72) {82/40(51) - 143/73(98)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 523 mL\n 60 mL\n PO:\n TF:\n IVF:\n 223 mL\n Blood products:\n Total out:\n 1,620 mL\n 135 mL\n Urine:\n 1,620 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,097 mL\n -75 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n Ventilator mode: Standby\n Vt (Spontaneous): 73 (73 - 432) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 17 cmH2O\n SpO2: 93%\n ABG: ///28/\n Ve: 8.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 369 K/uL\n 10.5 g/dL\n 87 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 104 mEq/L\n 142 mEq/L\n 30.3 %\n 7.7 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n Plt\n 74\n 423\n 369\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.1 mg/dL,\n Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 12:52 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": "2138-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340237,
"text": ".\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology required reintubation on had rigid\n bronch on resulted as WNL now s/p extubation.\n Respiratory failure, chronic\n Assessment:\n Received on vent MMV weaned to CPAP and then successfully extubated\n at 1115,AO X 3,Afebrile neo weaned off at 1000 NBP maintained since\n then.LS are clear diminished bibasilar.Appears to be comfortable but\n needs to be attended frequently for O2 requirements,initially placed\n on Cool mist 50%,changed to CPAP\npt,s own as requested by pt followed\n by hospital CPAP machine.currently on 50% cool mist.\n Action:\n On and off CPAP and cool mist Ativan 0.5 X 1dose and morphine1 mg/IV\n for leg pain Successfully extubated O2 requirements as mentioned above\n and neo weaned off.\n Response:\n Heamodinamically remained stable appears comfortable denies any SOB or\n related discomfort.\n Plan:\n Monitor resp status, ,Ativan 0.5mg Q6H for anxiety.started on clear\n liquids.plan to continue on hospital CPAP machine for overnight.\n"
},
{
"category": "Respiratory ",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 340238,
"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 Pt was weaned and extubated. Currently on OFM. Did attempt pt\ns own\n cpap from home, did not tolerate. Was placed on our autoset unit\n tolerated very well. Plan for AS cpap overnight as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 340707,
"text": "Chief Complaint: respiratory failure\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress.\n 24 Hour Events:\n No events. Feeling better. Tolerating regular diet.\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n zoloft, seroquel, aspirin, simvastatin, lamictal, senna, colace,\n bupropion, albuterol\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.3\nC (97.4\n HR: 78 (71 - 85) bpm\n BP: 106/55(67) {83/38(53) - 138/79(91)} mmHg\n RR: 14 (8 - 19) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 660 mL\n 153 mL\n PO:\n 460 mL\n TF:\n IVF:\n 40 mL\n 153 mL\n Blood products:\n Total out:\n 1,325 mL\n 115 mL\n Urine:\n 1,325 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n -665 mL\n 38 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 5L NC\n SpO2: 92%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress, breathing\n comfortably, eating lunch\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Crackles : , Wheezes : at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, conversant\n Labs / Radiology\n 10.6 g/dL\n 420 K/uL\n 115 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 103 mEq/L\n 142 mEq/L\n 30.5 %\n 6.8 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n 04:12 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n 6.8\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n 30.5\n Plt\n 74\n 423\n 369\n 420\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n 115\n Other labs: PT / PTT / INR:13.8/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Suspect mucus plug as\n the etiology +/- aspiration. Now much improved, s/p extubation .\n 1) Respiratory failure: Acute event the other night appears to be due\n to a mucus plug with aspiration in RLL. No airway pathology seen on\n rigid bronch.\n - aspiration precautions\n - no evidence of pneumonia, off antibiotics\n - standing inhalers/nebs\n - CPAP prn per home regimen\n - appreciate ENT & IP input\n 2) Elevated troponin/Hx CHF: Likely demand in setting of hypotension,\n now resolving. No ECG changes.\n - on home dose of lasix\n - bp stable off antihypertensives\n 3) F/E/N: Diet per speech/swallow recommendations.\n 4) Anxiety: ativan prn (home regimen.)\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 12:52 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Code status: Full code\n Disposition :Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340577,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340578,
"text": "67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology required reintubation on had rigid\n bronch on resulted as WNL now s/p extubation on .\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p left hip replacement and states she always has discomfort in her\n right hip but will never get\nthis one\n repaired. Pt did c/o \n constant pain in right hip. She takes vicodin at home for the pain.\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 340664,
"text": "67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology required reintubation on had rigid\n bronch on resulted as WNL now s/p extubation on .\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p left hip replacement and states she always has discomfort in her\n right hip but will never get\nthis one done\n. Pt did c/o constant pain\n in right hip. She takes vicodin at home for the pain.\n Action:\n Pt given last dose of 1 tab vicodin at 0430 in addition to\n repositioning and emotional support.\n Response:\n Pt stated pain tolerable at 4/10 after interventions. Pt stated\nThis\n hip always hurts\n Plan:\n Continue to assess for pain, medicate as needed, emotional support and\n repositioning.\n Respiratory failure, chronic\n Assessment:\n AO X 3,appears comfortable,CPAP overnight then on and off Cool mist 70%\n and NC 5L, sats are maintained 92-95%,denies any SOB. Has strong\n productive cough.\n Action:\n On and off NC and cool mist as mentioned above\n Response:\n Pt remains comfortable\n Plan:\n Continue to monitor resp status,\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339896,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Pt. has been evaluated and is presently a\nadd on\n case for the O.R. to\n perform a rigid bronchoscopy, by A. M.D.\n Pulmonary edema\n Assessment:\n Pt\ns am CXR shows slight congestion.\n Action:\n Lasix 40mg po via OGT administered.\n Response:\n Pt. has diuresed appropriately with this. Lungs are clear mid to upper\n lobes and remain diminished bibasilar.\n Plan:\n Daily CXR along with lasix 40mg po qd order.\n Hypotension (not Shock)\n Assessment:\n Pt\ns B/P remains labile. Map\ns occasionally drop below 60.\n Action:\n Pt. remains on Neo gtt at 0.75mcq/kg/min.\n Response:\n Pt.\ns map\ns have been better controlled with Neo support.\n Plan:\n To wean Neo gtt when able, while maintaining map\ns >60. Neo has been\n weaned off as of 1630\n Respiratory failure, chronic\n Assessment:\n Pt. remains intubated and is presently on P.S. settings of . Resp\n rate is controlled and pt. voices no complaints of SOB.\n Action:\n Pt. is scheduled for rigid bronch, with expected time to O.R. around\n 1800.\n Response:\n O2 sats remain >97%. Pt. denies any SOB.\n Plan:\n Extubate pt. post bronch.\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 340500,
"text": "Chief Complaint: respiratory failure\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:18 AM\n PICC LINE - STOP 12:48 AM\n PICC LINE - START 12:52 AM\n Extubated yesterday. Was on cpap per her request which she uses at\n home.\n BP as low as 80s/40s, resolved without intervention.\n History obtained from Patient\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 07:50 PM\n Morphine Sulfate - 08:08 PM\n Other medications:\n zoloft, seroquel, aspirin, simvastatin, lamictal, senna, insulin\n sliding scale, protonix, colace, lasix 40 mg daily, atrovent,\n albuterol, ativan 0.5 mg IV q6h, morphine 1 mg IV prn\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:49 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: 36.1\nC (96.9\n HR: 93 (75 - 93) bpm\n BP: 122/48(66) {82/40(51) - 143/70(98)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 523 mL\n 160 mL\n PO:\n TF:\n IVF:\n 223 mL\n Blood products:\n Total out:\n 1,620 mL\n 235 mL\n Urine:\n 1,620 mL\n 235 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,097 mL\n -75 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n FiO2: 70%\n SpO2: 96%\n ABG: ///28/\n Ve: 8.9 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.5 g/dL\n 369 K/uL\n 87 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 104 mEq/L\n 142 mEq/L\n 30.3 %\n 7.7 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n Plt\n 74\n 423\n 369\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.1 mg/dL,\n Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR: clear\n Microbiology: C diff negative.\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Suspect mucus plug as\n the etiology +/- aspiration. Now much improved, s/p extubation\n yesterday.\n 1) Respiratory failure: Acute event the other night appears to be due\n to a mucus plug with aspiration in RLL. No airway pathology seen on\n rigid bronch.\n - aspiration precautions\n - no evidence of pneumonia, off antibiotics\n - standing inhalers\n - CPAP prn per home regimen\n - appreciate ENT & IP input\n 2) Elevated troponin/Hx CHF: Likely demand in setting of hypotension,\n now resolving. No ECG changes.\n - on home dose of lasix\n - hold anithypertensives given bp 80s/40s overnight\n 3) F/E/N: Diet per speech/swallow recommendations.\n 4) Anxiety: ativan prn (home regimen.)\n ICU Care\n Nutrition:\n Comments: advance diet as above\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 12:52 AM\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: 25 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340641,
"text": "Chief Complaint:\n 24 Hour Events:\n - patient weaned to nasal cannula during day, CPAP at night. No events\n of respiratory distress overnight.\n - Patient received one extra dose of PO ativan 0.5mg overnight for\n anxiety\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 09:03 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.1\nC (97\n HR: 75 (71 - 94) bpm\n BP: 98/54(64) {83/38(53) - 138/79(91)} mmHg\n RR: 16 (8 - 21) insp/min\n SpO2: 94%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 60 Inch\n Total In:\n 660 mL\n 112 mL\n PO:\n 460 mL\n TF:\n IVF:\n 40 mL\n 112 mL\n Blood products:\n Total out:\n 1,325 mL\n 15 mL\n Urine:\n 1,325 mL\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n -665 mL\n 97 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 420 K/uL\n 10.6 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 103 mEq/L\n 142 mEq/L\n 30.5 %\n 6.8 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n 04:12 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n 6.8\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n 30.5\n Plt\n 74\n 423\n 369\n 420\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n 115\n Other labs: PT / PTT / INR:13.8/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 12:52 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": "2138-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340644,
"text": "Chief Complaint:\n 24 Hour Events:\n - patient weaned to nasal cannula during day, CPAP at night. No events\n of respiratory distress overnight.\n - Patient received one extra dose of PO ativan 0.5mg overnight for\n anxiety\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 09:03 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.1\nC (97\n HR: 75 (71 - 94) bpm\n BP: 98/54(64) {83/38(53) - 138/79(91)} mmHg\n RR: 16 (8 - 21) insp/min\n SpO2: 94%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 60 Inch\n Total In:\n 660 mL\n 112 mL\n PO:\n 460 mL\n TF:\n IVF:\n 40 mL\n 112 mL\n Blood products:\n Total out:\n 1,325 mL\n 15 mL\n Urine:\n 1,325 mL\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n -665 mL\n 97 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 420 K/uL\n 10.6 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 103 mEq/L\n 142 mEq/L\n 30.5 %\n 6.8 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n 04:12 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n 6.8\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n 30.5\n Plt\n 74\n 423\n 369\n 420\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n 115\n Other labs: PT / PTT / INR:13.8/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Ms. is a 67F with CAD s/p CABG, CHF, COPD and complicated\n pulmonary history with prolonged tracheostomy with recent decannulation\n and subsequent fistula closure (on ENT service at on ) with\n complicated MRSA PNA presented with worsened respiratory distress. Now\n s/p bronchoscopy which did not reveal significant upper airway\n stenosis.\n .\n 1. Respiratory failure. Patient was intubated on after episode of\n flash pulmonary edema while being bathed and concern for upper airway\n obstruction due to previous intubations/trach. Patient also has\n history of trace aspiration. Completed 10 day course for aspiration\n pneumonia on . Rigid bronchoscopy on showed no significant upper\n airway stenosis. Extubated successfully on . No episodes of\n respiratory distress overnight, but given history, will watch closely\n today as patient is advanced on her diet with aspiration precautions.\n - IP and ENT following, appreciate recs\n - watch patient closely overnight as we advance her diet today\n - strict aspiration precautions with PO intake\n regular food with thin\n liquids with aspiration precautions, but pills must be taken with\n thickened liquids\n - continue nebs\n - continue home lasix for interstial edema\n - ativan prn for anxiety\n .\n 2.Hypotension. Patient off pressors, still with some low BP overnight,\n but asymptomatic\n - monitor BP and fluid boluses prn\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\n edema/HTN. Troponins have trended down.\n -continue ASA, BB\n - consider resuming ACEI when BP tolerates and if renal function\n continues to improve\n .\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\n on . CXR yesterday showed mild interstitial edema. Currently\n euvolemic, but will continue home lasix dose. TTE recently done\n () showed preserved EF with some focal wall motion abnormality.\n Patient euvolemic and net even overnight without any additional\n diuretics\n -continue home lasix\n -monitor I/Os\n -Continue BB\n - holding ACEI until blood pressure stable\n .\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\n - consider resuming lisinopril when BP tolerates, Cr improved\n 6. COPD.\n -continue nebs\n .\n 7. Depression/anxiety. Patient has significant anxiety.\n -ativan prn anxiety, caution not to oversedate. Can change Ativan from\n IV to PO\n -Continue home lamotrigine, quetiapine, sertraline\n .\n 8. Hyperlipidemia:\n -Continue statin\n ICU Care\n Nutrition: Advance diet to regular diet with aspiration precautions,\n pills with thickened liquids\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: pantoprazole\n VAP: Extubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU care for now\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340645,
"text": "Chief Complaint:\n 24 Hour Events:\n - patient weaned to nasal cannula during day, CPAP at night. No events\n of respiratory distress overnight.\n - Patient received one extra dose of PO ativan 0.5mg overnight for\n anxiety\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 09:03 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Morphine 1 mg IV prn hip pain\n Ativan PO/ IV prn anxiety\n Lasix 40 mg daily\n Lactulose 30 mg daily\n Albuterol q4 hr\n Atrovent\n Colace 100 \n Pantoprazole 40 IV daily\n Chlorhexidine mouthwash\n Senna\n Lamotrigine 25 mg \n Simvastatin 40 mg daily\n Aspirin 81 daily\n Seroquel\n Sertraline 100 daily\n Albuterol/ipratroprium nebs\n Insuline sliding scale\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.1\nC (97\n HR: 75 (71 - 94) bpm\n BP: 98/54(64) {83/38(53) - 138/79(91)} mmHg\n RR: 16 (8 - 21) insp/min\n SpO2: 94%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 60 Inch\n Total In:\n 660 mL\n 112 mL\n PO:\n 460 mL\n TF:\n IVF:\n 40 mL\n 112 mL\n Blood products:\n Total out:\n 1,325 mL\n 15 mL\n Urine:\n 1,325 mL\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n -665 mL\n 97 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 420 K/uL\n 10.6 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 103 mEq/L\n 142 mEq/L\n 30.5 %\n 6.8 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n 04:12 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n 6.8\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n 30.5\n Plt\n 74\n 423\n 369\n 420\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n 115\n Other labs: PT / PTT / INR:13.8/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Ms. is a 67F with CAD s/p CABG, CHF, COPD and complicated\n pulmonary history with prolonged tracheostomy with recent decannulation\n and subsequent fistula closure (on ENT service at on ) with\n complicated MRSA PNA presented with worsened respiratory distress. Now\n s/p bronchoscopy which did not reveal significant upper airway\n stenosis.\n .\n 1. Respiratory failure. Patient was intubated on after episode of\n flash pulmonary edema while being bathed and concern for upper airway\n obstruction due to previous intubations/trach. Patient also has\n history of trace aspiration. Completed 10 day course for aspiration\n pneumonia on . Rigid bronchoscopy on showed no significant upper\n airway stenosis. Extubated successfully on . No episodes of\n respiratory distress overnight, but given history, will watch closely\n today as patient is advanced on her diet with aspiration precautions.\n - IP and ENT following, appreciate recs\n - watch patient closely overnight as we advance her diet today\n - strict aspiration precautions with PO intake\n regular food with thin\n liquids with aspiration precautions, but pills must be taken with\n thickened liquids\n - continue nebs\n - continue home lasix for interstial edema\n - ativan prn for anxiety\n .\n 2.Hypotension. Patient off pressors, still with some low BP overnight,\n but asymptomatic\n - monitor BP and fluid boluses prn\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\n edema/HTN. Troponins have trended down.\n -continue ASA, BB\n - consider resuming ACEI when BP tolerates and if renal function\n continues to improve\n .\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\n on . CXR yesterday showed mild interstitial edema. Currently\n euvolemic, but will continue home lasix dose. TTE recently done\n () showed preserved EF with some focal wall motion abnormality.\n Patient euvolemic and net even overnight without any additional\n diuretics\n -continue home lasix\n -monitor I/Os\n -Continue BB\n - holding ACEI until blood pressure stable\n .\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\n - consider resuming lisinopril when BP tolerates, Cr improved\n 6. COPD.\n -continue nebs\n .\n 7. Depression/anxiety. Patient has significant anxiety.\n -ativan prn anxiety, caution not to oversedate. Can change Ativan from\n IV to PO\n -Continue home lamotrigine, quetiapine, sertraline\n .\n 8. Hyperlipidemia:\n -Continue statin\n ICU Care\n Nutrition: Advance diet to regular diet with aspiration precautions,\n pills with thickened liquids\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: pantoprazole\n VAP: Extubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU care for now\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340652,
"text": "Chief Complaint:\n 24 Hour Events:\n - patient weaned to nasal cannula during day, CPAP at night. No events\n of respiratory distress overnight.\n - diet advanced following speech/swallow guidelines. Patient tolerating\n regular diet with aspiration precautions. Pills with thickened liquids\n - Patient received one extra dose of PO ativan 0.5mg overnight for\n anxiety\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 09:03 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Morphine 1 mg IV prn hip pain\n Ativan PO/ IV prn anxiety\n Lasix 40 mg daily\n Lactulose 30 mg daily\n Albuterol q4 hr\n Atrovent\n Colace 100 \n Pantoprazole 40 IV daily\n Chlorhexidine mouthwash\n Senna\n Lamotrigine 25 mg \n Simvastatin 40 mg daily\n Aspirin 81 daily\n Seroquel\n Sertraline 100 daily\n Albuterol/ipratroprium nebs\n Insuline sliding scale\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.1\nC (97\n HR: 75 (71 - 94) bpm\n BP: 98/54(64) {83/38(53) - 138/79(91)} mmHg\n RR: 16 (8 - 21) insp/min\n SpO2: 94%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 60 Inch\n Total In:\n 660 mL\n 112 mL\n PO:\n 460 mL\n TF:\n IVF:\n 40 mL\n 112 mL\n Blood products:\n Total out:\n 1,325 mL\n 15 mL\n Urine:\n 1,325 mL\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n -665 mL\n 97 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 420 K/uL\n 10.6 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 103 mEq/L\n 142 mEq/L\n 30.5 %\n 6.8 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n 04:12 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n 6.8\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n 30.5\n Plt\n 74\n 423\n 369\n 420\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n 115\n Other labs: PT / PTT / INR:13.8/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Ms. is a 67F with CAD s/p CABG, CHF, COPD and complicated\n pulmonary history with prolonged tracheostomy with recent decannulation\n and subsequent fistula closure (on ENT service at on ) with\n complicated MRSA PNA presented with worsened respiratory distress. Now\n s/p bronchoscopy which did not reveal significant upper airway\n stenosis.\n .\n 1. Respiratory failure. Patient was intubated on after episode of\n flash pulmonary edema while being bathed and concern for upper airway\n obstruction due to previous intubations/trach. Patient also has\n history of trace aspiration. Completed 10 day course for aspiration\n pneumonia on . Rigid bronchoscopy on showed no significant upper\n airway stenosis. Extubated successfully on . No episodes of\n respiratory distress overnight, but given history, will watch closely\n today as patient is advanced on her diet with aspiration precautions.\n - IP and ENT following, appreciate recs\n - watch patient closely overnight as we advance her diet today\n - strict aspiration precautions with PO intake\n regular food with thin\n liquids with aspiration precautions, but pills must be taken with\n thickened liquids\n - continue nebs\n - continue home lasix for interstial edema\n - ativan prn for anxiety\n .\n 2.Hypotension. Patient off pressors, still with some low BP overnight,\n but asymptomatic\n - monitor BP and fluid boluses prn\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\n edema/HTN. Troponins have trended down.\n -continue ASA, BB\n - consider resuming ACEI when BP tolerates and if renal function\n continues to improve\n .\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\n on . CXR yesterday showed mild interstitial edema. Currently\n euvolemic, but will continue home lasix dose. TTE recently done\n () showed preserved EF with some focal wall motion abnormality.\n Patient euvolemic and net even overnight without any additional\n diuretics\n -continue home lasix\n -monitor I/Os\n -Continue BB\n - holding ACEI until blood pressure stable\n .\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\n - consider resuming lisinopril when BP tolerates, Cr improved\n 6. COPD.\n -continue nebs\n .\n 7. Depression/anxiety. Patient has significant anxiety.\n -ativan prn anxiety, caution not to oversedate. Can change Ativan from\n IV to PO\n -Continue home lamotrigine, quetiapine, sertraline\n .\n 8. Hyperlipidemia:\n -Continue statin\n ICU Care\n Nutrition: Advance diet to regular diet with aspiration precautions,\n pills with thickened liquids\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: pantoprazole\n VAP: Extubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU care for now\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340653,
"text": "Chief Complaint:\n 24 Hour Events:\n - patient weaned to nasal cannula during day, CPAP at night. No events\n of respiratory distress overnight.\n - diet advanced following speech/swallow guidelines. Patient tolerating\n regular diet with aspiration precautions. Pills with thickened liquids\n - Patient received one extra dose of PO ativan 0.5mg overnight for\n anxiety\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 09:03 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Morphine 1 mg IV prn hip pain\n Ativan PO/ IV prn anxiety\n Lasix 40 mg daily\n Lactulose 30 mg daily\n Albuterol q4 hr\n Atrovent\n Colace 100 \n Pantoprazole 40 IV daily\n Chlorhexidine mouthwash\n Senna\n Lamotrigine 25 mg \n Simvastatin 40 mg daily\n Aspirin 81 daily\n Seroquel\n Sertraline 100 daily\n Albuterol/ipratroprium nebs\n Insuline sliding scale\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.1\nC (97\n HR: 75 (71 - 94) bpm\n BP: 98/54(64) {83/38(53) - 138/79(91)} mmHg\n RR: 16 (8 - 21) insp/min\n SpO2: 94%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 60 Inch\n Total In:\n 660 mL\n 112 mL\n PO:\n 460 mL\n TF:\n IVF:\n 40 mL\n 112 mL\n Blood products:\n Total out:\n 1,325 mL\n 15 mL\n Urine:\n 1,325 mL\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n -665 mL\n 97 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n GEN: NAD, sleeping, easily aroused\n HEENT: MMM\n CV: RRR\n Pulm: bibasilr rales, occ scattered rhonchi\n Abd: obese, soft, nt/nd\n Ext: no c/c.e\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 420 K/uL\n 10.6 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 103 mEq/L\n 142 mEq/L\n 30.5 %\n 6.8 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n 04:12 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n 6.8\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n 30.5\n Plt\n 74\n 423\n 369\n 420\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n 0.9\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n 115\n Other labs: PT / PTT / INR:13.8/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Ms. is a 67F with CAD s/p CABG, CHF, COPD and complicated\n pulmonary history with prolonged tracheostomy with recent decannulation\n and subsequent fistula closure (on ENT service at on ) with\n complicated MRSA PNA presented with worsened respiratory distress. Now\n s/p bronchoscopy which did not reveal significant upper airway\n stenosis.\n .\n 1. Respiratory failure. Patient was intubated on after episode of\n flash pulmonary edema while being bathed and concern for upper airway\n obstruction due to previous intubations/trach. Patient also has\n history of trace aspiration. Completed 10 day course for aspiration\n pneumonia on . Rigid bronchoscopy on showed no significant upper\n airway stenosis. Extubated successfully on . No episodes of\n respiratory distress overnight, but given history, will watch closely\n today as patient is advanced on her diet with aspiration precautions.\n - IP and ENT following, appreciate recs\n - watch patient closely overnight as we advance her diet today\n - strict aspiration precautions with PO intake\n regular food with thin\n liquids with aspiration precautions, but pills must be taken with\n thickened liquids\n - continue nebs\n - continue home lasix for interstial edema\n - ativan prn for anxiety\n .\n 2.Hypotension. Patient off pressors, still with some low BP overnight,\n but asymptomatic\n - monitor BP and fluid boluses prn\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\n edema/HTN. Troponins have trended down.\n -continue ASA, BB\n - consider resuming ACEI when BP tolerates and if renal function\n continues to improve\n .\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\n on . CXR yesterday showed mild interstitial edema. Currently\n euvolemic, but will continue home lasix dose. TTE recently done\n () showed preserved EF with some focal wall motion abnormality.\n Patient euvolemic and net even overnight without any additional\n diuretics\n -continue home lasix\n -monitor I/Os\n -Continue BB\n - holding ACEI until blood pressure stable\n .\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\n - consider resuming lisinopril when BP tolerates, Cr improved\n 6. COPD.\n -continue nebs\n .\n 7. Depression/anxiety. Patient has significant anxiety.\n -ativan prn anxiety, caution not to oversedate. Can change Ativan from\n IV to PO\n -Continue home lamotrigine, quetiapine, sertraline\n .\n 8. Hyperlipidemia:\n -Continue statin\n ICU Care\n Nutrition: Advance diet to regular diet with aspiration precautions,\n pills with thickened liquids\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: pantoprazole\n VAP: Extubated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU care for now\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 340660,
"text": "Respiratory failure, chronic\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": "2138-09-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 340661,
"text": "Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339863,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Pt. has been evaluated and is presently a\nadd on\n case for the O.R. to\n perform a rigid bronchoscopy, by M.D.\n Pulmonary edema\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339920,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Pt. has been evaluated and is presently a\nadd on\n case for the O.R. to\n perform a rigid bronchoscopy, by A. M.D.\n Pulmonary edema\n Assessment:\n Pt\ns am CXR shows slight congestion.\n Action:\n Lasix 40mg po via OGT administered.\n Response:\n Pt. has diuresed appropriately with this. Lungs are clear mid to upper\n lobes and remain diminished bibasilar.\n Plan:\n Daily CXR along with lasix 40mg po qd order.\n Hypotension (not Shock)\n Assessment:\n Pt\ns B/P remains labile. Map\ns occasionally drop below 60.\n Action:\n Pt. remains on Neo gtt at 0.75mcq/kg/min.\n Response:\n Pt.\ns map\ns have been better controlled with Neo support.\n Plan:\n To wean Neo gtt when able, while maintaining map\ns >60. Neo has been\n weaned off as of 1630\n Respiratory failure, chronic\n Assessment:\n Pt. remains intubated and is presently on P.S. settings of . Resp\n rate is controlled and pt. voices no complaints of SOB.\n Action:\n Pt. is scheduled for rigid bronch, with expected time to O.R. around\n 1800.\n Response:\n O2 sats remain >97%. Pt. denies any SOB.\n Plan:\n Extubate pt. post bronch.\n Pt. has received Vicoden one tab, twice. And, Ativan 1.5 mg throughout\n this shift. Last dose for both was 1740. Report called to in the\n O.R. at 1810. Pt. is to be taken down shortly for bronchoscopy. Pt\n husband is aware.\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 340151,
"text": "Chief Complaint: respiratory failure\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia.\n 24 Hour Events:\n BRONCHOSCOPY - At 07:00 PM\n Rigid bronchoscopy reportedly normal. Extubated in OR but became\n hypoxic, felt related to sedation so reintubated.\n Given lasix for pulmonary edema on CXR.\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Infusions:\n Other ICU medications:\n Other medications:\n senna, lamictal, simvastatin, aspirin 81 mg daily, seroquel, zoloft,\n peridex, colace, protonix, insulin SQ, atrovent, albuterol, lasix 40 mg\n daily, propofol is off\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 11:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.4\nC (99.3\n HR: 86 (54 - 86) bpm\n BP: 127/73(86) {92/44(55) - 130/73(86)} mmHg\n RR: 21 (13 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,242 mL\n 493 mL\n PO:\n TF:\n IVF:\n 942 mL\n 223 mL\n Blood products:\n Total out:\n 1,660 mL\n 905 mL\n Urine:\n 1,660 mL\n 905 mL\n NG:\n Stool:\n Drains:\n Balance:\n -418 mL\n -412 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): 73 (73 - 541) mL\n PS : 10 cmH2O\n RR (Set): 8\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 43\n PIP: 17 cmH2O\n SpO2: 98%\n ABG: ///29/\n Ve: 11.1 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic, trach site healing well\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.1 g/dL\n 423 K/uL\n 205 mg/dL\n 1.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 14 mg/dL\n 100 mEq/L\n 137 mEq/L\n 26.9 %\n 8.2 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n Plt\n 74\n 423\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:8.8 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR: bilateral LL infiltrates, minimal.\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology +/- aspiration.\n 1) Respiratory failure: Acute event the other night appears to be due\n to a mucus plug vs aspiration. No airway pathology seen on rigid\n bronch which would limit extubation.\n - good RSBI this AM, comfortable on , so will proceed with\n extubation.\n - no evidence of pneumonia, off antibiotics\n 2) Hypotension: Resolved. off neo. Likely related to propofol.\n 3) Elevated troponin/Hx CHF: Likely demand in setting of hypotension,\n now resolving. No ECG changes. Goal euvolemic. Restart\n antihypertensives in AM if stable today.\n 4) ARF: Resolved. Creatinine improved.\n 5) F/E/N: NPO, restart clear liquids tonight if she does well. Follow /\n replete lytes as needed. Goal euvolemic for now.\n ICU Care\n Nutrition:\n Comments: holding TF for extubation\n Glycemic Control: Regular insulin sliding scale\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340031,
"text": "67F with CAD s/p CABG, CHF, COPD and complicated pulmonary history with\n prolonged tracheostomy with recent decannulation and subsequent fistula\n closure (on ENT service at on ) with complicated MRSA PNA\n presented with worsened respiratory distress. Patient with acute event\n of respiratory failure overnight requiring intubation.\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology\n Pt to OR for Rigid bronch; official report not yet available.\n According to a verbal report, the condition of the airway should not\n interfere with a successful extubation.\n The patient was awake and alert on return from OR; Pt became agitation\n when she learned that the tube would stay in until morning. Propofol\n was resumed then held for low Blood Pressure; Pt did not tolerate;\n Propofol resumed at 30mcg; Ativan 0.5mg adm x2 ~midnight. Neo added.\n Frequent runs PVCs. Sm-mod amt thick ET secr. OG placed for oral med\n adm. Foley output 30-60/hour.\n Respiratory failure, chronic\n Assessment:\n Rigid Bronch; Pt somnolent after procedure; Re-intubated until a.m.\n Action:\n Provided sedation for comfort; Resp support increased to MVV\n Response:\n Pt required more Propofol than previously; increased to 30mcg then\n tapered back to 15mcg). HR low 50s on 30mcg.\n Plan:\n Wean Propofol and Neo in preparation for extubation in am.\n Hypotension (not Shock)\n Assessment:\n Hypotensive during Propofol administration\n Action:\n Neo re-started for BP support\n Response:\n BP 100s-1teens and MAPS >60\n Plan:\n Wan Neo off when sedation lightened/DCd.\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340311,
"text": ".\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Her recent worsening\n appears most consistent with a multifactorial etiology: upper airway\n procedure (fistula repair) with upper airway edema, bronchospasm/COPD,\n recent MRSA pneumonia. No problems with the surgical site. Suspect\n mucus plug as the etiology required reintubation on had rigid\n bronch on resulted as WNL now s/p extubation.\n Respiratory failure, chronic\n Assessment:\n Pt on Face Tent initially; Requested CPAP mask ( unit) ~8pm.\n Anxiety contributes to SOB\n Low sats on CPAP\n Action:\n Contact Respiratory to assists patient with CPAP mask. O2 increased\n on BIPAP/Resp treatments ordered and administered for low sats.\n Ativan 0.5 IV for anxiety and Morphine 1mg IV for pain adm at 8pm.\n Ativan 0.5mg PO for anxiety adm at 0030\n Response:\n Pt slept; BP dropped briefly to MAP50-60; UOP maintained at 30cc+; O2\n sats improved after resp treatments, 02 flow adjustment and Ativan.\n Plan:\n Continue CPAP nocturnally; pt uses during day. , Cool Mist face tent\n during the day. Encourage deep breathing. Advance diet/Aspiration\n precautions.\n"
},
{
"category": "Nursing",
"chartdate": "2138-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340309,
"text": "Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340419,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient Extubated. Initially on face tent, but patient requested\n CPAP.\n Asymptomatic hypotension of 80s/40 that resolved without intervention.\n Patient is hungry and requring advancement of her diet\n INVASIVE VENTILATION - STOP 11:18 AM\n PICC LINE - STOP 12:48 AM\n PICC LINE - START 12:52 AM\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 07:50 PM\n Morphine Sulfate - 08:08 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 06:39 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: 36.3\nC (97.4\n HR: 79 (66 - 91) bpm\n BP: 121/55(72) {82/40(51) - 143/73(98)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 523 mL\n 60 mL\n PO:\n TF:\n IVF:\n 223 mL\n Blood products:\n Total out:\n 1,620 mL\n 135 mL\n Urine:\n 1,620 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,097 mL\n -75 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n Ventilator mode: Standby\n Vt (Spontaneous): 73 (73 - 432) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 17 cmH2O\n SpO2: 93%\n ABG: ///28/\n Ve: 8.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 369 K/uL\n 10.5 g/dL\n 87 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 104 mEq/L\n 142 mEq/L\n 30.3 %\n 7.7 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n Plt\n 74\n 423\n 369\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.1 mg/dL,\n Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n In Summary, Ms. is a 67F with CAD s/p CABG, CHF, COPD and\n complicated pulmonary history with prolonged tracheostomy with recent\n decannulation and subsequent fistula closure (on ENT service at \n on ) with complicated MRSA PNA presented with worsened respiratory\n distress. Now s/p bronchoscopy which did not reveal significant upper\n airway stenosis.\n .\n 1. Respiratory failure. Patient was intubated on after episode of\n flash pulmonary edema while being bathed and concern for upper airway\n obstruction due to previous intubations/trach. Patient also has\n history of trace aspiration. Copmleted 10 day course for aspiration\n pneumonia on . Anxiety also contributes to patient\ns respiratory\n distress. Bronchoscopy on showed no significant upper airway\n stenosis. Will need permanent trach if extubation is unsuccessful\n today.\n - extubate today\n - continue nebs\n - continue home lasix for interstial edema\n - ativan prn\n - transition to PO meds if successfully extubated\n .\n 2. Hypotension. Patient required pressors while on propofol for\n sedation. Will wean neo and extubate today. Hopeful that patient will\n not require pressors when not on sedation.\n 3. CAD. Patient had troponin leak in setting of flash pulmonary\n edema/HTN. Troponins have trended down.\n -continue ASA, BB\n - consider resuming ACEI tomorrow if hemodynamically stable\n .\n 4. CHF. Patient had episode of pulmonary edema requiring intubation\n on . CXR yesterday showed mild interstitial edema. Currently\n euvolemic, but will continue home lasix dose. TTE recently done\n () showed preserved EF with some focal wall motion abnormality.\n Patient euvolemic and net even overnight without any additional\n diuretics\n -continue home lasix\n -monitor I/Os\n -Continue BB\n - holding ACEI until blood pressure stable for 24 hours off pressors\n .\n 5. ARF. Pre-renal ARF is resolved now. Cr now 1.0.\n - consider resuming lisinopril in AM\n 6. COPD.\n -continue nebs\n .\n 7. Depression/anxiety. Patient has significant anxiety.\n -ativan prn anxiety, caution not to oversedate\n -Continue home lamotrigine, quetiapine, sertraline\n .\n 8. Hyperlipidemia:\n -Continue statin\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n RIC - 10:00 AM\n PICC Line - 09:34 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: pantoprazole\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU care for now\n"
},
{
"category": "Physician ",
"chartdate": "2138-09-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 340446,
"text": "Chief Complaint: respiratory failure\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 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:18 AM\n PICC LINE - STOP 12:48 AM\n PICC LINE - START 12:52 AM\n Extubated yesterday. Was on cpap per her request which she uses at\n home.\n BP as low as 80s/40s, resolved without intervention.\n History obtained from Patient\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 01:45 AM\n Vancomycin - 09:03 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 07:50 PM\n Morphine Sulfate - 08:08 PM\n Other medications:\n zoloft, seroquel, aspirin, simvastatin, lamictal, senna, insulin\n sliding scale, protonix, colace, lasix 40 mg daily, atrovent,\n albuterol, ativan 0.5 mg IV q6h, morphine 1 mg IV prn\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:49 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: 36.1\nC (96.9\n HR: 93 (75 - 93) bpm\n BP: 122/48(66) {82/40(51) - 143/70(98)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 523 mL\n 160 mL\n PO:\n TF:\n IVF:\n 223 mL\n Blood products:\n Total out:\n 1,620 mL\n 235 mL\n Urine:\n 1,620 mL\n 235 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,097 mL\n -75 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n FiO2: 70%\n SpO2: 96%\n ABG: ///28/\n Ve: 8.9 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.5 g/dL\n 369 K/uL\n 87 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 104 mEq/L\n 142 mEq/L\n 30.3 %\n 7.7 K/uL\n [image002.jpg]\n 09:05 AM\n 12:45 AM\n 03:50 AM\n 11:40 AM\n 04:25 AM\n 03:11 AM\n 03:35 AM\n WBC\n 13.1\n 10.3\n 8.0\n 10.4\n 8.2\n 7.7\n Hct\n 32.3\n 30.5\n 27.7\n 28.3\n 26.9\n 30.3\n Plt\n 74\n 423\n 369\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.0\n 1.0\n TropT\n 0.03\n <0.01\n 0.03\n 0.13\n 0.08\n Glucose\n 70\n 168\n 120\n 161\n 205\n 87\n Other labs: PT / PTT / INR:14.3/30.1/1.2, CK / CKMB /\n Troponin-T:39/6/0.08, Differential-Neuts:89.8 %, Band:0.0 %, Lymph:6.9\n %, Mono:2.4 %, Eos:0.7 %, Lactic Acid:1.2 mmol/L, Ca++:9.1 mg/dL,\n Mg++:1.8 mg/dL, PO4:3.2 mg/dL\n Imaging: CXR: clear\n Microbiology: C diff negative.\n Assessment and Plan\n 67yo woman with h/o CAD s/p CABG, complicated pulmonary history\n including tracheobronchiomalacia, trach / decannulation, and recent\n tracheal fistula repair (on ENT service at on ) c/b MRSA\n pneumonia presenting with respiratory distress. Suspect mucus plug as\n the etiology +/- aspiration. Now much improved, s/p extubation\n yesterday.\n 1) Respiratory failure: Acute event the other night appears to be due\n to a mucus plug vs aspiration. No airway pathology seen on rigid\n bronch.\n - aspiration precautions\n - no evidence of pneumonia, off antibiotics\n - standing inhalers\n - CPAP prn per home regimen\n - appreciate ENT & IP input\n 2) Elevated troponin/Hx CHF: Likely demand in setting of hypotension,\n now resolving. No ECG changes.\n - on home dose of lasix\n - hold anithypertensives given bp 80s/40s overnight\n 3) F/E/N: Diet per speech/swallow recommendations.\n 4) Anxiety: ativan prn (home regimen.)\n ICU Care\n Nutrition:\n Comments: advance diet as above\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 12:52 AM\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:\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032156,
"text": ", D. MED MICU-7 10:02 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: OGT placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p bronch. new OGT placement\n REASON FOR THIS EXAMINATION:\n OGT placement\n ______________________________________________________________________________\n PFI REPORT\n PFI: NG tube tip is out of view below the diaphragm likely in the stomach.\n Improved interstitial pulmonary edema and improved right lower lobe aeration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031968,
"text": " 4:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with respiratory distress possibly in setting of mucous\n plugging with\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 10:43 AM\n 1. Interval worsening of moderate-to-severe interstitial edema.\n 2. Right basal opacity, developing pneumonia or aspiration are not excluded,\n repeat radiograph after improvement of edema would be helpful to better\n delineate the abnormality.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 67-year-old woman with respiratory distress possibly in the\n setting of mucus plugging.\n\n COMPARISON: Multiple prior studies, most recent dated .\n\n FINDINGS: The patient remains intubated, support devices are in unchanged\n positions. Moderate-to-severe interstitial edema has significantly worsened\n compared to the most recent prior study. Additionally, there is a patchy\n right basal opacity, developing pneumonia is not excluded. Left retrocardiac\n opacity has a more linear shape and may be due to atelectasis. Small pleural\n effusions are present. There is no pneumothorax.\n\n IMPRESSION:\n 1. Significant worsening of moderate-to-severe interstitial edema.\n 2. Right basal patchy opacity, developing pneumonia is not excluded, repeat\n radiograph after resolution of pulmonary edema would help to better delineate\n the abnormality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031969,
"text": ", D. MED MICU-7 4:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with respiratory distress possibly in setting of mucous\n plugging with\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n PFI REPORT\n 1. Interval worsening of moderate-to-severe interstitial edema.\n 2. Right basal opacity, developing pneumonia or aspiration are not excluded,\n repeat radiograph after improvement of edema would be helpful to better\n delineate the abnormality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-23 00:00:00.000",
"description": "ESOPHAGUS",
"row_id": 1031675,
"text": ", C. MED MICU-7 2:40 PM\n ESOPHAGUS; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: ? evidence reflux, pls perform barium swallow.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with imaging findings c/w aspiration\n REASON FOR THIS EXAMINATION:\n ? evidence reflux, pls perform barium swallow.\n ______________________________________________________________________________\n PFI REPORT\n No evidence for gastroesophageal reflux. Small-to-moderate hiatal hernia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-23 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1031579,
"text": " 9:40 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r dl picc 46cm\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with\n REASON FOR THIS EXAMINATION:\n r dl picc 46cm\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 10:55 AM\n 1) Right PICC ends in the low superior vena cava.\n\n 2) Bibasal consolidations.\n\n 3) Interval improvement in pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH:\n\n INDICATION: 67-year-old woman with CHF, post-PICC placement.\n\n COMPARISON: Prior radiograph dated . Note is made of CTA\n chest dated .\n\n FINDINGS: Right PICC ends in the distal superior vena cava. The degree of\n interstitial edema has improved, area of consolidation in the right lower and\n middle lobe persists. Left retrocardiac opacity is also present, could be\n secondary to atelectasis or aspiration. The degree of pulmonary edema has\n improved. There is no pneumothorax.\n\n The osseous structures are demineralized.\n\n IMPRESSION: Right PICC ends in the low superior vena cava.\n\n Interval decrease in interstitial edema.\n\n 3) Bibasal consolidations.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-23 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1031580,
"text": ", C. MED MICU-7 9:40 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r dl picc 46cm\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with\n REASON FOR THIS EXAMINATION:\n r dl picc 46cm\n ______________________________________________________________________________\n PFI REPORT\n 1) Right PICC ends in the low superior vena cava.\n\n 2) Bibasal consolidations.\n\n 3) Interval improvement in pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032155,
"text": " 10:02 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: OGT placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman s/p bronch. new OGT placement\n REASON FOR THIS EXAMINATION:\n OGT placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld 12:51 PM\n PFI: NG tube tip is out of view below the diaphragm likely in the stomach.\n Improved interstitial pulmonary edema and improved right lower lobe aeration.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess NG tube.\n\n NG tube tip is out of view below the diaphragm likely in the stomach. ET tube\n is in the standard position. Right PICC remains in place. There is no\n pneumothorax or enlarging pleural effusions. Improved still mild interstitial\n pulmonary edema. Mild cardiomegaly is stable. Mediastinal wires are aligned.\n Residual barium is in the colon.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2138-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031423,
"text": " 8:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? chf too\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with sob, on bipap, Rll pna,\n REASON FOR THIS EXAMINATION:\n ? chf too\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRX MON 11:28 AM\n _____ worsening of interstitial edema.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Short of breath, pneumonia. Possible CHF.\n\n One view. Comparison with . Diffusely increased interstitial markings\n consistent with edema. This finding appears slightly worse. A more focal\n zone of increased density at the right lung base which may represent\n pneumonia. The heart and mediastinal structures are unchanged in appearance.\n The patient is status post median sternotomy as before. A left subclavian\n line has been withdrawn.\n\n IMPRESSION: Increasing interstitial markings consistent with CHF. Asymmetric\n density at the right base which may represent focal consolidation, unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031424,
"text": ", J. EU 8:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? chf too\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with sob, on bipap, Rll pna,\n REASON FOR THIS EXAMINATION:\n ? chf too\n ______________________________________________________________________________\n PFI REPORT\n _____ worsening of interstitial edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-23 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1031673,
"text": " 2:38 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: ? silent aspiration\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with imaging findings c/w aspiration\n REASON FOR THIS EXAMINATION:\n ? silent aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 67-year-old female with imaging findings consistent\n with aspiration. Please evaluate for possible aspiration.\n\n EXAMINATION: Oropharyngeal video fluoroscopic swallowing evaluation.\n\n TECHNIQUE: An oral and pharyngeal swallowing video fluoroscopy was performed\n today in collaboration with the speech pathology department. Barium of\n various consistencies were administered to the patient under continuous video\n fluoroscopic surveillance. Results are as follows.\n\n ORAL PHASE: Bolus formation and bolus control were mildly reduced. Premature\n spillage was noted into the pharynx.\n\n PHARYNGEAL PHASE: Velar elevation and upper esophageal sphincter relaxation\n were within functional limits. Laryngeal elevation and laryngeal valve\n closure were mild to moderately reduced. Epiglottic deflection was complete.\n\n ASPIRATION/PENETRATION: Penetration was noted to occur one time before the\n swallow secondary to premature spillage inconsistently during the swallow of\n nectar-thick liquids and thin liquids. The majority of the penetration was\n able to be cleared spontaneously; however, trace residue still remained, which\n was effectively cleared by a cued cough.\n\n IMPRESSION: Mild-to-moderate oropharyngeal dysphagia with episodes of\n penetration on nectar thick and thin liquids.\n\n Please refer to speech pathology note in OMR from for full report,\n assessment, and further recommendations.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-23 00:00:00.000",
"description": "ESOPHAGUS",
"row_id": 1031674,
"text": " 2:40 PM\n ESOPHAGUS; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: ? evidence reflux, pls perform barium swallow.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with imaging findings c/w aspiration\n REASON FOR THIS EXAMINATION:\n ? evidence reflux, pls perform barium swallow.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc TUE 4:56 PM\n No evidence for gastroesophageal reflux. Small-to-moderate hiatal hernia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 67-year-old female with imaging findings consistent\n with aspiration. With oropharyngeal video swallowing study, _____ no evidence\n of significant aspiration. Please perform barium swallow to evaluate for\n possible gastroesophageal reflux.\n\n EXAMINATION: Barium esophagram.\n\n FINDINGS: Secondary to patient's limited mobility, this study was technically\n limited, and the patient was placed in a modified AP position. A single\n contrast barium esophagram was obtained. Barium passes freely through the\n esophagus. There is no significant aspiration into the airway and no\n significant retention in the valleculae. No structural abnormalities are\n detected in the region of the pharynx and cervical esophagus. There were\n normal primary peristaltic contractions; however, proximal escape was noted.\n There is a moderate-sized hiatal hernia. There is no associated free\n gastroesophageal reflux demonstrated.\n\n IMPRESSION: No evidence for gastroesophageal reflux. Small- to moderate-\n sized hiatal hernia.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031759,
"text": " 5:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? et tube placement, ? pulm edema, ? evidence new collapse\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with resp distetress s/p intubation\n REASON FOR THIS EXAMINATION:\n ? et tube placement, ? pulm edema, ? evidence new collapse\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf WED 11:50 AM\n Interval development of moderate to severe pulmonary edema and increase in\n degree of cardiomegaly.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH:\n\n INDICATION: 67-year-old woman with respiratory distress post-intubation.\n\n COMPARISON: at 9:50.\n\n FINDINGS: Since prior study, moderate to severe pulmonary edema has\n developed. Bilateral small pleural effusions are present. The cardiac\n silhouette is moderately enlarged. The endotracheal tube ends at the level of\n the thoracic inlet. Right PICC ends in the mid SVC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031760,
"text": ", C. MED MICU-7 5:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? et tube placement, ? pulm edema, ? evidence new collapse\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with resp distetress s/p intubation\n REASON FOR THIS EXAMINATION:\n ? et tube placement, ? pulm edema, ? evidence new collapse\n ______________________________________________________________________________\n PFI REPORT\n Interval development of moderate to severe pulmonary edema and increase in\n degree of cardiomegaly.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031784,
"text": " 8:39 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: OGT placement.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with new OGT placed.\n REASON FOR THIS EXAMINATION:\n OGT placement.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf WED 11:46 AM\n Significant improvement in now moderate pulmonary edema. Orogastric tube\n reaches the stomach.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH:\n\n INDICATION: 67-year-old woman with new orogastric tube placed.\n\n COMPARISON: @ 5:22 a.m.\n\n FINDINGS: Now moderate interstitial pulmonary edema has improved in the\n interval. Patient remains intubated, with the endotracheal tube just below\n the level of the thoracic inlet. Right PICC ends in the SVC. The enteric\n tube reaches the stomach. Tiny pleural effusions are present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031785,
"text": ", C. MED MICU-7 8:39 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: OGT placement.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with new OGT placed.\n REASON FOR THIS EXAMINATION:\n OGT placement.\n ______________________________________________________________________________\n PFI REPORT\n Significant improvement in now moderate pulmonary edema. Orogastric tube\n reaches the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-22 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1031475,
"text": ", C. MED MICU-7 12:17 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Please perform CTA to eval for PE.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with h/o recent PNA, s/p trach, tracheomalacia, who presents\n w/ hypoxemia & respiratory distress. CXR relatively unchanged. Recent\n surgery.\n REASON FOR THIS EXAMINATION:\n Please perform CTA to eval for PE.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Minimal subcutaneous emphysema along both anterior chest walls. No PE.\n Aspiration, with fluid in the right lower lobe and right middle lobe bronchi,\n with atelectasis and patchy consolidation suspicious for pneumonia. There are\n also findings suspicious for interstitial edema. Discussed with clinical\n service.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-22 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1031474,
"text": " 12:17 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Please perform CTA to eval for PE.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with h/o recent PNA, s/p trach, tracheomalacia, who presents\n w/ hypoxemia & respiratory distress. CXR relatively unchanged. Recent\n surgery.\n REASON FOR THIS EXAMINATION:\n Please perform CTA to eval for PE.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TKCb MON 3:27 PM\n Minimal subcutaneous emphysema along both anterior chest walls. No PE.\n Aspiration, with fluid in the right lower lobe and right middle lobe bronchi,\n with atelectasis and patchy consolidation suspicious for pneumonia. There are\n also findings suspicious for interstitial edema. Discussed with clinical\n service.\n ______________________________________________________________________________\n FINAL REPORT\n CTA OF THE CHEST WITHOUT AND WITH CONTRAST, \n\n INDICATION: 67-year-old with history of recent pneumonia, status post\n tracheostomy. Please evaluate for pulmonary embolism.\n\n TECHNIQUE: Initial non-contrast CT of the chest was performed using 5-mm\n contiguous axial sections. Following the uneventful administration of\n intravenous contrast, CTA was performed using 2.5-mm contiguous axial\n sections.\n\n Multiplanar reformations were created.\n\n FINDINGS: There is no filling defect within the main, right, left, lobar, or\n segmental branches of the pulmonary artery to suggest the presence of\n pulmonary embolism.\n\n There is fluid within the right lower lobe bronchus, with distal\n atelectasis/consolidation. Most of the right lower lobe is involved.\n Similarly, there is fluid within the right middle lobe bronchus. Patchy\n atelectasis/consolidation is also present within the right middle lobe. Within\n the posterior segment of the right upper lobe, there are small patches of\n consolidation, consistent with pneumonia. There is minimal patchy\n atelectasis/consolidation within the left lower lobe. There is a calcified\n granuloma within the right upper lobe.\n\n There is diffuse interstitial thickening as well as foci of hazy ground glass\n attenuation, likely representing interstitial edema. There are bilateral,\n right greater than left small to moderate effusions. Background pattern of\n emphysema is noted.\n\n As described on the previous CT of , there is mediastinal and\n hilar lymphadenopathy. Subcentimeter axillary nodes are identified.\n (Over)\n\n 12:17 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Please perform CTA to eval for PE.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Postoperative changes from CABG are present. Heart remains enlarged. There\n is no pericardial effusion.\n\n OSSEOUS STRUCTURES: There are no suspicious osseous lesions. Multilevel\n degenerative changes are noted. There is subcutaneous emphysema along the\n chest wall bilaterally. Clinical correlation suggested.\n\n IMPRESSION:\n 1. No PE.\n 2. Findings compatible with aspiration within the right lower and middle lobe\n bronchi, with atelectasis and airspace consolidation suspicious for pneumonia.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032395,
"text": " 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman recently extubated after episode of flash pulmonary edema.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH FROM AT 0428 HOURS.\n\n HISTORY: Recently extubated after pulmonary edema. Assess for change.\n\n COMMENT: AP view of the chest provided. Comparison is made with .\n\n Previously seen pulmonary edema has improved. Minimal residual pulmonary\n vascular congestion. Cardiac silhouette is mildly enlarged. Calcification of\n aortic arch. Sternotomy wires. The patient's lung apices are obscured by the\n chin.\n\n IMPRESSION: Improvement in pulmonary edema.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2138-09-29 00:00:00.000",
"description": "Report",
"row_id": 293035,
"text": "Sinus rhythm. Occasional premature atrial contractions. Compared to the\nprevious tracing of no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2138-09-24 00:00:00.000",
"description": "Report",
"row_id": 293036,
"text": "Sinus rhythm\nShort P-R interval\nConsider old inferior myocardial infarction\nExtensive ST-T changes\nSince previous tracing of the same date, heart rate slower, ventricular ectopic\nactivity less, ST-T wave abnormalities more apparent\n\n"
},
{
"category": "ECG",
"chartdate": "2138-09-24 00:00:00.000",
"description": "Report",
"row_id": 293037,
"text": "Sinus tachycardia with frequent ventricular ectopy. Prior inferior myocardial\ninfarction. Compared to the previous tracing of the rate has increased.\nFrequent ventricular ectopy has appeared. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2138-09-23 00:00:00.000",
"description": "Report",
"row_id": 293038,
"text": "Sinus tachycardia with increase in rate as compared with prior tracing\nof . Prior inferior myocardial infarction. Compared to the previous\ntracing of there is variation in precordial lead placement. The lateral\nST-T wave changes have improved. Atrial ectopy persists. No diagnostic\ninterim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2138-09-22 00:00:00.000",
"description": "Report",
"row_id": 293039,
"text": "Sinus rhythm and frequent atrial ectopy. Prominent Q waves in\nleads II, III and aVF as recorded on tracing of with\nST-T wave flattening in these leads. Biphasic T waves in leads V4-V6\nas previously recorded. However, there has been improvement in\nthe anterior ischemic appearing ST-T wave changes. Clinical correlation is\nsuggested.\nTRACING #1\n\n"
}
] |
15,175 | 182,061 | 48 year old female with history of HIV (last CD4 114 in ) HCV, polysubstance abuse, tobacco use, and multiple admissions for pneumonia over the last few years, who presented to ED from her methadone clinic with lethargy, found here to have a RLL consolidation. In the ICU she was started on Zosyn and azithromycin, and her course was uneventful, with discontinuation of pressors by the following morning. She was transfused 1 U PRBC on after a drop of hematocrit from 26-22 which was likely dilutional. Her hematocrit rose appropriately. | 1:29 PM CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: Any change in RLL consolidation, evidence of empyema. (Over) 1:29 PM CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: Any change in RLL consolidation, evidence of empyema. PRESEPT CATH IN RIGHT SUBCLAVIAN WITH SCANT AMOUNT BLEEDING AT SITE. SENT TO EW AND WAS FOUND TO BE FEBRILE, HYPOTNESIVE WITH ELEVATED WBC. Interval development of a dependent moderate size left pleural effusion. FINDINGS: Cardiac, mediastinal, and hilar contours are within normal limits. Admitting Diagnosis: HYPOTENSION Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) SINGLE FRONTAL VIEW OF THE CHEST: There is interval placement of a right subclavian line that terminates in the SVC. Small right sided hydropneumothorax. Sinus rhythmIndeterminate frontal QRS axisLow QRS voltages in limb leadsNonspecific ST-T abnormalitiesSince previous tracing of , no significant change PT X3.CV--ARRIVED ON LEVOPHED GTT, 0.33MC/KG/MIN, ATTEMPTED TO WEAN OFF, BUT UNSUCCESSFUL AT THIS TIME. The patchy right lower lung zone opacity is again identified, unchanged compared to the study done three hours prior. HR 60'S, SR, NO ECTOPY NOTED. Shift NotePt had emesis after 1800 methadone and benadryl given. IMPRESSION: Patchy parenchymal opacity at the right lung base which appears improved in the interval. Loculated right sided pleural effusion with enhancing pleural margins suggestive of an empyema. There is a tiny right pleural effusion as well as pleural thickening along the right chest wall. TECHNIQUE: PA & lateral chest. PT WAS RECENTLY D/C' FROM HOSPITAL AND WAS TREATED FOR PNX. Previously evident right basilar parenchymal opacities are again noted, but they appear less confluent in the interval. These appear unchanged from the prior study. Small right pleural effusion and right pleural thickening. There is a small pericardial effusion. O2 via NC on because sat was dropping when pt very sleepy.GI - Tolerating PO's well. Amt is increasing slowly as pt recieved a substantial amt of IVF over the course of the night.Endocrine - BS stable - no insulin coverage needed.Neuro - Initially very lethargic but arousible and X2. There is a small right hydropneumothorax as well. Aware to watch for methadone withdraw. ABD SOFT NONTENDER WITH GOOD BS IN ALL 4 QUDS. R SC TLC intact and patent.Resp - BS cl bilat but course to bases. Methadone quickly absorbed in GI tract, but prior shift nurse unsure of how much might have been absorb before emesis...Pill not noted in emesis. REASON FOR THIS EXAMINATION: Any change in RLL consolidation, evidence of empyema. PT ENROLLED IN MUST PROTOCOL, PRESEPT CATH PLACED AND TRANS TO MICU FOR MONITORING.ALLERGIES--LAMICTALROSNEURO--PT LETHARGIC, SLEEPING WHEN NOT BE STIMULATED. Nsg Progress Note 1900-0700CV - Pt in NSR most of night - had a very short episode of vent bigeminy which resolved itself. CT OF THE CHEST WITH IV CONTRAST: Please note that the study has been presented for redictation on . LACTATE WNL SINCE ARRIVAL TO MICU. Report called to floor nurse and aware that meds held d/t upset stomach. The degree of consolidation in the right lower lobe remains unchanged. No significant change in right lower lobe consolidation. Hypoactive BS and no bowel activity noted.GU - Foley cath draining adequate amt cl yellow urine. INR 1.5.GI--NPO EXCPET FOR MEDS. DENIES N/V AT THIS TIME, STATES HAD SEVERAL EPISODES IN PAST FEW DAYS.RESP--ON 2L NC, LUNGS WITH RHONCI IN BASES, EXPECTORATING SM AMOUNTS THICK YELLOW SECRETIONS, SPEC SNET FOR GS, AND CX, WILL NEED INDUCED SPUTUM FOR PCP IN AM. RECEIVED PO MAG OXIDE FOR MAG 1.4, WILL ALSO RECEIVE IV MAG WHEN AVAILABLE, CA 6.5, WILL RECIEVE IV CALCIUM WHEN AVAILABLE. There is enhancement of the visceral and parietal pleura (a split pleural sign) suggestive of an empyema. No further vent ectopy noted. 11:48 AM CHEST (PORTABLE AP) Clip # Reason: infiltrate, effusion, edema MEDICAL CONDITION: 48 year old HIVpos woman with remote pmh pcp pna, recent adm for pna, now with klonopin intox, temp 101, rhonchorous RLL BS REASON FOR THIS EXAMINATION: infiltrate, effusion, edema WET READ: CCqc TUE 12:32 PM right basilar parenchymal opacity, slightly improved since prior; small right pleural effusion FINAL REPORT HISTORY: 48 y/o HIV+ female with recent history of pneumonia, here with fevers and decreased breath sounds at the right lung base. There is a dependent new left pleural effusion as well. MICU team aware and decided not to given another does of methadone. Again seen are an enlarged right hilar and precarinal lymph nodes. PT WENT TO CLINIC THIS AM AND WAS FOUND TO BE LETHARGIC, PT HAD ADMITTED TO TAKING 3 EXTRA KLONIPIN THIS AM. No new parenchymal opacities are seen. Compared to the prior study, the right sided pleural effusion has slightly increased in size with loculated components. The osseous structures demonstrate old healed right 12th rib fracture. To be transferred to 716 via bed accompanied by RN and co-worker. SVO2 ~80%, CATH CALIBRATED. CREAT 1.5 IN EW.SOCIAL--PT ARRIVED FROM EW WITH CLOTHES, BUT NOT HER PURSE. | 8 | [
{
"category": "Radiology",
"chartdate": "2118-10-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 844662,
"text": " 11:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate, effusion, edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old HIVpos woman with remote pmh pcp pna, recent adm for pna, now with\n klonopin intox, temp 101, rhonchorous RLL BS\n REASON FOR THIS EXAMINATION:\n infiltrate, effusion, edema\n ______________________________________________________________________________\n WET READ: CCqc TUE 12:32 PM\n right basilar parenchymal opacity, slightly improved since prior; small right\n pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 48 y/o HIV+ female with recent history of pneumonia, here with fevers\n and decreased breath sounds at the right lung base.\n\n TECHNIQUE: PA & lateral chest.\n\n COMPARISON: .\n\n FINDINGS: Cardiac, mediastinal, and hilar contours are within normal limits.\n Previously evident right basilar parenchymal opacities are again noted, but\n they appear less confluent in the interval. No new parenchymal opacities are\n seen. There is a tiny right pleural effusion as well as pleural thickening\n along the right chest wall. Visualized osseous structures are unremarkable.\n\n IMPRESSION: Patchy parenchymal opacity at the right lung base which appears\n improved in the interval. Small right pleural effusion and right\n pleural thickening.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-10-13 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 844892,
"text": " 1:29 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Any change in RLL consolidation, evidence of empyema.\n Admitting Diagnosis: HYPOTENSION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with RLL pneumonia, recurrent, with previous evidence of\n effusion on chest CT done on , here with fever, rhonchi on R on exam.\n REASON FOR THIS EXAMINATION:\n Any change in RLL consolidation, evidence of empyema.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 48 year-old woman with right lower lobe pneumonia, evaluate for\n empyemia.\n\n COMPARISON: .\n\n TECHNIQUE: Multiple axial images of the chest were obtained following the\n administration of 100 cc of Optiray.\n\n CT OF THE CHEST WITH IV CONTRAST: Please note that the study has been\n presented for redictation on . Compared to the prior study,\n the right sided pleural effusion has slightly increased in size with loculated\n components. There is enhancement of the visceral and parietal pleura (a split\n pleural sign) suggestive of an empyema. There is a small right\n hydropneumothorax as well. There is a dependent new left pleural effusion as\n well.\n\n The degree of consolidation in the right lower lobe remains unchanged. Again\n seen are an enlarged right hilar and precarinal lymph nodes. These appear\n unchanged from the prior study. There is a small pericardial effusion.\n\n A few images through the abdomen demonstrate some fluid in the gallbladder\n fossa. The adrenal glands are not enlarged.\n\n The osseous structures demonstrate old healed right 12th rib fracture.\n\n IMPRESSION: 1. Interval development of a dependent moderate size left pleural\n effusion.\n\n 2. Loculated right sided pleural effusion with enhancing pleural margins\n suggestive of an empyema.\n\n 3. Small right sided hydropneumothorax.\n\n 4. No significant change in right lower lobe consolidation.\n (Over)\n\n 1:29 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Any change in RLL consolidation, evidence of empyema.\n Admitting Diagnosis: HYPOTENSION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-10-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 844676,
"text": " 1:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check catheter placement\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with low bp and fever\n REASON FOR THIS EXAMINATION:\n check catheter placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status-post new catheter placement.\n\n COMPARISON: Radiograph dated at 12 P.M.\n\n SINGLE FRONTAL VIEW OF THE CHEST: There is interval placement of a right\n subclavian line that terminates in the SVC. There is no pneumothorax. The\n patchy right lower lung zone opacity is again identified, unchanged compared\n to the study done three hours prior. No other interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2118-10-11 00:00:00.000",
"description": "Report",
"row_id": 314164,
"text": "Sinus rhythm\nIndeterminate frontal QRS axis\nLow QRS voltages in limb leads\nNonspecific ST-T abnormalities\nSince previous tracing of , no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-10-12 00:00:00.000",
"description": "Report",
"row_id": 1459680,
"text": "Shift Note\nPt had emesis after 1800 methadone and benadryl given. Methadone quickly absorbed in GI tract, but prior shift nurse unsure of how much might have been absorb before emesis...Pill not noted in emesis. MICU team aware and decided not to given another does of methadone. Report called to floor nurse and aware that meds held d/t upset stomach. Aware to watch for methadone withdraw. Pt currently resting comfortably. To be transferred to 716 via bed accompanied by RN and co-worker.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-10-11 00:00:00.000",
"description": "Report",
"row_id": 1459677,
"text": "MICU A ADMIT NOTE\naddendum--Ordered for 1u pc's and hung at 1845, premed with tylenol 650mg po.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-10-11 00:00:00.000",
"description": "Report",
"row_id": 1459678,
"text": "MICU A ADMIT NOTE\nPLEASE SEE \nPT SI A 48 YO WOMAN WITH PMED HX OF HIV, HCV, IVDA, NEUROPATHY, ANXIETY, CURRENTLY IN A METHADONE PROGRAM. PT WAS RECENTLY D/C' FROM HOSPITAL AND WAS TREATED FOR PNX. PT WENT TO CLINIC THIS AM AND WAS FOUND TO BE LETHARGIC, PT HAD ADMITTED TO TAKING 3 EXTRA KLONIPIN THIS AM. SENT TO EW AND WAS FOUND TO BE FEBRILE, HYPOTNESIVE WITH ELEVATED WBC. PT ENROLLED IN MUST PROTOCOL, PRESEPT CATH PLACED AND TRANS TO MICU FOR MONITORING.\nALLERGIES--LAMICTAL\n\nROS\nNEURO--PT LETHARGIC, SLEEPING WHEN NOT BE STIMULATED. AWOKE AT 4PM, REQUESTING HER METHADONE DOSE, DOSE CONFIRMED BY HOUSE STAFF, AND GIVEN AT 1700. PT ABLE TO MOVE ALL EXTREMITES EQUALLY AND STRONG, INTACT GAG AND COUGH, PERRL AT 3MM AND BRISK. PT X3.\n\nCV--ARRIVED ON LEVOPHED GTT, 0.33MC/KG/MIN, ATTEMPTED TO WEAN OFF, BUT UNSUCCESSFUL AT THIS TIME. HR 60'S, SR, NO ECTOPY NOTED. CVP 6-12, RECEIVED NS IVF BOLUS 500CC FOR CVP 6, STARTED ON LR GTT AT 150CC/HR X2L. NO SKIN BREAKDOWN NOTED. PRESEPT CATH IN RIGHT SUBCLAVIAN WITH SCANT AMOUNT BLEEDING AT SITE. SVO2 ~80%, CATH CALIBRATED. RECEIVED PO MAG OXIDE FOR MAG 1.4, WILL ALSO RECEIVE IV MAG WHEN AVAILABLE, CA 6.5, WILL RECIEVE IV CALCIUM WHEN AVAILABLE. REPEAT HCT 22, WILL NEED REPEAT LABS AT 10PM. LACTATE WNL SINCE ARRIVAL TO MICU. INR 1.5.\n\nGI--NPO EXCPET FOR MEDS. ABD SOFT NONTENDER WITH GOOD BS IN ALL 4 QUDS. DENIES N/V AT THIS TIME, STATES HAD SEVERAL EPISODES IN PAST FEW DAYS.\n\nRESP--ON 2L NC, LUNGS WITH RHONCI IN BASES, EXPECTORATING SM AMOUNTS THICK YELLOW SECRETIONS, SPEC SNET FOR GS, AND CX, WILL NEED INDUCED SPUTUM FOR PCP IN AM. C/O RIGHT SIDE CHEST PAIN WITH COUGH.\n\nGU--FOLEY CATH IN PLACE, DRAINING CLEAR YELLOW URINE QS. CREAT 1.5 IN EW.\n\nSOCIAL--PT ARRIVED FROM EW WITH CLOTHES, BUT NOT HER PURSE. EW STATES NOT IN THEIR SAFE. AMBULANCE COMPANY CONTACT AND NOT FOUND IN AMBULANCE. CURRENTLY EW STAFF LOOKING FOR PURSE. PT CONCERNED ABOUT CAT AND WHO WILL CARE FOR IT, ATTEMPTING TO CONTACT NEIGHBOR, BUT ADDRESS BOOK IS IN THE PURSE. STATES WOULD LIKE HER SISTER TO BE HER HEALTH CARE PROXY, FORMS PROVIDED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-10-12 00:00:00.000",
"description": "Report",
"row_id": 1459679,
"text": "Nsg Progress Note 1900-0700\n\nCV - Pt in NSR most of night - had a very short episode of vent bigeminy which resolved itself. No further vent ectopy noted. Unable to wean levo off. Given bolus of IVF and kept on 150/hr all night but still requiring levo. Afebrile. Venous sat remained in the 80's throughout the night with no changes. Hct increased to 26.6 after one unit PC's. Mg WNL after recieving Mg last night. R SC TLC intact and patent.\n\nResp - BS cl bilat but course to bases. Strong spont prod cough of thick yellowish phlegm - mod to large amt. O2 via NC on because sat was dropping when pt very sleepy.\n\nGI - Tolerating PO's well. Took all of her evening meds without problem. Hypoactive BS and no bowel activity noted.\n\nGU - Foley cath draining adequate amt cl yellow urine. Amt is increasing slowly as pt recieved a substantial amt of IVF over the course of the night.\n\nEndocrine - BS stable - no insulin coverage needed.\n\nNeuro - Initially very lethargic but arousible and X2. Presently very awake and alert and X3. MAE. Very pleasant and cooperative. Concerned about lost purse. This RN has not heard any news on its whereabouts. Pt also concerned about contacting appropriate people on where she is and how long she will be here.\n\n\n"
}
] |
25,259 | 171,245 | He was admitted to the Trauma Service. Orthopedics was consulted for his bilateral femur fractures for which he underwent intramedullary nail of both. There were no intraoperative complications. He remained in the Trauma ICU for several days for close monitoring and was eventually transferred to the regular nursing unit. He was started on Lovenox postoperatively. A Physical therapy consultation was placed and it was recommended that he be discharged home with services. An Otolaryngology consult was placed for glass in his nose, no surgical intervention was warranted. Saline nasal spray was ordered and he will follow up in clinic as an outpatient. He was also seen by Social work for emotional support and counseling. | TECHNIQUE: Contiguous axial imaging was performed from the thoracic inlet to the pubic symphysis following the uneventful administration of IV contrast. Proximal thoracic trachea demonstrates 2 discrete foci of air at its right lateral surface. TECHNIQUE: Contiguous axial imaging was performed from the cranial vertex to the foramen magnum without IV contrast. FINDINGS: The heart, lungs, and mediastinum are within normal limits with no evidence of acute cardiopulmonary disease. On the right, there is a comminuted segmental fracture of the proximal femoral diaphysis. Bilateral proximal femoral fractures, no other fracture identified. TRAUMA VIEWS OF THE CHEST AND PELVIS: The cardiomediastinal contour is normal. ; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST BILAT IN O.R.Clip # Reason: BILAT FEMUR FX Admitting Diagnosis: BLUNT TRAUMA;TELEMETRY FINAL REPORT HISTORY: Trauma. The sacroiliac joints are unremarkable. The rectum, prostate, and sigmoid colon are unremarkable. CT ABDOMEN WITH IV CONTRAST: No intra-abdominal hemorrhage, free fluid, or air. FINDINGS: The collapsed bladder with contrast is noted within the pelvis. CT CERVICAL SPINE WITHOUT IV CONTRAST: The skull base to the superior aspect of the T1 vertebral body are imaged. Otherwise, no diagnostic interimchange. No displaced rib fractures or pneumothorax is identified. HEAD CT WITHOUT IV CONTRAST: There is no fracture or hemorrhage. The proximal femurs demonstrate comminuted fractures bilaterally. left ring finger lac, dressing intact.plan- monitor crit, ? On the right, the distal fracture fragments demonstrate lateral displacement of approximately one shaft width. Mucosal thickening in the ethmoid air cells bilaterally is not accompanied by any fracture. The normal cervical lordosis is maintained. No fracture involving the femoral heads, acetabula bilaterally, or remainder of pelvis are identified. Bilateral femoral heads are appropriately located. COMPARISON: Concurrent trauma radiographs. The heart, aorta, and great vessels are unremarkable. Bilateral proximal femoral fractures. Arising from the right lateral aspect of the proximal thoracic trachea, two foci of air within the mediastinum are identified (2:6, 2:9). IMPRESSION: 1) No evidence of fracture, hemorrhage, or other acute traumatic injury. On the left, there is an oblique fracture involving the proximal femoral diaphysis. The anterior superior aspect of the C3 vertebral body demonstrates an osteophyte or ossific density which could possibly relate to prior trauma. There is approximately one shaft width of lateral and posterior displacement of the major distal fracture fragment. The bony thorax is unremarkable. There is a comminuted left proximal femur fracture with medial displacement of the distal fracture fragment. lytes wnl.Skin- bilat femur dsg, D&I, original surgical dsg not to be changed untill POD 2. abrasions to head, and left arm. In the setting of trauma, tracheal injury cannot be entirely excluded, though this injury does not typically occur in isolation either. No rib fractures are identified. There is no pleural or pericardial effusion. There is no evidence of traumatic injury to the more inferior trachea, or bronchi. IMPRESSION: No evidence of acute fracture, alignment abnormality, or other acute traumatic injury. The esophagus follows a normal course on the left anterior surface of the spine. No significant displacement or angulation noted. The distal femur is intact. IMPRESSION: Comminuted fractures of the proximal femurs as detailed above. There is no edema or shift of normally midline structures. There is no mesenteric or retroperitoneal lymphadenopathy. There is no evidence of solid parenchymal organ injury. Incidental note is made of a tiny splenule in the left upper quadrant (2:57). The heart is not enlarged. Although a common site for tracheal diverticula, the size of these foci and their multiplicity are atypical. b/p 138/62. The pelvis and sacrum are intact. There is no fracture, alignment abnormality, or evidence of prevertebral soft tissue swelling. A tiny hypoattenuating lesion in segment 7 of the liver (2:46) is too small to characterize, but likely a cyst. No cervical lymphadenopathy or hematoma is identified. There is no pelvic hemorrhage or fluid collection. CT CHEST WITH IV CONTRAST: There is no evidence of traumatic aortic injury or hematoma or hemorrhage within the mediastinum. 1:19 PM CT C-SPINE W/O CONTRAST Clip # Reason: assess for traumatic injury MEDICAL CONDITION: 43 yo M restrained driver w/ severe pelvis pain, internally rotated R thigh, ext rotated L; seatbelt sign REASON FOR THIS EXAMINATION: assess for traumatic injury No contraindications for IV contrast WET READ: RSRc TUE 2:07 PM No fracture or acute alignment abnormality. 2) Multiple fragments of glass in left naris/proximal nasal cavity. No other fracture identified in the pelvis, sacrum, or bony thorax. The maxillary sinuses bilaterally demonstrate small polyps or mucous retention cysts. No trochanteric fracture, femoral head fracture, acetabular fracture, or other pelvic or sacral fracture is identified. Comminuted bilateral proximal femoral fractures with lateral displacement of the distal fracture fragment on the right, and medial displacement of the distal fracture fragment on the left. 1:18 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: trauma protocol, please obtain images through mid femur give MEDICAL CONDITION: 43 yo M restrained driver w/ severe pelvis pain, internally rotated R thigh, ext rotated L; seatbelt sign REASON FOR THIS EXAMINATION: trauma protocol, please obtain images through mid femur given likelihood of pelvis and/or femur fractures No contraindications for IV contrast WET READ: RSRc TUE 2:06 PM Two foci of air possibly continuous with right lateral aspect of proximal thoracic trachea. | 9 | [
{
"category": "Nursing/other",
"chartdate": "2144-04-15 00:00:00.000",
"description": "Report",
"row_id": 1592091,
"text": "Admit note\n\n43 yr male involved in MVC. pt stated in ED that his breaks locked and car slid into a pole. pt medflighted to . Ct head- neg, CT-c-spine- neg, Ct torso- bilat femur fx.\n\npmh- MVC C2-C3 fx and Halo, + ETOH, + Cocaine, +smoker.\n\nNKDA\n\n pt had bilat ORIF with IM nailling.\n\nFrom OR at .\n\nneuro- pt alert and oriented X3, consistantly. on CIWA scale, highest score 9. pt has anxiety and some aggiation. is able to be talked down for short periods. very short attention span and short term memory. ativan given TID, and prn. pt on dilaudid PCA .25/6/2.5. states he is having pain but it is much exaggerated by \"aggitation from not being able to drink water\". is able to MAE, but does not lift bilat LE due to pain, and refuses to be turned. c-collar d/c.\n\nCV- HR SR- ST 80's to low 100's. b/p 138/62. + peripheral pulses. skin warm and dry. P-boots and SQ heparin. crit down to 26.4 from 29.5. EKG shows some Q waves, ? old infarct or from cocaine use.\n\nresp- lung sounds clear to coarse. + smoker. o2 weaned off sat mid to high 90's. encouraged to cough and deep breathe, IS given and instructed on use.\n\nGI- NPO but taking lots of ice chips. abd soft, + BS.\n\nGU- foley clear yellow urine. avg 45cc/hr. IVF cont 100cc/hr. lytes wnl.\n\nSkin- bilat femur dsg, D&I, original surgical dsg not to be changed untill POD 2. abrasions to head, and left arm. left ring finger lac, dressing intact.\n\nplan- monitor crit, ? OOB with PT, pt is full weight bearing on bilat LE. ? transfer to floor.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1015734,
"text": " 8:27 PM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for sources of fever\n Admitting Diagnosis: BLUNT TRAUMA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with fever POD 3 s/p ORIF bilateral femur fx's\n REASON FOR THIS EXAMINATION:\n Please evaluate for sources of fever\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON AT 20:32\n\n INDICATION: Fevers.\n\n FINDINGS: The heart, lungs, and mediastinum are within normal limits with no\n evidence of acute cardiopulmonary disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-14 00:00:00.000",
"description": "BO FEMUR (AP & LAT) BILAT IN O.R.",
"row_id": 1015237,
"text": " 9:05 PM\n FEMUR (AP & LAT) BILAT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST BILAT IN O.R.Clip # \n Reason: BILAT FEMUR FX\n Admitting Diagnosis: BLUNT TRAUMA;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n These two examinations consist of eighteen intraoperative radiographs during\n fixation of bilateral femoral fractures. On both sides there are poorly\n assessed intertrochanteric and subtrochanteric fractures which are fixated by\n long intramedullary rods with interlocking nails extending into each femoral\n head as well as distal interlocking screws. This patient has no preoperative\n radiographs on PACS.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-14 00:00:00.000",
"description": "B FEMUR (AP & LAT) BILAT",
"row_id": 1015183,
"text": " 1:48 PM\n FEMUR (AP & LAT) BILAT; KNEE (2 VIEWS) BILAT Clip # \n Reason: please evaluate fractures\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with gross deformity bilateral thighs\n REASON FOR THIS EXAMINATION:\n please evaluate fractures\n ______________________________________________________________________________\n FINAL REPORT\n AP PELVIS, MULTIPLE VIEWS OF BILATERAL FEMURS, AT 13:53 HOURS:\n\n HISTORY: Question deformity of bilateral thighs.\n\n COMPARISON: None.\n\n FINDINGS:\n\n The collapsed bladder with contrast is noted within the pelvis. There is an\n intraluminal Foley catheter. The pelvis and sacrum are intact. The\n sacroiliac joints are unremarkable. Bilateral femoral heads are appropriately\n located. On the right, there is a comminuted segmental fracture of the\n proximal femoral diaphysis. There is approximately one shaft width of lateral\n and posterior displacement of the major distal fracture fragment. The knee\n joint is grossly aligned. The distal femur is intact. On the left, there is\n an oblique fracture involving the proximal femoral diaphysis. Femoral\n comminution is also noted on this side as well. No significant displacement\n or angulation noted. The left knee joint is grossly appropriately aligned as\n well.\n\n IMPRESSION: Comminuted fractures of the proximal femurs as detailed above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-14 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 1015163,
"text": " 12:51 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MVC, trauma.\n\n COMPARISON: None available.\n\n TRAUMA VIEWS OF THE CHEST AND PELVIS: The cardiomediastinal contour is\n normal. The heart is not enlarged. The lungs are clear. The bony thorax is\n unremarkable. No displaced rib fractures or pneumothorax is identified.\n\n There is a comminuted left proximal femur fracture with medial displacement of\n the distal fracture fragment. The right femur demonstrates an oblique\n fracture of the proximal femur with lateral angulation of the distal fracture\n fragment. No trochanteric fracture, femoral head fracture, acetabular\n fracture, or other pelvic or sacral fracture is identified.\n\n IMPRESSION:\n 1. Bilateral proximal femoral fractures.\n 2. No other fracture identified in the pelvis, sacrum, or bony thorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-14 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1015173,
"text": " 1:19 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: assess for traumatic injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 yo M restrained driver w/ severe pelvis pain, internally rotated R thigh,\n ext rotated L; seatbelt sign\n REASON FOR THIS EXAMINATION:\n assess for traumatic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc TUE 2:07 PM\n No fracture or acute alignment abnormality.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 43-year-old male restrained driver with pelvic pain. Please\n evaluate for cervical injury.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial imaging was performed from the skull base to the\n cervicothoracic junction. Coronal and sagittal reformations were provided.\n\n CT CERVICAL SPINE WITHOUT IV CONTRAST: The skull base to the superior aspect\n of the T1 vertebral body are imaged. There is no fracture, alignment\n abnormality, or evidence of prevertebral soft tissue swelling. The normal\n cervical lordosis is maintained. The anterior superior aspect of the C3\n vertebral body demonstrates an osteophyte or ossific density which could\n possibly relate to prior trauma. No cervical lymphadenopathy or hematoma is\n identified.\n\n IMPRESSION: No evidence of acute fracture, alignment abnormality, or other\n acute traumatic injury. These findings were posted to the ED dashboard at 2\n p.m., .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-14 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1015171,
"text": " 1:18 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: trauma protocol, please obtain images through mid femur give\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 yo M restrained driver w/ severe pelvis pain, internally rotated R thigh,\n ext rotated L; seatbelt sign\n REASON FOR THIS EXAMINATION:\n trauma protocol, please obtain images through mid femur given likelihood of\n pelvis and/or femur fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc TUE 2:06 PM\n Two foci of air possibly continuous with right lateral aspect of proximal\n thoracic trachea. Though these may be tracheal diverticula, in setting of\n trauma, and especially before positive pressure ventilation, tracheoscopy for\n tracheal rupture is recommended.\n\n Flattening of IVC and small spleen likely due to intravascular depletion. No\n evidence of solid organ injury or intraabdominal gas or hemorrhage.\n\n Bilateral proximal femoral fractures, no other fracture identified.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 43-year-old male restrained driver with severe pelvic pain and\n bilateral femoral fractures identified on pelvic radiograph. Please evaluate\n for traumatic injury to chest, abdomen, and pelvis.\n\n COMPARISON: Concurrent trauma radiographs.\n\n TECHNIQUE: Contiguous axial imaging was performed from the thoracic inlet to\n the pubic symphysis following the uneventful administration of IV contrast.\n Coronal and sagittal reformations were provided.\n\n CT CHEST WITH IV CONTRAST: There is no evidence of traumatic aortic injury or\n hematoma or hemorrhage within the mediastinum. Arising from the right lateral\n aspect of the proximal thoracic trachea, two foci of air within the\n mediastinum are identified (2:6, 2:9). The esophagus follows a normal course\n on the left anterior surface of the spine. There is no evidence of traumatic\n injury to the more inferior trachea, or bronchi. There is no pleural or\n pericardial effusion. Incidental note is made of subsegmental atelectasis. The\n lungs are otherwise clear. There is no supraclavicular, mediastinal, or\n axillary lymphadenopathy. The heart, aorta, and great vessels are\n unremarkable.\n\n CT ABDOMEN WITH IV CONTRAST: No intra-abdominal hemorrhage, free fluid, or\n air. There is no evidence of solid parenchymal organ injury. A tiny\n hypoattenuating lesion in segment 7 of the liver (2:46) is too small to\n characterize, but likely a cyst. Incidental note is made of a tiny splenule\n in the left upper quadrant (2:57). The remainder of liver, spleen, pancreas,\n adrenal glands, kidneys, ureters, large bowel, and small bowel are\n unremarkable. There is no mesenteric or retroperitoneal lymphadenopathy.\n (Over)\n\n 1:18 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: trauma protocol, please obtain images through mid femur give\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT PELVIS WITH IV CONTRAST: A Foley catheter is in place, and the bladder is\n collapsed. The rectum, prostate, and sigmoid colon are unremarkable. There\n is no pelvic hemorrhage or fluid collection.\n\n The proximal femurs demonstrate comminuted fractures bilaterally. On the\n right, the distal fracture fragments demonstrate lateral displacement of\n approximately one shaft width. On the left, there is medial displacement of\n the distal fracture fragment. No fracture involving the femoral heads,\n acetabula bilaterally, or remainder of pelvis are identified. No rib\n fractures are identified.\n\n IMPRESSION:\n\n 1. Comminuted bilateral proximal femoral fractures with lateral displacement\n of the distal fracture fragment on the right, and medial displacement of the\n distal fracture fragment on the left.\n\n 2. Proximal thoracic trachea demonstrates 2 discrete foci of air at its right\n lateral surface. Although a common site for tracheal diverticula, the size of\n these foci and their multiplicity are atypical. In the setting of trauma,\n tracheal injury cannot be entirely excluded, though this injury does not\n typically occur in isolation either. Given the inevitability of positive\n pressure ventilation for orthopedic surgery, tracheal injury must be assumed\n until proven otherwise. likely by direct visualization (tracheoscopy).\n\n These findings were posted to the ED dashboard and discussed with Dr. \n at 2:00 p.m. and 2:25 p.m. respectively, .\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1015172,
"text": " 1:19 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for traumatic injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 yo M restrained driver w/ severe pelvis pain, internally rotated R thigh,\n ext rotated L; seatbelt sign\n REASON FOR THIS EXAMINATION:\n assess for traumatic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc TUE 2:07 PM\n No hemorrhage, edema, or cranial fracture. Left nares demonstrates multiple\n fragments of glass.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 43-year-old male restrained driver with severe pelvic pain. Please\n evaluate for traumatic injury.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial imaging was performed from the cranial vertex to\n the foramen magnum without IV contrast.\n\n HEAD CT WITHOUT IV CONTRAST: There is no fracture or hemorrhage. There is no\n edema or shift of normally midline structures. The ventricles and sulci are\n normal in size and configuration. Mucosal thickening in the ethmoid air cells\n bilaterally is not accompanied by any fracture. The maxillary sinuses\n bilaterally demonstrate small polyps or mucous retention cysts. The left\n naris demonstrates approximately 5 square or rectangular 3 mm fragments of\n apparently leaded glass.\n\n IMPRESSION:\n 1) No evidence of fracture, hemorrhage, or other acute traumatic injury.\n 2) Multiple fragments of glass in left naris/proximal nasal cavity. These\n findings were discussed with the trauma surgery resident and entered into the\n ED dashboard at 2 p.m., .\n\n\n"
},
{
"category": "ECG",
"chartdate": "2144-04-14 00:00:00.000",
"description": "Report",
"row_id": 184768,
"text": "Sinus rhythm. Baseline artifact. Normal tracing. Compared to the previous\ntracing of the rate is increased. Otherwise, no diagnostic interim\nchange.\n\n"
}
] |
69,469 | 179,397 | 82 y/o F with hypertension, atrial fibrillation, remote seizure disorder and thyroidectomy, past episodes of self-neglect, presenting to ED after several days of immobilization fall at home. . #. Atrial fibrillation: Likely withdrawal of dual rate control with diltiazem and metoprolol in addition to significant dehydration while the patient was on the floor of her home. The patient was transferred to the ICU for rate control with a diltiazem drip, to which she responded. Ultimately was able to control rate on the drip, with hemodynamic stablitiy (mildly elevated blood pressures). Was transferred to the floor on a PO regimen of diltiazem and metoprolol similar to her home regimen. On telemetry, patient was noted to have atrial fibrillation, mostly in 50s-60s, with occasional asymptomatic bradycardia to 40s. The patient did not have any further episodes of Afib with RVR on the floor. She was hemodynamically stable, and was discharged on her home dose of diltiazem and 50 mg of metoprolol , as opposed to 100 mg , given her asymptomatic bradycardia. | Patchy retrocardiac opacity is noted. Consider left ventricularhypertrophy with repolarization abnormality. There is right-sided bullosa with left nasal septum deviation. There is mild left-sided nasal septum deviation. Enlarged left thyroid gland. Nonspecidfic sub-cm hypodense skull lesions in the frontal bone (pls compare to prior if available). Multilevel degenerative changes with moderate-to-severe neural foraminal narrowing, disc space narrowing and minimal anterior and posterior disc osteophyte complexes causing minimal narrowing of the spinal canal are noted. There is a lacunar infarct in the left basal ganglia, just adjacent to the left lateral ventricle (2:18). Enlarged left thyroid gland, likely multinodular goiter, but clinical correlation recommended. Atrial fibrillation. Mild prominence of the ventricles and cerebral sulci is compatible with age-appropriate atrophy. Mild mucosal sinus disease is again noted. Mild mucosal thickening in the maxillary sinuses, left more than right, is noted. A subcentimeter hypodense skull lesion in the left frontal bone just superior to the orbit (3:19) is nonspecific. osteopenia. Minimal anterolisthesis of C4 on C5 is likely degenerative. Normal cervical spine lordosis is preserved. Nonspecific hypodense bony lesions in the frontal bone. The aorta is calcified and tortuous. l thyroid mass. Fibrotic changes in bilateral lung apices, most likely related to prior granulomatous disease. Large left thyroid lobe and clips in the right thyroid bed are again noted. Periventricular and subcortical white matter hypodensities are compatible with chronic small vessel ischemic disease. Moderate mucosal thickening in the ethmoid sinus air cells is also noted. SINGLE FRONTAL VIEW OF THE CHEST: Please note that this exam is limited as the left costophrenic angle was not included in the image. NON-CONTRAST CT OF THE CERVICAL SPINE: Bones are osteopenic. Prevertebral soft tissues are not thickened. The patient is status post right thyroid lobe resection with enlargement of the left lobe and coarse calcifications. There is right-sided bullosa containing some mucosal secretions. Correlation with history of malignancy and comparison with prior CTs if available is recommended. Fibrotic changes with bronchiectasis and calcification in both lung apices, possibly related to prior granulomatous disease are noted. COMPARISON: Thyroid ultrasound from . fibrotic changes in lung apices. IMPRESSION: 1. IMPRESSION: 1. Known fibrotic changes are again noted within bilateral lung apices, better seen on cervical spine CT from same date. IMPRESSION: Retrocardiac atelectasis or pneumonia. Atrial fibrillation with rapid ventricular response. Cardiomegaly. No evidence of acute intracranial injury. COMPARISON: None. COMPARISON: None. Clinical correlationis suggested.TRACING #2 Atherosclerotic calcifications of the carotid artery are severe. No evidence of acute injury to the cervical spine. change. No previous tracing available forcomparison.TRACING #1 Since the previous tracing the rate has decreased.QRS voltage has increased and is probably more apparent. There is no pneumothorax or right-sided pleural effusion. There is also mild mucosal thickening in the sphenoid sinuses. 2. 2. NON-CONTRAST HEAD CT: There is no intracranial hemorrhage, mass effect, or -white matter differentiation abnormality. Orbits and globes are unremarkable. There is no vertebral body height loss. 3. Imaged mastoid air cells are clear. Heart is severely enlarged. There is no fracture. There is no evidence of fracture. mucosal sinus dz FINAL REPORT REASON FOR EXAM: Status post fall. 3:51 PM CHEST (SINGLE VIEW) Clip # Reason: eval for infiltrate MEDICAL CONDITION: 82 year old woman found down REASON FOR THIS EXAMINATION: eval for infiltrate FINAL REPORT REASON FOR EXAM: Found down. FINAL REPORT REASON FOR EXAM: Status post fall. 12:29 PM CT C-SPINE W/O CONTRAST Clip # Reason: fx MEDICAL CONDITION: 82 year old woman with s/p fall REASON FOR THIS EXAMINATION: fx No contraindications for IV contrast WET READ: 4:18 PM No fx. | 5 | [
{
"category": "Radiology",
"chartdate": "2119-11-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1158090,
"text": " 12:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 4:03 PM\n No ICH. Nonspecidfic sub-cm hypodense skull lesions in the frontal bone (pls\n compare to prior if available). mucosal sinus dz\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Status post fall.\n\n COMPARISON: None.\n\n NON-CONTRAST HEAD CT: There is no intracranial hemorrhage, mass effect, or\n -white matter differentiation abnormality. Mild prominence of the\n ventricles and cerebral sulci is compatible with age-appropriate atrophy.\n Periventricular and subcortical white matter hypodensities are compatible with\n chronic small vessel ischemic disease. There is a lacunar infarct in the left\n basal ganglia, just adjacent to the left lateral ventricle (2:18). There is\n no fracture. There is right-sided bullosa containing some mucosal\n secretions. There is mild left-sided nasal septum deviation. Mild mucosal\n thickening in the maxillary sinuses, left more than right, is noted. There is\n also mild mucosal thickening in the sphenoid sinuses. Moderate mucosal\n thickening in the ethmoid sinus air cells is also noted. Orbits and globes\n are unremarkable. Imaged mastoid air cells are clear. A subcentimeter\n hypodense skull lesion in the left frontal bone just superior to the orbit\n (3:19) is nonspecific.\n\n IMPRESSION:\n 1. No evidence of acute intracranial injury.\n 2. Nonspecific hypodense bony lesions in the frontal bone. Correlation with\n history of malignancy and comparison with prior CTs if available is\n recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-11-09 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1158092,
"text": " 12:29 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 4:18 PM\n No fx. osteopenia. change. l thyroid mass. fibrotic changes in lung\n apices.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Status post fall.\n\n COMPARISON: Thyroid ultrasound from .\n\n NON-CONTRAST CT OF THE CERVICAL SPINE: Bones are osteopenic. There is no\n evidence of fracture. Minimal anterolisthesis of C4 on C5 is likely\n degenerative. Normal cervical spine lordosis is preserved. There is no\n vertebral body height loss. Multilevel degenerative changes with\n moderate-to-severe neural foraminal narrowing, disc space narrowing and\n minimal anterior and posterior disc osteophyte complexes causing minimal\n narrowing of the spinal canal are noted. Prevertebral soft tissues are not\n thickened. Mild mucosal sinus disease is again noted. The patient is status\n post right thyroid lobe resection with enlargement of the left lobe and coarse\n calcifications. Fibrotic changes with bronchiectasis and calcification in\n both lung apices, possibly related to prior granulomatous disease are noted.\n Atherosclerotic calcifications of the carotid artery are severe. There is\n right-sided bullosa with left nasal septum deviation.\n\n\n IMPRESSION:\n 1. No evidence of acute injury to the cervical spine.\n\n 2. Enlarged left thyroid gland, likely multinodular goiter, but clinical\n correlation recommended.\n\n 3. Fibrotic changes in bilateral lung apices, most likely related to prior\n granulomatous disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-11-09 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1158132,
"text": " 3:51 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman found down\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Found down.\n\n COMPARISON: None.\n\n SINGLE FRONTAL VIEW OF THE CHEST: Please note that this exam is limited as\n the left costophrenic angle was not included in the image. Heart is severely\n enlarged. The aorta is calcified and tortuous. Patchy retrocardiac opacity\n is noted. Known fibrotic changes are again noted within bilateral lung\n apices, better seen on cervical spine CT from same date. Large left thyroid\n lobe and clips in the right thyroid bed are again noted. There is no\n pneumothorax or right-sided pleural effusion.\n\n IMPRESSION: Retrocardiac atelectasis or pneumonia. Cardiomegaly. Enlarged left\n thyroid gland.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2119-11-09 00:00:00.000",
"description": "Report",
"row_id": 142897,
"text": "Atrial fibrillation. Since the previous tracing the rate has decreased.\nQRS voltage has increased and is probably more apparent. Clinical correlation\nis suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2119-11-09 00:00:00.000",
"description": "Report",
"row_id": 142898,
"text": "Atrial fibrillation with rapid ventricular response. Consider left ventricular\nhypertrophy with repolarization abnormality. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
}
] |
11,204 | 183,293 | 1. CARDIOVASCULAR: A. CORONARY ARTERY DISEASE: The patient had previous cardiac catheterization five years ago that was within normal limits. The patient had his cardiac enzymes cycled and he ruled out for myocardial infarction. He had a cardiac catheterization on which showed normal coronary arteries. At this time, aspirin was discontinued. | ABG 7.44/39/93. STARTED ON ATROVENT MDIS. Since the previous tracing sinus rhythm is now seen.Borderline Q-T interval prolongation is noted. There is nopericardial effusion. SGOT,SGPT, T. BILI UP.RESP- CONT. ABG pnd. t/f held for extubation. levoquin IVHR 95-109 AF. He came in at 1.0. LS course lower airways.neuro: pt. (-)1.7liter for . FREQ BOLUSES. ECHO done, EKG done. Since the previous tracing multifocal atrial prematurebeats are seen. EDEMA. ?TRY WEAN VENT AGAIN IN AM. Was given Ativan, MSO4 and Vec. Suction prn. PT WITH SM. K+ 4.2. Mild (1+) mitral regurgitation is seen. DiffuseSt-T wave abnormalities are seen.TRACING #1 Was placed on Hep gtt after bolus, T.L placed. U/O LOW, DRIFTED DOWN TO 1-6CC/HR. WILL WITHDRAW TO DEEP TACTILE STIUMLATION UPPER EXT. ativan weaned off gradually and d/c'd for extubation. SVO2 69. k-3.6, replaced with 40meq iv, repeat 4.0. Consideralso left ventricular hypertrophy. for day.gi- ogt clamped and d/c'd prior to extubation. OCC. sedation decreased.P: change to PSV and assess wakefullness. Chest CT priliminary, neg for PE, disection. follow PAP's, u/o. CHF, RESP FAILURECCU NPNO- TEMP UP TO 102.3 PO, RE'D TYLENOL. ON PROPOFOL AND REQ. BCx2 sent, given rocephin and Vanco. To be ruled out for MI. X4.PULM: PT CONTINUES ON VENT. CCU NPN 2300-0700O: afeb. PAP 52-60/30-34. BP dropped to 80's/50's, MAP 64-66, cont with good diuresis. BLD C+S SENT X1, PERIPHERAL STICK. CCU NPN 3-11PMCV: remains off pressors, BP 90-100/60, HR 120-140 A.fib. LS with fine crackles at bases bilaterally.ID: afebrile. MAP 65-71. milrinone at .38mcq/kg/min. REINFORCE PRN.PLAN- FOLLOW TEMPS, ?WILL NEED ABX. reinforce prn. PT. Sinus rhythm, rate 99. SATS 95-99. Echo done showing systolic dysfunction, no shunt.PMH: HTN, previously on atenolol, stopped himself ~1mo ago.ALL: NKDACV: on Dopa BP 90-110/, weaned from 6ug to 5ug/kg/min. FOLLOW U/O, BUN, CREAT, LFTS. C.O. fent. cont. cont. ABD SOFT/DIST. 5.3/2.2/1200. SBP 80-90S. PAD's up since last diuresis. 40 KCL IV given this am with repeat K+ 4.2. Consider prior anterior myocardial infarction. HR 110-90 NSR. recieved second dose of dig. TITRATION OF DIPRIVAN TO SEDATION. Atrial fibrillation. suctioned for small amt. A rare ventricular premature beat is noted. Sinus rhythm, rate 78. ORDERS TO KEEP MEAN >65. Cont on Milrinone at .38ug/kg/min and amiodarone at .5mg/min. WITH B. K-5.1, RECHECK IN PM 4.6. Since the previous tracing of lateral T waveinversions are less. CCU NSG NOTE: ALT IN CVO: For complete VS see CCU flow sheet.ID: T-max 100R. on milrinone, amiodarone, heparin- same doses. Left axisdeviation. TO MOD. U/O IMPROVED SLIGHTLY THIS PM. PAD 19-22.CVP 7-10 and WEDge 18. u/o 50-60cc/hr.heparin 1000u/hr. Intraventricular conduction delay. PTT HIGH, HEPARIN DECREASED X2 AND HELD FOR 1HR WITH 1ST CHANGE. heart failure, afccu npno- t max 99.3. c+s pnd/neg. Specimen sent for lytes. 30CC/HR. fentanyl d/c'd prior to extubation. DOPA CURRENTLY AT 3.6 MCGS. OGT CLAMPED. ATTEMPT TO WEAN OFF. SEDATED ON DIPRIVAN (SEE VS SCREEN). Coarse atrial fibrillation with a moderate ventricular response. D/C'D AT MIDNOC & NPO-> ? LEVOPHED 4.5MCG/MIN-> CO 4.5/1.95/1227. ECTOPY RESOLVED. wbc 11.5. c+s pnd, sputum oroph. addendumstarted on captopril, tol well. recheck ptt. in and pnd. ON IV LEVOFLOX.ENDO: BS 130->111. A right IJ line is present, tip overlying proximal SVC. abg adeq, later po2 down 68, peep up to 7.5 and abg- 79,39,7.41,0. sats 92-96. l/s sl. CHF and bilateral effusions. k- 4.3. creat 1.0. hct 46.7, plts 93. lfts improved, still elevated. chf, resp failure, afccu npno- t max 100.8 po. however, pt. LEVOPHED STARTED & DOPA WEANED TO OFF. HO AWARE OF HEMODYNAMICS.GI: TF: FS NEPRO 10CC/HR. PTT 61.3. (+) BSA: confusion after extubation good diuresis. BS+. AMTS. gaze traks.TM 100.2R. INTUBATED. EXTUBATION. wakes slightly with repos or sx'ing. HO AWARE.ID: AFEBRILE. contin, gtts per plan. contins. edematous. on levo IV for presumed pnxHR 95-116 AF. follow u/o, lytes. 1.2l u/o responce. BP high, req. bp 80s-90s/. A right- sided central line is identified with tip at the proximal superior vena cava. pt. IMPRESSION: Mild chf with effusions and bibasilar collpase/consolidation. SX FOR SM.-MOD. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. cont. cont. cont. cont. cont. CONT. CONT. CCU NSG NOTE: ALT IN CVS: I'm in the ".O: For complete VS see ccu flow sheet.ID: T-max 100.4R. SVO2 71. HO CALLED->WEAN DOPA AS TOL. Probable residual small right pleural effusion. C.O. An endotracheal tube is identified in place. CA,MG,PO4 SENT. Held further fluid boluses. k-4.7. When pt awake, is out of sinc with vent, RR in 30's. ABG 7.43/38/91/26 97% SAT.CARDIAC: HR 93-110 AF. prod. pt consult to eval strength, etc. MG 1.6->TREATED WITH MGS04 2GMS PB X1. No bm.RENAL: Creat down to 1.1. PAD 21-27, CVP 9-14, W 23, CO 6.1/2.64/866. bp maintained at 90s-100s. flora.cv- hr max 122 in am, afib, down to 90s-100s, no vea. ATTEMPTS TO OPEN EYES.RESP: ON VENT: FIO2 WEANED FROM .60->.40 X 700 + AC 10 & 7.5 PEEP. Compared with one day earlier, a right IJ Swan-Ganz catheter is now in place. Will need repeat ABG. BS COURSE AND DIMINISHED AT BASES. co improved to 5.9, ci 2.55, svr down to 719. pa 57/35 down to low 43/20, wedge down to 20. cvp 22-11. cvp changed to rv pattern x2, pa line withdrawn x2 by mds, cvp now with ra trace, pa cont. CVP transduced via T.L., 24. Heparin was also d/c and lovenox begun. CCU NPN 7P-7ACV: Pt has remained in A.fib, rate 140's on Amiodarone gtt at 1mg/min, given another bolus of 150mg at MN, HR down a bit to 120's a.fib, BP has been 80-90/70, MAP 65-75. sat 98. pt calm/sedated at time of rhythm conversion. | 37 | [
{
"category": "Radiology",
"chartdate": "2121-07-02 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 760334,
"text": " 8:15 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: HEP C NEWLY DIAGNOSED CHECK FOR HEPATOMA ASCITES AND CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with new HCV dx.\n REASON FOR THIS EXAMINATION:\n eval for hepatoma, ascites, cirrhosis\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL ULTRASOUND:\n\n INDICATION: Hepatitis C virus.\n\n FINDINGS:\n\n The hepatic parenchyma is coarsened and nodular compatible with cirrhosis. A\n few tiny cysts are visualized in segment 4 measuring up to 7 mm. A tiny\n echogenic focus is seen in the right hepatic lobe, probably representing a\n granuloma. No solid liver lesions are identified. The main portal vein is\n patent with appropriate directional flow. There is no ascites, evidence of\n varices or splenomegaly. The gallbladder is normal in appearance. The common\n duct is not dilated. The visualized pancreas is unremarkable. The kidneys\n are normal in size and architecture with the right kidney measuring 11.7 cm in\n length and the left kidney measuring 11.5 cm in length. There is no\n hydronephrosis, renal mass or calculus.\n\n IMPRESSION:\n\n Cirrhotic liver with no complications of chronic liver disease.\n\n"
},
{
"category": "Echo",
"chartdate": "2121-06-20 00:00:00.000",
"description": "Report",
"row_id": 71437,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cyanosis on ventilator. R/o large right-left shunt\nBP (mm Hg): 112/76\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 16:39\nTest: Portable TTE(Focused views)\nDoppler: Focused pulse and color flow\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nLEFT VENTRICLE: There is severe global left ventricular hypokinesis.\n\nRIGHT VENTRICLE: There is severe global right ventricular free wall\nhypokinesis.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with one iv injection of 8 ccs\nof agitated normal saline at rest.\n\nConclusions:\nThe left atrium is mildly dilated. There is severe global left ventricular\nhypokinesis. There is severe global right ventricular free wall hypokinesis.\nThe aortic valve leaflets are mildly thickened. The mitral valve leaflets are\nmildly thickened. Mild (1+) mitral regurgitation is seen. There is no\npericardial effusion. A contrast injection at rest did not reveal any right to\nleft shunting.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2121-06-21 00:00:00.000",
"description": "Report",
"row_id": 176676,
"text": "Sinus rhythm, rate 99. Since the previous tracing the heart rate is somewhat\nfaster. No significant ectopy is noted. The T wave inversions previously seen\nare somewhat less impressive.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2121-06-20 00:00:00.000",
"description": "Report",
"row_id": 176677,
"text": "Sinus rhythm, rate 88. Since the previous tracing multifocal atrial premature\nbeats are seen. A rare ventricular premature beat is noted. No other\nsignificant changes have occurred.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2121-06-20 00:00:00.000",
"description": "Report",
"row_id": 176678,
"text": "Sinus rhythm, rate 78. Since the previous tracing sinus rhythm is now seen.\nBorderline Q-T interval prolongation is noted. Deep T wave inversions are\npresent in leads I, aVL and across the precordium.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2121-06-20 00:00:00.000",
"description": "Report",
"row_id": 176679,
"text": "Atrial fibrillation, average ventricular rate 148. Left axis deviation. Diffuse\nSt-T wave abnormalities are seen.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2121-07-02 00:00:00.000",
"description": "Report",
"row_id": 176436,
"text": "Atrial fibrillation with a controlled ventricular response. Left axis\ndeviation. Intraventricular conduction delay. Left ventricular hypertrophy.\nDeep T wave inversions in leads V3-V6 and T wave inversions in leads I and aVL.\nCompared to the previous tracing of T wave inversions in the lateral\nleads are much more prominent and the rate is slower. Cannot rule out an\nischemic process. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2121-06-27 00:00:00.000",
"description": "Report",
"row_id": 176437,
"text": "Atrial fibrillation. Since the previous tracing of lateral T wave\ninversions are less. Other abnormalities as previously described persist.\n\n"
},
{
"category": "ECG",
"chartdate": "2121-06-24 00:00:00.000",
"description": "Report",
"row_id": 176438,
"text": "Coarse atrial fibrillation with a moderate ventricular response. Q-T interval\nis long for rate. Left axis deviation - consider left anterior fascicular\nblock. Anterolateral and lateral ST-T wave abnormalities concerning for\nmyocardial ischemia. Consider prior anterior myocardial infarction. Consider\nalso left ventricular hypertrophy. Compared to the previous tracing of \nthe ventricular response is slower and the ST-T wave abnormalities persist.\nClinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2121-06-21 00:00:00.000",
"description": "Report",
"row_id": 176439,
"text": "Atrial fibrillation with a rapid ventricular response. Left axis deviation.\nConsider left anterior fascicular block. Anterolateral and lateral ST-T wave\nabnormalities concerning for myocardial ischemia. Compared to the previous\ntracing of the atrial fibrillation is new and the ST-T wave\nabnormalities persist. Clinical correlation is suggested.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-24 00:00:00.000",
"description": "Report",
"row_id": 1409936,
"text": "CCU NPN 2300-0700\nO: afeb. levoquin IV\nHR 95-109 AF. no VEA. amiodarone .5mg/min. recieved second dose of dig. .25mg IV. to start QD dose today.\n\nBP 89-95/60's. MAP 65-71. milrinone at .38mcq/kg/min. PAD 19-22.CVP 7-10 and WEDge 18. u/o 50-60cc/hr.\n\nheparin 1000u/hr. PTT 90.(within range) AM pnd.\n\nresp: for overnight rest, placed on AC in eve: rate 10/700/.40/7.5peep. sats 97-99%. ABG 7.44/39/93. no overbreathing vent. suctioned for small amt. thick yellow/tan secretions. LS course lower airways.\n\nneuro: pt. sedated when left alone, no spont. movement. but arouses with any stimulation. trys to open eyes, moving arms, coughing becomes very red in face. settles down on own if left alone. ativan at 4mg/hr. decreased to 3mg during night. no change in sedaton level noted. fent. gtt at 50mcq.\n\nA: no change in VS/C.O. numbers. good diurses in eve.\n stable on AC. no spont. breathing. sedation decreased.\nP: change to PSV and assess wakefullness. . sedation slowly.\nfollow swan numbers. monitor HR/rythym for change. dig. today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-24 00:00:00.000",
"description": "Report",
"row_id": 1409937,
"text": "heart failure, af\nccu npn\no- t max 99.3. c+s pnd/neg. cont. on abx.\ncv- hr 120s to 90s af, no vea. bp 100s to 130s/. cont. on milrinone, amiodarone, heparin- same doses. k-3.6, replaced with 40meq iv, repeat 4.0. 2 amps mgso4 also given x1. ptt 90.7. plts 93.\nresp- weaned to psv and extubated at 4:30pm. on 50% cool neb, sats 98-100. abg- 113,46,7.39,29. no sob noted after extubation. sx'd for sm amts white to tan sputum, bld tinged. coughing well after extubation with encouragement, orally sx'd or ?swallows sputum. l/s sl. coarse/dim. lasix 20mg iv given x1 in am with good response. i+o about 500cc neg. for day.\ngi- ogt clamped and d/c'd prior to extubation. t/f held for extubation. no bm.\nskin- intact, repos side to back with skin/oral care.\nms- awake and reponsive all day, most time interactive- nodding and following commands. also agitated and anxious at times. fentanyl d/c'd prior to extubation. ativan weaned off gradually and d/c'd for extubation. unable to speak, mouthing words, then able to speak in hoarse voice, difficult to understand.\nsocial- fx, friends visited most day, supportive to pt. fx updated on status, plan and understand. reinforce prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-23 00:00:00.000",
"description": "Report",
"row_id": 1409934,
"text": "CCU NSG NOTE: ALT IN CV\nO: For complete VS see CCU flow sheet.\nID: T-max 100R. Pt conts on abx.\nCV: HR increased from low 100s to 120s a-fib. 40 KCL IV given this am with repeat K+ 4.2. Levophed weaned off at 11:15 with BP staying in 90-low 100s. He continues on milrinone at .32 mic/kilo, amiodarone at .5mg and heparin with theraputic PTT. PAP has ranged 40-50s/28-32 with wedge of 23, ra 13-16 and last CO/CI off levophed for 45 minutes was 4.8/2.08/ 1133. He was started on 12.5 aldactone NG.\nRESP: Pt has been weaned to C-PAP with gas on 40% 7.5 PEEP 10 PS with RR 8-15 was 7.40/ 39/ 127/ 25. PEEP has since been weaned to 5 with 02 sats 98-100%. He is being suctioned ~Q2 for thick yellow secretions. He has a strong cough. Breath sounds are decreased and occasional wheezes are heard. He is getting MDIs from resp. Pt has been observed to have periods of apnea followed by increased resp rate and pt jerking awake. Wife states she has noted this at home.\nRENAL: Creatinine decreased from 2.5 yesterday ato 1.5 today. He came in at 1.0. Urine appears very consentrated and cloudy. Specimen sent for lytes. He is ~600cc positive for the day but k~2800cc neg LOS.\nGI: Nepro was restarted at 10cc/hr at 10am. Pt had residual of 50cc at noon but it was mostly bile and G-. No BM.\nENDO: FS at noon 128 and no ss reg insulin given.\nMS/SEDATION: Pt has been rouseable to verbal stimuli, as well as startling awake on his own. He has followed simple commands and seems to recognise and respond to family members. is moving all extremities. He continues on ativan 5mg/hr and fentanyl 50mic/min.\nA: Contd elevated filling pressures/marginal BP off levo/poor u/o/tolerating c-pap\nP: If bp drops too low try neo to maintain bp. Suction prn. 5pm labs. Support pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-23 00:00:00.000",
"description": "Report",
"row_id": 1409935,
"text": "CCU NPN 3-11PM\nCV: remains off pressors, BP 90-100/60, HR 120-140 A.fib. Given .25mg Dig, 20mg Lasix IV, diuresed ~1L over next few hours. BP dropped to 80's/50's, MAP 64-66, cont with good diuresis. K+ 4.2. HR has dropped to 110-120. Cont on Milrinone at .38ug/kg/min and amiodarone at .5mg/min. Heparin adjusted for PTT of 58 at 8 PM, will need PTT at 2AM. CO 6.5, CI 2.8\n\nNeuro: sedated on Fent 50ug, Ativan 5mg, decreased to 4mg. Responds to voice, nods appropriately at times.\n\nResp: on PS 10/5 PEEP, after getting 50ug bolus of fent x2 for agitation, was having periods of apnea, placed back on AC rate of 10, VT 700 for the night, will changed back to PS early AM. Suctioned for scant pale yellow secretions x2. LS with fine crackles at bases bilaterally.\n\nID: afebrile. cont on levofloxacin q 24hrs.\n\nEndo: BS 108, no ins required.\n\nGI:Kept TF, Nepro at 10cc for high residul at 4PM, 30cc residual at 10PM, increased TF to 20cc. Nutrition saw pt, check chart for recommendations.\n\nSoc: wife and children in, updated by Dr. .\n\nA: Showing improvement in CO on Milrinone and off pressors, diuresing well.\n\nP: Cont hemodynamic monitoring, cont vent support, change back to PS in AM, diurese as tolerated with hopes of weaning in next few days.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-21 00:00:00.000",
"description": "Report",
"row_id": 1409926,
"text": "END OF SHIFT/NURSE CLINICAL UPDATE\nPT ADMITTED FOR CHF/SOB WITH PULM. EDEMA. AFIB-CARDIOVERTED BACK INTO SINUS (SEE MD HISTORY)\n\nNEURO: PT DOES NOT FOLLOW COMMANDS AT THIS TIME. SEDATED ON DIPRIVAN (SEE VS SCREEN). WILL WITHDRAW TO DEEP TACTILE STIUMLATION UPPER EXT. PEARL. PT VERY AGITATED WITH LOW DOSE SEDATION. TITRATION OF DIPRIVAN TO SEDATION. COUGHING WITH DECREASING SATS WHEN AGITATED. X4.\n\nPULM: PT CONTINUES ON VENT. PT WITH SM. TO MOD. AMTS OF THICK WHITE SECRETIONS FROM ET TUBE. BS COARSE BILATERAL BUT CLEARS SOME WITH SUCTION. PT PO >90% ON VENT.\n\nCV: PT . ON LOW DOSE DOPAMINE (RENAL DOSE). ATTEMPT TO WEAN OFF. ORDERS TO KEEP MEAN >65. DOPA CURRENTLY AT 3.6 MCGS. SBP 80-90S. HR <100, SINUS WITH FREQUENT PAC'S (SEE STRIP POSTED).\n\nGI/GU: PT WITH LARGE URINE OUTPUT BEGINNING OF SHIFT BUT HAS SINCE TAPPERED TO APPROX. 30CC/HR. MD UPDATED ON URINE OUTPUT. ORDER FOR LASIX GIVEN (SEE MED SHEET). PT CONTINUES TO HAVE POOR URINE OUTPUT. NO BM NOTED.\n\nLINES: CENTRAL LINE WITH SLIGHT BLOODY DRAINAGE TO PT AGITATION. A-LINE INTACT WITH FAIR WAVE FORM.\n\nFAMILY: GENERAL UPDATE GIVEN DAUGHTER OVER TELEPHONE. VERABLIZES UNDERSTANDING.\n\nPLEASE SEE CLINICAL INFORMATION SCREENS FOR HOURLY TRENDS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-21 00:00:00.000",
"description": "Report",
"row_id": 1409927,
"text": "Respiratory Care Note\n\nPt currently on AC 700*10 +5 40%. Pt tol current settings well. Pt on CPAP for ~ 1 hour today...pt became very agitated and had periods of apnea with Increasing sedation. Will cont to suport and change to PSV when pt ready\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-20 00:00:00.000",
"description": "Report",
"row_id": 1409925,
"text": "CCU Nursing Admission Note:\n61 yr old admitted from EW today with CHF. Pt has had increased leg edema and SOB for past 10 days. On arrival to EW was found to be in rapid A.fib at 140, BP initially 90/70, was cyanotic and SOB in EW, sat 99% on 2L, EKG with rate related changes. Cardioverted after receiving sedation, back to NSR, cont to have SOB, BP dropping to 70-80/, started Dopamine 15ug/kg/min and was intubated. Dopa able to be weaned to 5ug. Was given Ativan, MSO4 and Vec. BCx2 sent, given rocephin and Vanco. Chest CT priliminary, neg for PE, disection. Was placed on Hep gtt after bolus, T.L placed. Echo done showing systolic dysfunction, no shunt.\n\nPMH: HTN, previously on atenolol, stopped himself ~1mo ago.\n\nALL: NKDA\n\nCV: on Dopa BP 90-110/, weaned from 6ug to 5ug/kg/min. HR 110-90 NSR. ECHO done, EKG done. To be ruled out for MI. Cath potentially next week. On hep gtt at 1800U/hr.\n\nResp: Vented, AC 700x12, 100%, 10 PEEP. Suctioned for scant blood tinged sputum. ABG pnd. Sats 99-100%.\n\nGI: NGT in place, BS present, abd soft, no stool. HCT 47.6\n\nGU: aggressively diuresing from lasix given in EW.\n\nMS: Sedated on IV Ativan, given 1x bolus of vecuronium. Given MSO4x1 also.\n\nID: T 99 po, WBC 6.8, given AB in EW, BC sent.\n\nSoc: wife and children in, updated by RN/MD.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-21 00:00:00.000",
"description": "Report",
"row_id": 1409928,
"text": "CHF, RESP FAILURE\nCCU NPN\nO- TEMP UP TO 102.3 PO, RE'D TYLENOL. BLD C+S SENT X1, PERIPHERAL STICK. URINE AND SPUTUM SENT ALSO. WBC 10.1.\nCV- HR 101 TO 90S SR, NO VEA. BP 80-90S IN MA, MAPS 70S. DOPA WEANED TO OFF BY 2:30PM. BP 90S-100S LATER IN DAY. K-5.1, RECHECK IN PM 4.6. PTT HIGH, HEPARIN DECREASED X2 AND HELD FOR 1HR WITH 1ST CHANGE. LAST PTT 118 AND HEPARIN DOWN TO 1000UNITS/HR AT 4:15PM, CHECK PTT TONOCT. BLEEDING SMALL AMTS FROM TLC AND ALINE SITE. PLTS 122. CK 93 TODAY. SGOT,SGPT, T. BILI UP.\nRESP- CONT. ON A/C 10, TV 700, 60% WEANED X2 TO 40% WITH 5PEP. SATS 95-99. LAST ABG ON 40%- 100,29,7.42,19.\nHAD PSV TRIAL, AT 1ST TV 500S, RATE 21 ON PSV 12, BUT BECAME APNEIC WHEN AGITATED AND BACK ON A/C. L/S COARSE/JUNKY WITH SCAT WHEEZES TO SL. COARSE, DIM THRUOUT. STARTED ON ATROVENT MDIS. SX'D FOR THICK TAN X1, THEN WHITE TO BLOODY/BLD TINGED SEC. U/O LOW, DRIFTED DOWN TO 1-6CC/HR. HO AWARE AND RE'D 3 BOLUSES OF 250CC N/S WITHOUT CHANGE IN U/O. U/O IMPROVED SLIGHTLY THIS PM. POS. ABOUT 1100CC TODAY (NEG 4700CC ).\nGI- NPO. OGT CLAMPED. ABD SOFT/DIST. WITH B. SOUNDS. NO BM.\nMS- AGITATED OFF/ON. ON PROPOFOL AND REQ. FREQ BOLUSES. CHANGED TO ATIVAN IN HOPES OF RAISING HIS BP. REQUIRED DRIP TO BE TITRATED TO 4MG/HR WITH SEVERAL 2-3MG BOLUSES TO SEDATE. STILL AGITATED WITH SX'ING. OCC. FOLLOWS COMMANDS SUCH AS OPENING EYES OR SQUEEZING HANDS. IN BED. HANDS RESTRAINED FOR RISK OF EXTUBATION. RELEASED FREQ.\nSOCIAL- FX IN MOST DAY, SUPPORTIVE TO PT. STATUS, PLAN EXPLAINED TO FX MEMBERS, UNDERSTAND. REINFORCE PRN.\nPLAN- FOLLOW TEMPS, ?WILL NEED ABX. ?TRY WEAN VENT AGAIN IN AM. FOLLOW U/O, BUN, CREAT, LFTS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-26 00:00:00.000",
"description": "Report",
"row_id": 1409942,
"text": "CCU NPN 1900-0700\nS: \" I'm in , \"\nO: pt. confused on place/time. sometimes will state or hosp. able to state name. moving all extrem. on bed and able to lift arms up toward face. having spatial difficulties. able to hold up 2 fingers. speech slow and very soft.\nno agitation. sleeps most of time when left alone.\n\nHR 87-94AF. BP 130-140/80's. PAP 52-60/30-34. CVP 13-15. unable to wedge catheter. SVO2 69. C.O. 5.3/2.2/1200. unchanged from days.\ngiven 37.5 captopril in eve. increased to 50mg for 0600.\n\n\nno diuresis since . u/o 50cc/hr. (-)1.7liter for . currently 100cc neg.\n\nLS crackles bases. sat 95-98% 2lnc. RR 20-28.\n\ntaking pills with water. does better without straw.\n\nA: C.O. unchanged. PAD's up since last diuresis.\n no change in MS\nP: follow MS for change. follow PAP's, u/o. PT. ? try to dangle with PT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-26 00:00:00.000",
"description": "Report",
"row_id": 1409943,
"text": "heart failure, af\nccu npn\no- id- afebrile.\nms- lethargic, arouses to voice, at times needs loud voice, stimulation to arouse. mae. oriented to self, knows year, not month or place. does not remember when reoriented. cooperative.\ncv- hr 87-98 af, no vea. bp 130-140s/. k- 4.3. creat 1.0. hct 46.7, plts 93. lfts improved, still elevated. pa line d/c'd.\nresp- on 2l n/c, sats 96-98. no sob. prod. cough thin clear, bld tinged sputum. good u/o, with i+o neg. 730cc at 6pm. l/s dim thruout.\norder in to eval for cpt.\ngi- taking sips juice, water and pills with encouragement, tol fairly well, occ coughs after taking on pos. had few bites pudding, refused rest. increase diet as tol when more awake, asp. precautions. no bm.\nactivity- repos side to back in bed. oob to chair (slide). oob for 4.5hrs, tol well. pt consult to eval strength, etc. in and pnd. s/b ot.\nskin- intact. has some generalized edema.\nsocial- fx in, updated on pt status, procedures and plan.\naccess- i iv infiltrated, second patent. attempted iv insertion x2, unsuccessful, iv rn called and try for 2nd line.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-27 00:00:00.000",
"description": "Report",
"row_id": 1409944,
"text": "nursing progress note 7p-7a\nS\" I WANT TO GO TO \"\n\nO: NEURO: PT. ORIENTED TO PERSON ONLY. MOVING ALL EXTREMITIES, HAS SOME DIFFICULTIES WITH SPATIAL RELATIONS, IE UNABLE TO DIRECT YANKAUR CATH TO MOUTH. TAKING SIPS OF WATER BY STRAW WELL. SPEECH SLOW AND SOFT.\n\nRESP: LUNGS DIMINISHED. O2 SATS ON 2L 96%-98%. COUGHING AND RAISING THICK WHITE SPUTUM.\n\nCV: CONTINUES IN A-FIB RATE 80-90'S. NO VEA NOTED. BP STABLE, TOL INCREASED DOSE OF CAPTOPRIL. DIGOXIN CHANGED TO PO DIG LEVEL PENDING THIS AM.\n\nGI: ABD SOFT DISTENDED, NO BM TAKING SIPS OF WATER ONLY. PT STATES JUICE IS TO SWEET.\n\nGU: URINE ADEQUATE. AMBER COLORED.\n\nSLEPT IN SHORT NAPS OVERNIGHT. MORE AWAKE THIS AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-24 00:00:00.000",
"description": "Report",
"row_id": 1409938,
"text": "addendum\nstarted on captopril, tol well. increase as tol, as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-25 00:00:00.000",
"description": "Report",
"row_id": 1409939,
"text": "CCU NPN 1900-0700\nADDENDUM\n\n0600: pt. alert, Oriented to place and person. able to speak louder. continues to refuse to take any meds po. MD spoke to pt. without effect. BP 160/90 when awake. given hydralazine 20mg IV at 0630 with good effect. BP coming down to 130/60 by 0700.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-25 00:00:00.000",
"description": "Report",
"row_id": 1409940,
"text": "CCU NPN 1900-0700\nS: \" Where am I \"\nO: pt. confused to place and time. able to state name only. only speaks in very low whisper voice. follows commands but very weak. trying to get hands towards face and neck. hands restrained for safety with invasive lines in place. pt. restless in early eve, putting legs over bed, getting mildly anxious when telling pt. of recent events. later in eve, pt. refusing to take captopril po (he took it at 2130). sleeps when left alone. arouses to name and/or light shaking. eyes open spont. gaze traks.\n\nTM 100.2R. contins. on levo IV for presumed pnx\nHR 95-116 AF. BP 130-150/70-90. captopril inc. to 12.5, given at 2130. BP remaining high 140-150/80. captopril inc. to 25mg and additional dose of 12.5mg orderd. however, pt. refused to take, not agitated but refusing to take water or meds. instead , given hydralazine 10mg IV, only minimal effect.\n\nPAP 60/33, wedge 26, CVP 16 prior to lasix and when pt. more restless. down to PAD 23-27, CVP 13-15. SVO2 71. C.O. 5.8/2.5/1100.\n\nheparin 1000u/hr. amio .5mg/min. milrinone .32mcq/kg/min.\n\nLS diminished throughout. FIO2 weaned to 4lnc. sats 97-99%. RR 20-24, unlabored.\n\nGU: 20 lasix IV at 2100. 1.2l u/o responce. currently 100cc/hr.\nGI: took small sips of water in early eve, no issues. (+) BS\n\nA: confusion after extubation\n good diuresis.\n BP high, req. titration up captopril\nP: follow MS for change/improvement. follow u/o, lytes. contin, gtts per plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-25 00:00:00.000",
"description": "Report",
"row_id": 1409941,
"text": "CCU NSG NOTE: ALT IN CV\nS: I'm in the \".\nO: For complete VS see ccu flow sheet.\nID: T-max 100.4R. Pt conts on abx.\nCV: PT continues to improve. HR on digoxin has come down to 80-90s Afib. He continues on IV amiodarone at .5mic. He was able to take pills and captopril was increased this afternoon from 25mg to 37.5mg and bp is now in low 100s. Milrinone was d/c at 10:30 and c/o-ci decreased to 5.1/2.2 with svr 1286. Heparin was also d/c and lovenox begun. PAP has been stable in 40s/23-26 wedge of 12 and RA of . Swan and a-line will remain in overnight and probably be removed tomorrow.\nRESP: RR 16-22 with 02 sat on 2L NP 96-97%. He does have some creacles at bases. he has a strong cough.\nGI: Pt was able to take pills and some jello with encouragement, but would not be safe to attempt anything more at this time due to decreased mental status. No bm.\nRENAL: Creat down to 1.1. He was autodiuresing earlier and u/o has now dropped off to 40-60cc/hr. He is ~1600cc neg for the day.\nMS: Pt sleeps when left alone and can be roused with vebal stimuli and wet wash cloth to face. He knows he is in hospital, knows his name, but speach is slurred. He will follow simple commands and is moving all extremities. He seems to be swallowing safely, but needs to be watched and kept awake to ensure he swallows.\nA: Stable of milrinone/autodiuresing/slowly waking up\nP: Monitor for changes. Check CO/CI at 8p and in am. Increase captopril as tolerated. pt frequently. Increase diet as tolerated\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-20 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 759463,
"text": " 1:27 PM\n CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: R/O PE , EVALUATION OF RESPIRATORY DISTRESS.\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with RESPIRATORY DISTRESS AND AFIB. INTUBATED.\n REASON FOR THIS EXAMINATION:\n R/O PE\n EVALUATION OF RESPIRATORY DISTRESS.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n 61 year old respiratory distress and atrial fibrillation.\n\n CT OF THE CHEST WITH CONTRAST\n\n CONTRAST:\n 150 cc of IV Optiray.\n\n TECHNIQUE:\n Multiple axial images of the entire chest was obtained with the use of\n intravenous contrast.\n\n CT CHEST WITH CONTRAST:\n There is no evidence of pulmonary embolus. The great vessels are normal. The\n heart is moderately enlarged. Bilateral pleural effusions with associated\n atelectasis is noted. Prevascular lymphadenopathy is identified. There are no\n focal consolidations. The osseous structures demonstrate degenerative changes.\n An endotracheal tube is identified in place.\n\n The unenhanced abdominal organs are unremarkable.\n Reconstructed images demonstrate no evidence of pulmonary embolus.\n\n IMPRESSION:\n 1. No pulmonary embolus.\n 2. Moderate bilateral pleural effusions with associated atelectasis.\n 3. Marked cardiomegaly.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 759934,
"text": " 9:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval CHF/ PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with RESPIRATORY DISTRESS S/P swan.\n\n REASON FOR THIS EXAMINATION:\n eval CHF/ PNA\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE CHEST, is compared to 4 days earlier.\n\n INDICATION: Respiratory distress.\n\n A SG catheter is present, with the distal tip terminating in the main\n pulmonary artery region. No pneumothorax is identified.\n\n The heart is enlarged. There has been improvement in the previously reported\n findings of congestive heart failure, with associated pleural effusions.\n\n No new or progressive abnormalities are identified.\n\n IMPRESSION:\n 1) SG catheter in satisfactory position.\n\n 2) Near complete resolution of heart failure findings. Probable residual\n small right pleural effusion.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-21 00:00:00.000",
"description": "Report",
"row_id": 1409929,
"text": "addendum\nccu npn\npt into afib about 6:30pm, rate 140s-160s. bp maintained at 90s-100s. sat 98. pt calm/sedated at time of rhythm conversion. ho made aware. started on amiodarone at 7pm with 150mg bolus to 1mg/min drip. cont. for 6hrs, then down to .5mg/min as ordered.\nhr staying in 140s after bolus, cont. in af. bp 80s-90s/. fx in, aware of rhythm change and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-22 00:00:00.000",
"description": "Report",
"row_id": 1409930,
"text": "CCU NPN 7P-7A\nAddendum:TL changed to cortis and pt swaned at 6AM, opening pressures: PAP 57/30, CVP 21, PCWP 30, CO 4.6, CI 1.99, SVR 1148 these #'s on 5ug/kg/min of dopamine, with BP 100/60. UO improved since Dopa started 40-80cc/hr. Cardioverted at 6:20 with 200J, briefly went into NSR, then back to a.fib. Given another amiodarone 150mg bolus over 10min and attempted cardioversion with 300J, same thing happened, NSR briefly than back into a.fib. Tried to decreased dopa to 3ug, BP falling to 80's/, increased back to 5ug/kg/min. During line change sats dropped to 90%, increased FIO@ to 60%, CXR done. Will need repeat ABG.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-22 00:00:00.000",
"description": "Report",
"row_id": 1409931,
"text": "CCU NPN 7P-7A\nCV: Pt has remained in A.fib, rate 140's on Amiodarone gtt at 1mg/min, given another bolus of 150mg at MN, HR down a bit to 120's a.fib, BP has been 80-90/70, MAP 65-75. UO cont to be minimal. Attempted 500cc NS bolus with transient improvement in BP, no increase in UO. CVP transduced via T.L., 24. Held further fluid boluses. Plan to place swan-ganz catheter to aid evaluation of volume status and C.O.\n\nResp: suctioned q 3-4 for scant white secretions, LS clear. When pt awake, is out of sinc with vent, RR in 30's. Changed to IMV with 12 PS, but has not made no differance in his comfort when awake. ABG sent at time of agitation was good, has maintained sats of 99-100%.\n\nNeuro: Difficult to sedate pt, Ativan has been increased to 6mg after several 2 mg boluses. Given 25ug of fent at a time, does drop pressure to 80/60. Haldol given, 2.5mg x2 followed by 5mg IV. Pt cont to intermittently wake up, will calm somewhat to verbal reassurances. Has at times followed commands and nodded appropriately. Awakens startled and delerious.\n\nID: T 100-97, given 1x dose of Levaquin, awaiting ID approval for q 24hr dosing. Has been diaphoretic, with breaking of T.\n\nGI: no stool, BS present. NPO.\n\nSoc: wife called about swan and possible cardioversion.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-22 00:00:00.000",
"description": "Report",
"row_id": 1409932,
"text": "chf, resp failure, af\nccu npn\no- t max 100.8 po. cont. on levoquin. wbc 11.5. c+s pnd, sputum oroph. flora.\ncv- hr max 122 in am, afib, down to 90s-100s, no vea. cont. on amiodarone decreased to .5mg/min at 4pm. systolic bp 90-100s, occ 80s in am. maps 66-80s. cont. on dopamine at 5mic. milrinone started 10:30am with bolus given over 1/2hr to .38mic/kg/min. co improved to 5.9, ci 2.55, svr down to 719. pa 57/35 down to low 43/20, wedge down to 20. cvp 22-11. cvp changed to rv pattern x2, pa line withdrawn x2 by mds, cvp now with ra trace, pa cont. to wedge. heparin on 1000units/hr, ptt 99.8, heparin down to 800units/hr at 2:30pm, recheck ptt this eve. inr 2.2, ho aware. k-4.7. hct 47.8, plts 115.\nresp- cont intubated a/c 10, rarely overbreaths, tv 700, 60% with 5 peep. abg adeq, later po2 down 68, peep up to 7.5 and abg- 79,39,7.41,0. sats 92-96. l/s sl. coarse thruout, rare scat. wheeze.\nu/o improved with milrinone to 130-230cc/hr. sx'd infreq for small white sputum.\nrenal- creat up to 2.5 (1.3).\ngi- abd soft with b. sounds. ogt with small dk green bile. started on nepro at 10cc/hr, increase as tol to 30cc/hr. hold at 12am for possible extubation . no bm.\nms/neuro- sedated well on ativan 6mg/hr and 50mic fentanyl in am, not waking to sx'ing or movement. ativan decreased to 5mg/hr. wakes slightly with repos or sx'ing. able to follow commands and nod/shake head appropriately when sl. awake. mae.\nskin- intact repos side to side to back q3hrs with skin/oral care. hands sl. edematous. 2 rings removed with wife's permission and given to fx.\nsocial- fx in, supportive to each other and pt. enc to talk/interact with pt. status, plan explained to fx, understand. reinforce, update prn.\na/p- diuresing with improved hemodynamics on milrinone. sats gradually improving, ?try to decrease to 50% this eve if sats cont. to rise. would start with low dose lasix if used (20mg). cont. on ativan/fentanyl. hold t/f at 12am. recheck ptt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-23 00:00:00.000",
"description": "Report",
"row_id": 1409933,
"text": "NEURO: SEDATED WITH ATIVAN 5MG/HR & FENTANYL 50MCG/HR. RESPONDS TO\n PAINFUL STIMULI. MAE. ATTEMPTS TO OPEN EYES.\nRESP: ON VENT: FIO2 WEANED FROM .60->.40 X 700 + AC 10 & 7.5 PEEP.\n BS COURSE AND DIMINISHED AT BASES. O2 SAT 94-98%. RR 10/10.\n SX FOR SM.-MOD. AMTS. THICK YELLOW SPUTUM. ABG 7.43/38/91/26\n 97% SAT.\nCARDIAC: HR 93-110 AF. BP 90-117/50-60'S. PAD 21-27, CVP 9-14, W 23,\n CO 6.1/2.64/866. ~0100 HR 120'S AF WITH INCREASED VEA. HO\n CALLED->WEAN DOPA AS TOL. LEVOPHED STARTED & DOPA WEANED TO\n OFF. CA,MG,PO4 SENT. MG 1.6->TREATED WITH MGS04 2GMS PB X1.\n HR BACK TO 90-100'S. ECTOPY RESOLVED. LEVOPHED 4.5MCG/MIN->\n CO 4.5/1.95/1227. CONT. ON AMIODARONE .5MG/HR, MILRINONE\n .38MCG/KG, & HEPARIN GTT AT 800U/HR. PTT 61.3. HO AWARE OF\n HEMODYNAMICS.\nGI: TF: FS NEPRO 10CC/HR. MINIMAL RESIDUALS. D/C'D AT MIDNOC & NPO->\n ? EXTUBATION. ABD. SL. DISTENDED. BS+. NO STOOL.\nGU: FOLEY->CD PATENT & DRAINING CLEAR AMBER URINE. U/O 50-170CC/HR\n DOWN TO 20-30CC/HR THIS AM. HO AWARE.\nID: AFEBRILE. CONT. ON IV LEVOFLOX.\nENDO: BS 130->111. NO INSULIN REQUIRED.\nLABS: WBC 11.4, HCT 40.9, PLAT CT 106K, CHEMISTRIES PENDING.\nNEED TO ADDRESS DECREASED CI & LOW U/O.\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 759448,
"text": " 10:49 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with SOB, bilateral pedal edema\n REASON FOR THIS EXAMINATION:\n r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n Shortness of breath, pedal edema.\n\n CHEST PA AND LATERAL:\n The cardiomediastinal silhouette is stable. Acute fracture of the posterior\n 4th rib is identified. There are no focal consolidations. There is mild\n prominence of the interstitial markings. There is a small left-sided pleural\n effusion.\n\n IMPRESSION:\n 1. Minimal CHF.\n 2. Acute 4th posterior rib fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 759520,
"text": " 8:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with RESPIRATORY DISTRESS S/P TRIPLE LUMEN CL PLACEMENT\n REASON FOR THIS EXAMINATION:\n evaluate chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: SOB, S/P triple lumen placement.\n\n CHEST, SINGLE PORTABLE VIEW:\n\n The right portion of the chest is not included on this supine film. An ET\n tube is present, the tip 5.6 cm above the carina. An NG tube is present, tip\n partially obscured, but thought to overlie the stomach. A right IJ line is\n present, tip overlying proximal SVC.\n\n The cardiomediastinal silhouette is prominent. There is hazy opacity in both\n lungs, suggesting layering effusions. I suspect the presence of underlying\n vascular plethora/CHF. There is also left lower lobe collapse and/or\n consolidation and atelectasis in the visualized portion of the right base. No\n supine film evidence of pneumothorax is identified.\n\n Healed left 4th rib fracture noted.\n\n IMPRESSION: Mild chf with effusions and bibasilar collpase/consolidation. No\n pneumothorax detected.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 759462,
"text": " 1:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O PNEUMO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with RESPIRATORY DISTRESS S/P TRIPLE LUMEN CL PLACEMENT\n REASON FOR THIS EXAMINATION:\n R/O PNEUMO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old with respiratory distress S/P triple lumen central\n line placement.\n\n AP VIEW OF THE CHEST:\n\n Comparison made to examination from the same day at 12:57pm.\n\n Endotracheal tube identified at the level of the superior clavicles. A right-\n sided central line is identified with tip at the proximal superior vena cava.\n There is no pneumothorax. Heart and lungs are unchanged.\n\n IMPRESSION: Right central line catheter with tip in the proximal superior\n vena cava.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 759459,
"text": " 12:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CHECK OGT AND ETT PLACEMENT. , EVALUATION OF RESPIRATORY DI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with RESPIRATORY DISTRESS\n REASON FOR THIS EXAMINATION:\n CHECK OGT AND ETT PLACEMENT.\n EVALUATION OF RESPIRATORY DISTRESS.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress, evaluate endotracheal tube placement.\n\n PORTABLE AP VIEW OF THE CHEST:\n\n Comparison made to same-day examination performed at 10:59AM.\n\n Endotracheal tube is identified with the tip at the level of the superior\n portion of the clavicles. There is no pneumothorax. There is bilateral hilar\n vascular congestion consistent with congestive heart failure. The cardiac\n silhouette and osseous structures are unchanged.\n\n IMPRESSION: Endotracheal tube in satisfactory position.\n 2) mild CHF\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 759571,
"text": " 5:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval swan placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with RESPIRATORY DISTRESS S/P swan.\n REASON FOR THIS EXAMINATION:\n eval swan placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress status post Swan.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Compared with one day earlier, a right IJ Swan-Ganz catheter is now in place.\n The tip lies relatively distal in the right pulmonary artery and retraction of\n the tip should be considered. There is marked prominence of the\n cardiomediastinal silhouette, unchanged compared with one day earlier. There\n is upper zone redistribution and diffuse vascular blurring, consistent with\n CHF. There are bilateral pleural effusions, greater on the right, with\n underlying collapse and/or consolidation. The extreme left costophrenic angle\n is not included on this film.\n\n IMPRESSION:\n\n 1. Interval placement of right IJ Swan-Ganz catheter with tip relatively\n distal in right pulmonary artery. Retraction of the tip should be considered.\n\n 2. Prominence of the cardiomediastinal silhouette. This is similar to the\n appearance on the portable film, but more pronounced than on the PA view.\n This appearance is likely accentuated by AP supine technique. However,\n clinical correlation is requested. (Scattered nodes are present in the\n mediastinum on the CTA from and there was mediastinal lipomatosis but no\n hemorrhage within the mediastinum was identified at that time.)\n\n 3. CHF and bilateral effusions.\n\n\n"
}
] |
109 | 139,061 | ICU course: EKG showed no change from prior, and CXR showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home medication regimen. The patient was found to by hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. . history: . 1. Hypertensive urgency: During the patient's stay, her SBPs ranged from 140s-160s during the day, which is her baseline systolic blood pressure. She was maintained on her home oral medication regimen. At night, she became more hypertensive, with SBP to the 170s-180s, which was controlled with both IV hydralazine and PO nifedipine. PO nifedipine was most successful at bringing her SBP back to her baseline. SBP at discharge was 140. Throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. The renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. Right leg pain: Upon arrival on the floor, the patient complained of pain in R buttock and posterior thigh, much exacerbated with standing. Of note, lumbar spine MRI and R hip XR on most recent admission were both negative. Her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. Her pain when she was symptomatic was controlled well with PO dilaudid. If the pain recurs, an MRI of the right hip can be considered to evaluate for osteonecrosis. . 3. UTI: The patient had a urinalysis suggestive of UTI, though she remained asymptomatic throughout. She was treated with a three day course of ciprofloxacin. Her urine culture showed mixed flora consistent with skin contamination. . 4. ESRD: The patient has end-stage renal disease due to her lupus. The patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. She was followed by the renal consult service. Her potassium remained stable. Her calcium was low during admission, and supplemental calcium was given in addition to starting Calcitriol. She was not dialyzed through her PD catheter secondary to discomfort, but may reinitiate PD as an outpatient. Her laboratories will be checked as an outpatient in renal clinic. . 5. Anemia: The patient's hematocrit remained near her baseline low 20s throughout her stay. She has anemia from chronic kidney disease and chronic disease. The patient is not on Epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. Prior SVC thrombus: The patient has a reported history of prior thrombus related to catheter placement in , and was maintained on warfarin with INR goal 2.5 to 3.0. . 7. Systemic lupus erythematosus: No active issues. The patient's home prednisone regimen was continued. | Action: Bp lower beginning of shift (120/70) Hydralazine, Labetalol Aliskiren held. - Thrombocytopenia. malignant hypertension, baseline sBPs 180s-120s. - Thrombotic events. 3) Right lower extremity pain: 4) Hyperkalemia: Kayexalate as refusing dialysis. ALLERGIES: Penicillins / Percocet . hct 24.7, pt with baseline anemia. hct 24.7, pt with baseline anemia. hct 24.7, pt with baseline anemia. Zofran prn nausea. Zofran prn nausea. Reason for MICU Admission: Malignant Hypertension. Response: Sbp lowering to as low as 160s via noninvasive cuff and 180s aline. Response: Sbp lowering to as low as 160s via noninvasive cuff and 180s aline. There is a trivial/physiologic pericardial effusion. - Anemia. .H/O hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: Labetolol gtt off on days. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on labetalol gtt. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on labetalol gtt. Previous treatment with cytoxan, cellcept; currently on prednisone. Repeat k 5.0 from 5.9( 5.9 was moderately hemolyzed). When getting VS in , pt noted to be very hypertensive at 263/176. When getting VS in , pt noted to be very hypertensive at 263/176. - Malignant hypertension. - CKD/ESRD. Pt admitted to 4 for malignant hypertension, was on Labetolol gtt. bun 51, cr 8.4, k 5.9, moderately hemolyzed. bun 51, cr 8.4, k 5.9, moderately hemolyzed. bun 51, cr 8.4, k 5.9, moderately hemolyzed. Sent up from the ED on labetolol drip. .H/O hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: Action: Response: Plan: .H/O hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: Action: Response: Plan: Labetalol drip weaned to as low as 1mg/hr but sbp still 170s-180s noninvasive cuff and 190s-200s aline. Labetalol drip weaned to as low as 1mg/hr but sbp still 170s-180s noninvasive cuff and 190s-200s aline. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on home regimen. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on home regimen. Prn Zofran for nausea. # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen . # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen . .H/O hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: Sbp in 230s on arrival to icu via aline. .H/O hypertension, malignant (hypertensive crisis, hypertensive emergency) Assessment: Sbp in 230s on arrival to icu via aline. Tonsillectomy. Renal c/s initiated. - Thrombotic events. - Thrombocytopenia. malignant hypertension, baseline sBPs 180s-120s. malignant hypertension, baseline sBPs 180s-120s. There is a trivial/physiologic pericardial effusion. - Anemia. ALLERGIES: Penicillins / Percocet . Reason for MICU Admission: Malignant Hypertension. - CKD/ESRD. Left atrial enlargement. 8:54 AM UNILAT LOWER EXT VEINS RIGHT Clip # Reason: dvt? - Malignant hypertension. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on labetalol gtt. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on labetalol gtt. # Prior SVC thrombus: Related to catheter in . # Prior SVC thrombus: Related to catheter in . Previous treatment with cytoxan, cellcept; currently on prednisone. When getting VS in , pt noted to be very hypertensive at 263/176. Renal c/s initiated. TTP (got plasmapheresisis) versus malignant HTN. Tonsillectomy. Diagosed . Asymptomatic currently. Initiated dialysis . CV: mildly tachy, RR, +S4. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on home regimen. F with ESRD (not on HD or PD) and lupus, admitted for malignant hypertension, currently on home regimen. RIGHT LOWER EXTREMITY ULTRASOUND -scale and Doppler son of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. CKD/ESRD, diagnosed in , initiated hemodialysis . CKD/ESRD, diagnosed in , initiated hemodialysis . TTP (got plasmapheresis) versus malignant HTN thrombotic events. TTP (got plasmapheresis) versus malignant HTN thrombotic events. GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted. GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted. Mild (1+) aortic regurgitation is seen. # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen . # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen . previous treatment with cytoxan, cellcept, currently on prednisone. previous treatment with cytoxan, cellcept, currently on prednisone. Negative lupus anticoagulant (, , 9/). Negative lupus anticoagulant (, , 9/). Negative lupus anticoagulant (, , 9/). Evaluate for DVT. # ACCESS: Peripheral IV, A-line . # ACCESS: Peripheral IV, A-line . PD site - c/d/i. PD site - c/d/i. Past transfusion requirement. Past transfusion requirement. FINAL REPORT HISTORY: Shortness of breath. Not on epo given hypertension. Not on epo given hypertension. SVC thrombosis (); related to a catheter. Denies any swelling of her RLE. Uses commode to void. Uses commode to void. Currently, she has RLE pain. Some increased haziness of RLL/R diaphragm from CXR. The patient reportedly has bseline SBPs in 130-170s. | 21 | [
{
"category": "General",
"chartdate": "2141-09-11 00:00:00.000",
"description": "Initial H&P",
"row_id": 339012,
"text": " ADMISSION NOTE\n .\n Reason for MICU Admission: Malignant Hypertension.\n .\n Primary Care Physician: MD / MD\n .\n CC: Right leg pain.\n .\n HPI: Ms. is a 24 y.o. F with lupus, Chronic Kidney Disease V (not\n currently on HD or PD), and multiple admissions for hypertensive\n urgency/emergency, who presented to the ED for continued R leg pain\n that starts in her R buttocks and refers down her R leg. She describes\n it as feeling like the pain is deep within her bone. The pain was\n this AM, and she felt like she couldn't get out of bed. Denies\n any swelling of her RLE. When getting VS in , pt noted to be very\n hypertensive at 263/176. The patient reportedly has bseline SBPs in\n 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM\n on day of admission. She denies headache, vision changes, double\n vision, chest pain, shortness of breath, abdominal pain, BRBPR,\n dysuria. During MD interview, the patient was nauseous and had small\n amount of emesis of a recent Coolata. Pt states that flushing her PD\n cath causes a large amout of stomach pain. Currently, she has RLE\n pain.\n .\n In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in\n ED ranged from -175 with HR in 96-108. Initially given\n labetalol 10 mg IV x 1 and then started on labetalol gtt for her\n elevated blood pressures and titrated to 3 mg/min. LENI of R leg was\n negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per\n ED, cannot do V/Q scan due to volume overload after talking with\n radiology. Renal c/s initiated. A-line placed.\n .\n Of note, the patient was recently admitted from 08.26-29.08. The\n patient initially presented to the ED after referral from her\n nephrologist's office where she had complaints of right leg pain and\n was found to be hypertensive to 250/145. She was admitted after\n initiation of a labetalol drip and nitropaste with improvement in sbp\n to 180. The patient did receive 2 U of PRBC's during this\n hospitalization for baseline anemia. The patient did have a work-up for\n her right leg pain complaints with plain films of the right hip and MRI\n of the L-spine which did not reveal an explanation for her symptoms and\n did rule out avascular necrosis. The patient received dilaudid for pain\n control and was ambulating without pain prior to discharge. In\n addition, the patient completed a course of ciprofloxacin for a\n positive UA with negative cultures. The patient was unable to tolerate\n peritoneal dialysis for unclear reasons. Peritoneal dialysate culture\n was negative for infection.\n .\n ROS: as stated above in HPI.\n .\n MEDICATIONS (from discharge summary ):\n - Prednisone 5 mg Daily\n - Coumadin 2 mg at bedtime\n - Nifedipine 60 mg Sustained Release Daily\n - Hydralazine 50 mg every 8 hours\n - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday\n - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY\n - Aliskiren 150 mg Twice daily\n - Docusate Sodium 100 mg 2 times a day\n - Labetalol 900 mg three times a day\n - Lactulose 15-30 ml once a day: goal is soft bowel movements per\n day\n .\n ALLERGIES: Penicillins / Percocet\n .\n PAST MEDICAL HISTORY:\n - Systemic lupus erythematosus. Diagnosed (16 years old) when she\n had swollen fingers, arm rash and arthralgias. Previous treatment with\n cytoxan, cellcept; currently on prednisone. Complicated by uveitis\n () and ESRD ().\n - CKD/ESRD. Diagosed . Initiated dialysis . PD catheter\n placement . Pt reluctant to start PD.\n - Malignant hypertension. Baseline BPs 180's - 120's. History of\n hypertensive crisis with seizures. History of two intraparenchymal\n hemorrhages that were thought to be due to the posterior reversible\n leukoencephalopathy syndrome.\n - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN.\n - Thrombotic events. SVC thrombosis (); related to a catheter.\n Negative lupus anticoagulant (, , 9/). Negative\n anticardiolipin antibodies IgG and IgM x4 (-). Negative Beta-2\n glycoprotein antibody (, 8/).\n - HOCM: Last noted on echo .\n - Anemia.\n - History of left eye enucleation for fungal infection.\n - History of vaginal bleeding lasting 2 months s/p DepoProvera\n injection requiring transfusion.\n - History of Coag negative Staph bacteremia and HD line\n infection - and \n .\n PAST SURGICAL HISTORY:\n 1. Placement of multiple catheters including dialysis.\n 2. Tonsillectomy.\n 3. Left eye enucleation in .\n 4. PD catheter placement in .\n .\n SOCIAL HISTORY: Single. Lives with her mother and brother. On\n disability. Denies EtOH, tobacco or drug use.\n .\n FAMILY HISTORY: No history of autoimmune or thrombophilic disorders.\n .\n PHYSICAL EXAM:\n VS: T 98.9 99$% RA\n GEN: NAD, pleaseant female sitting in bed with moon facies\n HEENT: EOMI of R eye, L eye prosthesis, OP - no exudate, no erythema,\n MMM, no LAD\n CHEST: CTAB except at R base with decreased breath sounds; no w/r/r\n CV: tachy, no m/r/g appreciated, + S4\n ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i\n EXT: no c/c/e, + SLR of RLE, able to wiggle toes and raise BLE off bed\n NEURO: II - XII grossly intact\n DERM: no rashes noted\n .\n LABORATORIES:\n Na 138, K 5.9 (hemolyzed), Cl 108, Bicarb 21, BUN/Cr 51/8.4, glucose\n 85, WBC 5.5 (74 N, 17.5 L), Hct 24.7, platelets 101.\n .\n UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50\n WBC\n .\n MICROBIOLOGY:\n Blood culture (): Pending.\n Urine culture (): No growth.\n Peritoneal fluid (): Gram stain no PMN's or microorganisms.\n Culture pending.\n .\n STUDIES:\n EKG : sinus tachy @ 100 bpm, nl axis, borderline PR prolongation,\n long QT interval, no acute ST-TWI. No change from prio on .\n PORTABLE CXR (my read): Cardiomegaly. Some increased haziness of\n RLL/R diaphragm from CXR.\n R LENI (wet read): No DVT.\n .\n TTE (): The left atrium is normal in size. There is severe\n symmetric left ventricular hypertrophy. The left ventricular cavity is\n unusually small. Regional left ventricular wall motion is normal. Left\n ventricular systolic function is hyperdynamic (EF>75%). There is a mild\n resting left ventricular outflow tract obstruction. The gradient\n increased with the Valsalva manuever. The findings are consistent with\n hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular\n septal defect. Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) appear structurally normal with\n good leaflet excursion. No masses or vegetations are seen on the aortic\n valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears\n structurally normal with trivial mitral regurgitation. There is no\n mitral valve prolapse. No mass or vegetation is seen on the mitral\n valve. The estimated pulmonary artery systolic pressure is normal.\n There is a trivial/physiologic pericardial effusion.\n .\n R HIP XR : No acute fracture or dislocation.\n .\n MRI L-SPINE : Diffuse low-signal intensity is identified in the\n bone marrow of the lumbar and lower thoracic spine as described above,\n possibly related with anemic changes, please correlate clinically.\n There is no evidence of spinal canal stenosis or neural foraminal\n narrowing at the different intervertebral disc spaces.\n .\n ASSESSMENT & PLAN: 24 y.o. F with ESRD (not on HD or PD) and lupus,\n admitted for malignant hypertension, currently on labetalol gtt.\n .\n # Malignant hypertension: SBPs currently in 200s with baseline SBP\n 130-180s. No symptoms/signs of hypertensive emergency as pt without\n seizures, no acute worsening of renal function (anuric at baseline)\n Denies HA, blurry vision, chest pain. + nausea/vomiting\n - Continue labetalol drip with down-titration as possible for goal SBP\n in 170-180s\n - NTG transdermal now\n - Transition to home dose oral labetalol when able\n - Re-start home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren when able\n - Monitor BPs closely\n - Neuro checks q 4 hours\n .\n # Right leg pain: Lumbar spine MRI and R hip XR on most recent\n admission were both negative. Likely sciatica.\n - IV Morphine as needed for pain\n - Transition to po pain medications when able\n .\n # UTI: UCx pending. Asymptomatic currently.\n - ciprofloxacin x 3 days\n - f/u Urine culture\n - check EKGs daily while on FQ and borderline prolonged QT\n .\n # ESRD: Pt not on PD although with PD catheter. On last admission, she\n had difficulty tolerating PD secondary to pain.\n - Peritoneal dialysis as tolerated\n - Appreciate renal recommendations\n .\n # Hyperkalemia: K elevated to 5.9 on admission, but moderately\n hemolyzed\n - check electrolytes now\n - EKG on arrival to ICU\n .\n # Anemia: Likely related to chronic disease. Baseline Hct 20, currently\n 24. Not on epo given hypertension. Past transfusion requirement.\n - Trend Hct daily\n - Transfer if Hct < 20\n - active T&S\n .\n # Prior SVC thrombus: Related to catheter in . INR goal 2.5 to\n 3.0. Was elevated to 3.4 on d/c on \n - check coags now to decide whether to continue or hold coumadin.\n .\n # Systemic lupus erythematosus:\n - Continue prednisone daily\n .\n # HOCM: Seen on TTE in .\n - BP management as above.\n - Avoid excessive volume removal.\n .\n # Thrombocytopenia: Baseline platelets approximately 100.\n - trend platelets daily\n .\n # FEN: no IVFs / replete lytes prn / ADAT\n .\n # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen\n .\n # ACCESS: Peripheral IV, A-line\n .\n # CONTACT: (mother) \n .\n # CODE: Full Code\n .\n # DISPO: ICU pending blood pressure control\n .\n .\n .\n .\n , MD, MPH\n \n PGY-2\n"
},
{
"category": "Nursing",
"chartdate": "2141-09-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339074,
"text": "24 y.o. woman adm with hypertensive crisis with bp 260s/150s, hx\n htn, esrd, had pd catheter placed 2 months ago but uable to tolerate pd\n treatments d/t severe abd pain with exchange. pt was admitted last week\n with leg pain, was discharged on dilaudid but the leg pain grew worse.\n pt given morphine for the pain in the er. the hypertension was treated\n with 10mg iv labetolol without effect. pt was started on a labetolol\n drip at 1mg/min and titrated up to 3mg/mg with bp 230s/150s. pt also\n s/o shortness of breath. LENIs negative for dvt. cxr normal. urine sent\n in er. hct 24.7, pt with baseline anemia. bun 51, cr 8.4, k 5.9,\n moderately hemolyzed. pt transferred to 4 icu for treatement of\n her hypertensive crisis.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n Sbp in 230s on arrival to icu via aline. Sbp 10 points lower via\n noninvasive cuff. Labetalol drip was infusing at 3mg/hr and titrated up\n to as high as 5mg/hr with 1 inch nitropaste placed on chest wall. Pt\n c/o +n/v 10cc strawberry colored emesis (pt had strawberry drink in\n er). Also c/o right leg pain she\ns been having.\n Action:\n Labetalol drip maintained at 5mg/hr until pt able to take po meds.\n Given iv zofran for n/v with good effect. Given 2mg iv morphine with\n good effect with pain to her baseline 5. pt given po hydralazine\n and po labetalol with lunch.\n Response:\n Sbp lowering to as low as 160s via noninvasive cuff and 180s aline.\n (goal sbp 130-170, dbp <100). Labetalol drip weaned to as low as 1mg/hr\n but sbp still 170s-180s noninvasive cuff and 190s-200s aline. New 1\n inch nitropaste applied to chest wall with old paste wiped off at\n 16:55. developed a headache shortly after new nitropaste applied. Given\n 650mg Tylenol.\n Plan:\n Continue to attempt to wean labetalol drip, continue antihypertensives\n as ordered. Morphine prn right leg pain. Tylenol prn headache. Zofran\n prn nausea.\n"
},
{
"category": "Nursing",
"chartdate": "2141-09-12 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 339272,
"text": "24 y.o. F with ESRD (not on HD or PD) and lupus, admitted for malignant\n hypertension, currently on home regimen.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n SBP 160-170\ns/100\ns- 110\ns with baseline SBP 130-180s, No\n symptoms/signs of hypertensive emergency as pt without seizures, no\n acute worsening of renal function (anuric at baseline) Denies HA,\n blurry vision, chest pain. Denies nausea/vomiting. No peripheral\n edema. Peripheral pulses present.\n Action:\n Re-started home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren. - Monitor BPs closely. Neuro checks q 4 hours\n Response:\n SBP at 150-160\ns/100\ns ( 2 pm hydralazine held due to SBP of 120\n Plan:\n Continue to monitor patient hemodynamic status, hypertensive meds\n ASDIR.\n Neuro: alert oriented X3, follows commands, steady gait. Incompliant\n w/some of the care. RT leg pain - Lumbar spine MRI and R hip XR on most\n recent admission were both negative. Likely sciatica\n morphine IV\n given w/some effect\n Resp: on RA sats at high 90\ns-100%. Bil LS clear, RRR, unlabored\n breathing.\n GI: abd soft non tender, non distended, positive for BS. Regular diet\n (patient been refusing renal diet). Denies N/V. PD site - c/d/i.\n dressing changed today.\n GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted.\n Uses commode to void. Clean yellow urine. Dx of UTI on cipro. Urine\n cultures were sent. F/u results.\n Skin: no skin impairment\n Social: patient is a FULL CODE. Family in to visit.\n K- 5.4 kayexalate 30gr given at 11 am awaiting results.\n HX of SVC thrombus related to catheter in . INR goal 2.5 to 3.0.\n Patient on coumadin 5mg daily.\n SLE\n on daily prednisone.\n"
},
{
"category": "Physician ",
"chartdate": "2141-09-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 339234,
"text": "Chief Complaint: lower extremity pain\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n year old female presented with right lower extremity pain and found to\n be very hypertensive.\n Sent up from the ED on labetolol drip.\n 24 Hour Events:\n ARTERIAL LINE - START 11:15 AM\n EKG - At 12:47 PM\n History obtained from Patient\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Med list reviewed\n Changes to medical and family history:\n Lupus\n ESRD\n Malignant Hypertension\n Thrombocytopenia\n HOCM\n Anemia\n Left eye enucleation\n Coag negative staph\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis\n Flowsheet Data as of 10:04 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: 35.6\nC (96\n HR: 83 (71 - 99) bpm\n BP: 148/103(113) {115/58(74) - 208/153(166)} mmHg\n RR: 15 (13 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,725 mL\n 180 mL\n PO:\n 440 mL\n 180 mL\n TF:\n IVF:\n 1,285 mL\n Blood products:\n Total out:\n 255 mL\n 150 mL\n Urine:\n 250 mL\n 150 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 1,470 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///16/\n Physical Examination\n General Appearance: Well nourished\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric)\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, No(t) Oriented (to): , Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 8.3 g/dL\n 93 K/uL\n 99 mg/dL\n 8.5 mg/dL\n 16 mEq/L\n 5.4 mEq/L\n 52 mg/dL\n 107 mEq/L\n 136 mEq/L\n 24.7 %\n 3.9 K/uL\n [image002.jpg]\n 11:43 AM\n 06:10 AM\n WBC\n 3.9\n Hct\n 24.7\n Plt\n 93\n Cr\n 8.1\n 8.5\n Glucose\n 86\n 99\n Other labs: PT / PTT / INR:18.9/39.2/1.7, Ca++:6.6 mg/dL, Mg++:1.6\n mg/dL, PO4:5.6 mg/dL\n Assessment and Plan\n A:\n 1) Hypertensive Urgency: still with some relatively high BPs (160/100)\n but asymptomatic and off labetolol drip.\n Plan:\n - Continue clonidine, labetolol,\n 2) ESRD: still refusing dialysis. I discussed this with her including\n risk of refusal which include death.\n 3) Right lower extremity pain:\n 4) Hyperkalemia: Kayexalate as refusing dialysis.\n 5) SLE\n 6) Thromobocytopenia: Stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:15 AM\n 20 Gauge - 11:25 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: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2141-09-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339131,
"text": "Ms. is a 24 y.o. F with lupus, Chronic Kidney Disease V (not\n currently on HD or PD), and multiple admissions for hypertensive\n urgency/emergency, who presented to the ED for continued R leg pain\n that starts in her R buttocks and refers down her R leg. She describes\n it as feeling like the pain is deep within her bone. The pain was\n this AM, and she felt like she couldn't get out of bed. Denies\n any swelling of her RLE. When getting VS in , pt noted to be very\n hypertensive at 263/176. The patient reportedly has baseline SBPs in\n 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM\n on day of admission. She denies headache, vision changes, double\n vision, chest pain, shortness of breath, abdominal pain, BRBPR,\n dysuria. During MD interview, the patient was nauseous and had small\n amount of emesis of a recent Coolata. Pt states that flushing her PD\n cath causes a large amout of stomach pain. Currently, she has RLE\n pain. Pt admitted to\n 4 for malignant hypertension, was on Labetolol gtt.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n Labetolol gtt off on days. Bp on the lower side at change of shift\n 120-130/74. (nitropaste removed) currently bp 160/98 HR 70\ns SR\n BP higher via A-line (A-line with good dynamic response, good\n tracing) on left arm 20 point difference in BP . In Right\n arm 10 point difference). We are using the A-line to monitor bp\n INR 1.7 ~ pt received 5 mg po Coumadin. No further pain from right\n leg.\n Pt denies HA, blurry vision, chest pain. No further nausea/vomiting.\n Action:\n Bp lower beginning of shift (120/70) Hydralazine, Labetalol\n Aliskiren held.\n Response:\n Bp slowly rising over shift.\n Plan:\n Give antihypertensives if SBP over 160. Coumadine 5 mg po qd prn\n Morphine for leg pain, prn Tylenol for headache. Prn Zofran for\n nausea. Monitor lytes.\n GU: pt voiding in commode. Urine output 200 cc\ns. bun 49, crt\n 8.1 pt with UTI\n on Cipro.\n GI: pt on a regular diet poor appetite. On pantoprazole\n PAIN: no further right leg pain, lumbar spine MRI and R hip xray on\n most recent admission were both negative. Likely sciatica\n prn\n morphine as needed.\n .\n"
},
{
"category": "Physician ",
"chartdate": "2141-09-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339197,
"text": "Chief Complaint:\n 24 Hour Events:\n Pressures finally dropped to 130/80s and labetelol drip was stopped\n ARTERIAL LINE - START 11:15 AM\n EKG - At 12:47 PM\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 01:21 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 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: 36.9\nC (98.4\n HR: 79 (71 - 99) bpm\n BP: 142/105(113) {115/58(74) - 208/153(166)} mmHg\n RR: 13 (13 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,725 mL\n 180 mL\n PO:\n 440 mL\n 180 mL\n TF:\n IVF:\n 1,285 mL\n Blood products:\n Total out:\n 255 mL\n 150 mL\n Urine:\n 250 mL\n 150 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 1,470 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///16/\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 8.3 g/dL\n 86 mg/dL\n 8.1 mg/dL\n 16 mEq/L\n 5.0 mEq/L\n 49 mg/dL\n 110 mEq/L\n 139 mEq/L\n 24.7 %\n 3.9 K/uL\n [image002.jpg]\n 11:43 AM\n 06:10 AM\n WBC\n 3.9\n Hct\n 24.7\n Cr\n 8.1\n Glucose\n 86\n Other labs: PT / PTT / INR:18.4/42.8/1.7, Ca++:6.2 mg/dL, Mg++:1.6\n mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:15 AM\n 20 Gauge - 11:25 AM\n 18 Gauge - 11:26 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": "2141-09-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339202,
"text": "Chief Complaint:\n 24 Hour Events:\n Pressures finally dropped to 130/80s and labetelol drip was stopped\n ARTERIAL LINE - START 11:15 AM\n EKG - At 12:47 PM\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 01:21 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 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: 36.9\nC (98.4\n HR: 79 (71 - 99) bpm\n BP: 142/105(113) {115/58(74) - 208/153(166)} mmHg\n RR: 13 (13 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,725 mL\n 180 mL\n PO:\n 440 mL\n 180 mL\n TF:\n IVF:\n 1,285 mL\n Blood products:\n Total out:\n 255 mL\n 150 mL\n Urine:\n 250 mL\n 150 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 1,470 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///16/\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 8.3 g/dL\n 86 mg/dL\n 8.1 mg/dL\n 16 mEq/L\n 5.0 mEq/L\n 49 mg/dL\n 110 mEq/L\n 139 mEq/L\n 24.7 %\n 3.9 K/uL\n [image002.jpg]\n 11:43 AM\n 06:10 AM\n WBC\n 3.9\n Hct\n 24.7\n Cr\n 8.1\n Glucose\n 86\n Other labs: PT / PTT / INR:18.4/42.8/1.7, Ca++:6.2 mg/dL, Mg++:1.6\n mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n ASSESSMENT & PLAN: 24 y.o. F with ESRD (not on HD or PD) and lupus,\n admitted for malignant hypertension, currently on labetalol gtt.\n .\n # Malignant hypertension: SBPs currently in 200s with baseline SBP\n 130-180s. No symptoms/signs of hypertensive emergency as pt without\n seizures, no acute worsening of renal function (anuric at baseline)\n Denies HA, blurry vision, chest pain. + nausea/vomiting\n - Continue labetalol drip with down-titration as possible for goal SBP\n in 170-180s\n - NTG transdermal now\n - Transition to home dose oral labetalol when able\n - Re-start home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren when able\n - Monitor BPs closely\n - Neuro checks q 4 hours\n .\n # Right leg pain: Lumbar spine MRI and R hip XR on most recent\n admission were both negative. Likely sciatica.\n - IV Morphine as needed for pain\n - Transition to po pain medications when able\n .\n # UTI: UCx pending. Asymptomatic currently.\n - ciprofloxacin x 3 days\n - f/u Urine culture\n - check EKGs daily while on FQ and borderline prolonged QT\n .\n # ESRD: Pt not on PD although with PD catheter. On last admission, she\n had difficulty tolerating PD secondary to pain.\n - Peritoneal dialysis as tolerated\n - Appreciate renal recommendations\n .\n # Hyperkalemia: K elevated to 5.9 on admission, but moderately\n hemolyzed\n - check electrolytes now\n - EKG on arrival to ICU\n .\n # Anemia: Likely related to chronic disease. Baseline Hct 20, currently\n 24. Not on epo given hypertension. Past transfusion requirement.\n - Trend Hct daily\n - Transfer if Hct < 20\n - active T&S\n .\n # Prior SVC thrombus: Related to catheter in . INR goal 2.5 to\n 3.0. Was elevated to 3.4 on d/c on \n - check coags now to decide whether to continue or hold coumadin.\n .\n # Systemic lupus erythematosus:\n - Continue prednisone daily\n .\n # HOCM: Seen on TTE in .\n - BP management as above.\n - Avoid excessive volume removal.\n .\n # Thrombocytopenia: Baseline platelets approximately 100.\n - trend platelets daily\n .\n # FEN: no IVFs / replete lytes prn / ADAT\n .\n # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen\n .\n # ACCESS: Peripheral IV, A-line\n .\n # CONTACT: (mother) \n .\n # CODE: Full Code\n .\n # DISPO: ICU pending blood pressure control\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:15 AM\n 20 Gauge - 11:25 AM\n 18 Gauge - 11:26 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": "2141-09-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339030,
"text": "24 y.o. woman adm with hypertensive crisis with bp 260s/150s, hx\n htn, esrd, had pd catheter placed 2 months ago but uable to tolerate pd\n treatments d/t severe abd pain with exchange. pt was admitted last week\n with leg pain, was discharged on dilaudid but the leg pain grew worse.\n pt given morphine for the pain in the er. the hypertension was treated\n with 10mg iv labetolol without effect. pt was started on a labetolol\n drip at 1mg/min and titrated up to 3mg/mg with bp 230s/150s. pt also\n s/o shortness of breath. LENIs negative for dvt. cxr normal. urine sent\n in er. hct 24.7, pt with baseline anemia. bun 51, cr 8.4, k 5.9,\n moderately hemolyzed. pt transferred to 4 icu for treatement of\n her hypertensive crisis.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2141-09-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339099,
"text": "24 y.o. woman adm with hypertensive crisis with bp 260s/150s, hx\n htn, esrd, had pd catheter placed 2 months ago but uable to tolerate pd\n treatments d/t severe abd pain with exchange. pt was admitted last week\n with leg pain, was discharged on dilaudid but the leg pain grew worse.\n pt given morphine for the pain in the er. the hypertension was treated\n with 10mg iv labetolol without effect. pt was started on a labetolol\n drip at 1mg/min and titrated up to 3mg/mg with bp 230s/150s. pt also\n s/o shortness of breath. LENIs negative for dvt. cxr normal. urine sent\n in er. hct 24.7, pt with baseline anemia. bun 51, cr 8.4, k 5.9,\n moderately hemolyzed. pt transferred to 4 icu for treatment of\n her hypertensive crisis.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n Sbp in 230s on arrival to icu via aline. Sbp 10 points lower via\n noninvasive cuff. Labetalol drip was infusing at 3mg/hr and titrated up\n to as high as 5mg/hr with 1 inch nitropaste placed on chest wall. Pt\n c/o +n/v 10cc strawberry colored emesis (pt had strawberry drink in\n er). Also c/o right leg pain she\ns been having.\n Action:\n Labetalol drip maintained at 5mg/hr until pt able to take po meds.\n Given iv zofran for n/v with good effect. Given 2mg iv morphine with\n good effect with pain to her baseline 5. pt given po hydralazine\n and po labetalol with lunch.\n Response:\n Sbp lowering to as low as 160s via noninvasive cuff and 180s aline.\n (goal sbp 130-170, dbp <100). Labetalol drip weaned to as low as 1mg/hr\n but sbp still 170s-180s noninvasive cuff and 190s-200s aline. New 1\n inch nitropaste applied to chest wall with old paste wiped off at\n 16:55. developed a headache shortly after new nitropaste applied. Given\n 650mg Tylenol with relief. Sbp down to 150s noninvasive cuff. 180s\n aline. Labetolol drip currently at 1mg/hr.\n Plan:\n Continue to attempt to wean labetalol drip, continue antihypertensives\n as ordered. Morphine prn right leg pain. Tylenol prn headache. Zofran\n prn nausea. Monitor lytes. Receiving 3mg calcium gluconate currently\n for calcium relpletion. Repeat k 5.0 from 5.9( 5.9 was moderately\n hemolyzed).\n"
},
{
"category": "Nursing",
"chartdate": "2141-09-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339028,
"text": ".H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2141-09-12 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 339295,
"text": "24 y.o. F with ESRD (not on HD or PD) and lupus, admitted for malignant\n hypertension, currently on home regimen.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n SBP 160-170\ns/100\ns- 110\ns with baseline SBP 130-180s, No\n symptoms/signs of hypertensive emergency as pt without seizures, no\n acute worsening of renal function (anuric at baseline) Denies HA,\n blurry vision, chest pain. Denies nausea/vomiting. No peripheral\n edema. Peripheral pulses present.\n Action:\n Re-started home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren. - Monitor BPs closely. Neuro checks q 4 hours\n Response:\n SBP at 150-160\ns/100\ns ( 2 pm hydralazine held due to SBP of 120\n Plan:\n Continue to monitor patient hemodynamic status, hypertensive meds\n ASDIR.\n Neuro: alert oriented X3, follows commands, steady gait. Incompliant\n w/some of the care. RT leg pain - Lumbar spine MRI and R hip XR on most\n recent admission were both negative. Likely sciatica\n morphine IV\n given w/some effect\n Resp: on RA sats at high 90\ns-100%. Bil LS clear, RRR, unlabored\n breathing.\n GI: abd soft non tender, non distended, positive for BS. Regular diet\n (patient been refusing renal diet). Denies N/V. PD site - c/d/i.\n dressing changed today.\n GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted.\n Uses commode to void. Clean yellow urine. Dx of UTI on cipro. Urine\n cultures were sent. F/u results.\n Skin: no skin impairment\n Social: patient is a FULL CODE. Family in to visit.\n K- 5.4 kayexalate 30gr given at 11 am awaiting results. at 1500 K-5.6\n another 15gr of kayexalate given. PO4 -6.8 started on Sevelamer\n HX of SVC thrombus related to catheter in . INR goal 2.5 to 3.0.\n Patient on coumadin 5mg daily.\n SLE\n on daily prednisone.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERTENSION\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 51.6 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Precautions:\n PMH: Renal Failure\n CV-PMH: Hypertension\n Additional history: SLE diagnosed in (16yrs old) when she had\n swollen fingers, arm rash, and arthralgias. previous treatment with\n cytoxan, cellcept, currently on prednisone. complicated by uveitis\n () and ESRD ().\n CKD/ESRD, diagnosed in , initiated hemodialysis . PD catheter\n placement . pt reluctant to start PD and didn't tolerate PD flush\n well at all with severe abd pain.\n malignant hypertension, baseline sBPs 180s-120s. history of\n hypertensive crisis with seizures. history of 2 intraparenchymal\n hemorrhages that wer thought to be due to the posterior reversible\n leukoencephalopathy syndrome.\n TTP (got plasmapheresis) versus malignant HTN\n thrombotic events. SVC thrombosis () related to a catheter.\n Negative lupus anticoagulant (, , 9/).\n Negative anticardiolipin antiboties IgG and IgM x4 (-). Negtive\n Beta-2 gylcoprotein antibody (, 8/).\n -HOCM: last noted on echo .\n -anemia\n -history of left eye enucleation for fungal infection.\n -history of vaginal bleeding lasting 2 months s/p DepoProvera\n injection requiring transfusion.\n -history of coag negative Staph bacteremia and HD line infection \n and .\n past surgical histories: placement of multiple catheters including\n dialysis, tonsillectomy, left eye enucleation in , PD\n catheter placement in .\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:74\n Temperature:\n 97\n Arterial BP:\n S:157\n D:131\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,070 mL\n 24h total out:\n 450 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 02:38 PM\n Potassium:\n 5.6 mEq/L\n 02:38 PM\n Chloride:\n 110 mEq/L\n 02:38 PM\n CO2:\n 20 mEq/L\n 02:38 PM\n BUN:\n 49 mg/dL\n 02:38 PM\n Creatinine:\n 8.3 mg/dL\n 02:38 PM\n Glucose:\n 121 mg/dL\n 02:38 PM\n Hematocrit:\n 24.7 %\n 06:10 AM\n Valuables / Signature\n Patient valuables: sent w/patient\n Transferred from: MICU/\n Transferred to: 9\n Date & time of Transfer: \n ------ Protected Section ------\n Patient refused kayexalate. (k-5.6) team aware\n ------ Protected Section Addendum Entered By: , RN\n on: 15:53 ------\n"
},
{
"category": "General",
"chartdate": "2141-09-11 00:00:00.000",
"description": "Initial H&P",
"row_id": 339083,
"text": " ADMISSION NOTE\n .\n Reason for MICU Admission: Malignant Hypertension.\n .\n Primary Care Physician: MD / MD\n .\n CC: Right leg pain.\n .\n HPI: Ms. is a 24 y.o. F with lupus, Chronic Kidney Disease V (not\n currently on HD or PD), and multiple admissions for hypertensive\n urgency/emergency, who presented to the ED for continued R leg pain\n that starts in her R buttocks and refers down her R leg. She describes\n it as feeling like the pain is deep within her bone. The pain was\n this AM, and she felt like she couldn't get out of bed. Denies\n any swelling of her RLE. When getting VS in , pt noted to be very\n hypertensive at 263/176. The patient reportedly has bseline SBPs in\n 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM\n on day of admission. She denies headache, vision changes, double\n vision, chest pain, shortness of breath, abdominal pain, BRBPR,\n dysuria. During MD interview, the patient was nauseous and had small\n amount of emesis of a recent Coolata. Pt states that flushing her PD\n cath causes a large amout of stomach pain. Currently, she has RLE\n pain.\n .\n In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in\n ED ranged from -175 with HR in 96-108. Initially given\n labetalol 10 mg IV x 1 and then started on labetalol gtt for her\n elevated blood pressures and titrated to 3 mg/min. LENI of R leg was\n negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per\n ED, cannot do V/Q scan due to volume overload after talking with\n radiology. Renal c/s initiated. A-line placed.\n .\n Of note, the patient was recently admitted from 08.26-29.08. The\n patient initially presented to the ED after referral from her\n nephrologist's office where she had complaints of right leg pain and\n was found to be hypertensive to 250/145. She was admitted after\n initiation of a labetalol drip and nitropaste with improvement in sbp\n to 180. The patient did receive 2 U of PRBC's during this\n hospitalization for baseline anemia. The patient did have a work-up for\n her right leg pain complaints with plain films of the right hip and MRI\n of the L-spine which did not reveal an explanation for her symptoms and\n did rule out avascular necrosis. The patient received dilaudid for pain\n control and was ambulating without pain prior to discharge. In\n addition, the patient completed a course of ciprofloxacin for a\n positive UA with negative cultures. The patient was unable to tolerate\n peritoneal dialysis for unclear reasons. Peritoneal dialysate culture\n was negative for infection.\n .\n ROS: as stated above in HPI.\n .\n MEDICATIONS (from discharge summary ):\n - Prednisone 5 mg Daily\n - Coumadin 2 mg at bedtime\n - Nifedipine 60 mg Sustained Release Daily\n - Hydralazine 50 mg every 8 hours\n - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday\n - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY\n - Aliskiren 150 mg Twice daily\n - Docusate Sodium 100 mg 2 times a day\n - Labetalol 900 mg three times a day\n - Lactulose 15-30 ml once a day: goal is soft bowel movements per\n day\n .\n ALLERGIES: Penicillins / Percocet\n .\n PAST MEDICAL HISTORY:\n - Systemic lupus erythematosus. Diagnosed (16 years old) when she\n had swollen fingers, arm rash and arthralgias. Previous treatment with\n cytoxan, cellcept; currently on prednisone. Complicated by uveitis\n () and ESRD ().\n - CKD/ESRD. Diagosed . Initiated dialysis . PD catheter\n placement . Pt reluctant to start PD.\n - Malignant hypertension. Baseline BPs 180's - 120's. History of\n hypertensive crisis with seizures. History of two intraparenchymal\n hemorrhages that were thought to be due to the posterior reversible\n leukoencephalopathy syndrome.\n - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN.\n - Thrombotic events. SVC thrombosis (); related to a catheter.\n Negative lupus anticoagulant (, , 9/). Negative\n anticardiolipin antibodies IgG and IgM x4 (-). Negative Beta-2\n glycoprotein antibody (, 8/).\n - HOCM: Last noted on echo .\n - Anemia.\n - History of left eye enucleation for fungal infection.\n - History of vaginal bleeding lasting 2 months s/p DepoProvera\n injection requiring transfusion.\n - History of Coag negative Staph bacteremia and HD line\n infection - and \n .\n PAST SURGICAL HISTORY:\n 1. Placement of multiple catheters including dialysis.\n 2. Tonsillectomy.\n 3. Left eye enucleation in .\n 4. PD catheter placement in .\n .\n SOCIAL HISTORY: Single. Lives with her mother and brother. On\n disability. Denies EtOH, tobacco or drug use.\n .\n FAMILY HISTORY: No history of autoimmune or thrombophilic disorders.\n .\n PHYSICAL EXAM:\n VS: T 98.9 99$% RA\n GEN: NAD, pleaseant female sitting in bed with moon facies\n HEENT: EOMI of R eye, L eye prosthesis, OP - no exudate, no erythema,\n MMM, no LAD\n CHEST: CTAB except at R base with decreased breath sounds; no w/r/r\n CV: tachy, no m/r/g appreciated, + S4\n ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i\n EXT: no c/c/e, + SLR of RLE, able to wiggle toes and raise BLE off bed\n NEURO: II - XII grossly intact\n DERM: no rashes noted\n .\n LABORATORIES:\n Na 138, K 5.9 (hemolyzed), Cl 108, Bicarb 21, BUN/Cr 51/8.4, glucose\n 85, WBC 5.5 (74 N, 17.5 L), Hct 24.7, platelets 101.\n .\n UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50\n WBC\n .\n MICROBIOLOGY:\n Blood culture (): Pending.\n Urine culture (): No growth.\n Peritoneal fluid (): Gram stain no PMN's or microorganisms.\n Culture pending.\n .\n STUDIES:\n EKG : sinus tachy @ 100 bpm, nl axis, borderline PR prolongation,\n long QT interval, no acute ST-TWI. No change from prio on .\n PORTABLE CXR (my read): Cardiomegaly. Some increased haziness of\n RLL/R diaphragm from CXR.\n R LENI (wet read): No DVT.\n .\n TTE (): The left atrium is normal in size. There is severe\n symmetric left ventricular hypertrophy. The left ventricular cavity is\n unusually small. Regional left ventricular wall motion is normal. Left\n ventricular systolic function is hyperdynamic (EF>75%). There is a mild\n resting left ventricular outflow tract obstruction. The gradient\n increased with the Valsalva manuever. The findings are consistent with\n hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular\n septal defect. Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) appear structurally normal with\n good leaflet excursion. No masses or vegetations are seen on the aortic\n valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears\n structurally normal with trivial mitral regurgitation. There is no\n mitral valve prolapse. No mass or vegetation is seen on the mitral\n valve. The estimated pulmonary artery systolic pressure is normal.\n There is a trivial/physiologic pericardial effusion.\n .\n R HIP XR : No acute fracture or dislocation.\n .\n MRI L-SPINE : Diffuse low-signal intensity is identified in the\n bone marrow of the lumbar and lower thoracic spine as described above,\n possibly related with anemic changes, please correlate clinically.\n There is no evidence of spinal canal stenosis or neural foraminal\n narrowing at the different intervertebral disc spaces.\n .\n ASSESSMENT & PLAN: 24 y.o. F with ESRD (not on HD or PD) and lupus,\n admitted for malignant hypertension, currently on labetalol gtt.\n .\n # Malignant hypertension: SBPs currently in 200s with baseline SBP\n 130-180s. No symptoms/signs of hypertensive emergency as pt without\n seizures, no acute worsening of renal function (anuric at baseline)\n Denies HA, blurry vision, chest pain. + nausea/vomiting\n - Continue labetalol drip with down-titration as possible for goal SBP\n in 170-180s\n - NTG transdermal now\n - Transition to home dose oral labetalol when able\n - Re-start home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren when able\n - Monitor BPs closely\n - Neuro checks q 4 hours\n .\n # Right leg pain: Lumbar spine MRI and R hip XR on most recent\n admission were both negative. Likely sciatica.\n - IV Morphine as needed for pain\n - Transition to po pain medications when able\n .\n # UTI: UCx pending. Asymptomatic currently.\n - ciprofloxacin x 3 days\n - f/u Urine culture\n - check EKGs daily while on FQ and borderline prolonged QT\n .\n # ESRD: Pt not on PD although with PD catheter. On last admission, she\n had difficulty tolerating PD secondary to pain.\n - Peritoneal dialysis as tolerated\n - Appreciate renal recommendations\n .\n # Hyperkalemia: K elevated to 5.9 on admission, but moderately\n hemolyzed\n - check electrolytes now\n - EKG on arrival to ICU\n .\n # Anemia: Likely related to chronic disease. Baseline Hct 20, currently\n 24. Not on epo given hypertension. Past transfusion requirement.\n - Trend Hct daily\n - Transfer if Hct < 20\n - active T&S\n .\n # Prior SVC thrombus: Related to catheter in . INR goal 2.5 to\n 3.0. Was elevated to 3.4 on d/c on \n - check coags now to decide whether to continue or hold coumadin.\n .\n # Systemic lupus erythematosus:\n - Continue prednisone daily\n .\n # HOCM: Seen on TTE in .\n - BP management as above.\n - Avoid excessive volume removal.\n .\n # Thrombocytopenia: Baseline platelets approximately 100.\n - trend platelets daily\n .\n # FEN: no IVFs / replete lytes prn / ADAT\n .\n # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen\n .\n # ACCESS: Peripheral IV, A-line\n .\n # CONTACT: (mother) \n .\n # CODE: Full Code\n .\n # DISPO: ICU pending blood pressure control\n .\n .\n .\n .\n , MD, MPH\n \n PGY-2\n ------ Protected Section ------\n I saw this patient with Dr. , the ICU resident, and agree with her\n HPI, PMHx, Fhx, SocHX, ROS, PE and plan as outlined above. \n is a 24 yo bf with SLE, CRF not on dialysis, severe HTN who came\n to the ED today because of right leg pain, but noted to have elevated\n BP (260/130\ns).. She currently appears without distress, and denies\n CP/SOB/vision changes/headaches/MS changes to indicate HTN emergency.\n Lungs: slightly diminished at R base, otherwise clear. CV: mildly\n tachy, RR, +S4. Abd: soft, nontender, +bs. Ext without edema.\n She is in the for hypertensive urgency, which is being treated\n with a labetolol gtt, resumption of home medicines and invasive BP\n monitoring Renal team following. RLE pain treated with morphine and\n consider hip MRI for further evaluation. Further plans as outlined\n above.\n Pt is critically ill.\n Total time spent on patient: 40 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:57 ------\n"
},
{
"category": "Nursing",
"chartdate": "2141-09-12 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 339286,
"text": "24 y.o. F with ESRD (not on HD or PD) and lupus, admitted for malignant\n hypertension, currently on home regimen.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n SBP 160-170\ns/100\ns- 110\ns with baseline SBP 130-180s, No\n symptoms/signs of hypertensive emergency as pt without seizures, no\n acute worsening of renal function (anuric at baseline) Denies HA,\n blurry vision, chest pain. Denies nausea/vomiting. No peripheral\n edema. Peripheral pulses present.\n Action:\n Re-started home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren. - Monitor BPs closely. Neuro checks q 4 hours\n Response:\n SBP at 150-160\ns/100\ns ( 2 pm hydralazine held due to SBP of 120\n Plan:\n Continue to monitor patient hemodynamic status, hypertensive meds\n ASDIR.\n Neuro: alert oriented X3, follows commands, steady gait. Incompliant\n w/some of the care. RT leg pain - Lumbar spine MRI and R hip XR on most\n recent admission were both negative. Likely sciatica\n morphine IV\n given w/some effect\n Resp: on RA sats at high 90\ns-100%. Bil LS clear, RRR, unlabored\n breathing.\n GI: abd soft non tender, non distended, positive for BS. Regular diet\n (patient been refusing renal diet). Denies N/V. PD site - c/d/i.\n dressing changed today.\n GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted.\n Uses commode to void. Clean yellow urine. Dx of UTI on cipro. Urine\n cultures were sent. F/u results.\n Skin: no skin impairment\n Social: patient is a FULL CODE. Family in to visit.\n K- 5.4 kayexalate 30gr given at 11 am awaiting results.\n HX of SVC thrombus related to catheter in . INR goal 2.5 to 3.0.\n Patient on coumadin 5mg daily.\n SLE\n on daily prednisone.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERTENSION\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 51.6 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Precautions:\n PMH: Renal Failure\n CV-PMH: Hypertension\n Additional history: SLE diagnosed in (16yrs old) when she had\n swollen fingers, arm rash, and arthralgias. previous treatment with\n cytoxan, cellcept, currently on prednisone. complicated by uveitis\n () and ESRD ().\n CKD/ESRD, diagnosed in , initiated hemodialysis . PD catheter\n placement . pt reluctant to start PD and didn't tolerate PD flush\n well at all with severe abd pain.\n malignant hypertension, baseline sBPs 180s-120s. history of\n hypertensive crisis with seizures. history of 2 intraparenchymal\n hemorrhages that wer thought to be due to the posterior reversible\n leukoencephalopathy syndrome.\n TTP (got plasmapheresis) versus malignant HTN\n thrombotic events. SVC thrombosis () related to a catheter.\n Negative lupus anticoagulant (, , 9/).\n Negative anticardiolipin antiboties IgG and IgM x4 (-). Negtive\n Beta-2 gylcoprotein antibody (, 8/).\n -HOCM: last noted on echo .\n -anemia\n -history of left eye enucleation for fungal infection.\n -history of vaginal bleeding lasting 2 months s/p DepoProvera\n injection requiring transfusion.\n -history of coag negative Staph bacteremia and HD line infection \n and .\n past surgical histories: placement of multiple catheters including\n dialysis, tonsillectomy, left eye enucleation in , PD\n catheter placement in .\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:74\n Temperature:\n 97\n Arterial BP:\n S:157\n D:131\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,070 mL\n 24h total out:\n 450 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 06:10 AM\n Potassium:\n 5.4 mEq/L\n 06:10 AM\n Chloride:\n 107 mEq/L\n 06:10 AM\n CO2:\n 16 mEq/L\n 06:10 AM\n BUN:\n 52 mg/dL\n 06:10 AM\n Creatinine:\n 8.5 mg/dL\n 06:10 AM\n Glucose:\n 99 mg/dL\n 06:10 AM\n Hematocrit:\n 24.7 %\n 06:10 AM\n Valuables / Signature\n Patient valuables: sent w/patient\n Transferred from: MICU/\n Transferred to: 9\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2141-09-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 339288,
"text": "Chief Complaint:\n 24 Hour Events:\n Pressures finally dropped to 130/80s and labetelol drip was stopped\n ARTERIAL LINE - START 11:15 AM\n EKG - At 12:47 PM\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 01:21 PM\n Other medications:\n Nifedipine CR 60 po daily\n Labetalol 900 mg PO TID\n Hydral 50 mg PO q 8\n AlisKiren NF 150 mg PO BID\n Tylenol\n Clonidine patch 0.3 mg q wed\n Prednisone 5 mg PO daily\n Calcium carbonate 500 mg PO QID\n Warfarin 5 mg PO qhs\n Morphine\n Ondansetron\n Docusate, senna, bisacoldy\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 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: 36.9\nC (98.4\n HR: 79 (71 - 99) bpm\n BP: 142/105(113) {115/58(74) - 208/153(166)} mmHg\n RR: 13 (13 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,725 mL\n 180 mL\n PO:\n 440 mL\n 180 mL\n TF:\n IVF:\n 1,285 mL\n Blood products:\n Total out:\n 255 mL\n 150 mL\n Urine:\n 250 mL\n 150 mL\n NG:\n 5 mL\n Stool:\n Drains:\n Balance:\n 1,470 mL\n 30 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///16/\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 8.3 g/dL\n 86 mg/dL\n 8.1 mg/dL\n 16 mEq/L\n 5.0 mEq/L\n 49 mg/dL\n 110 mEq/L\n 139 mEq/L\n 24.7 %\n 3.9 K/uL\n [image002.jpg]\n 11:43 AM\n 06:10 AM\n WBC\n 3.9\n Hct\n 24.7\n Cr\n 8.1\n Glucose\n 86\n Other labs: PT / PTT / INR:18.4/42.8/1.7, Ca++:6.2 mg/dL, Mg++:1.6\n mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n ASSESSMENT & PLAN: 24 y.o. F with ESRD (not on HD or PD) and lupus,\n admitted for malignant hypertension, currently on labetalol gtt.\n .\n # Malignant hypertension: SBPs currently in 200s with baseline SBP\n 130-180s. No symptoms/signs of hypertensive emergency as pt without\n seizures, no acute worsening of renal function (anuric at baseline)\n Denies HA, blurry vision, chest pain. + nausea/vomiting\n - patient without any symptoms now, patient is refusing hemodialysis\n -labetalol drip stopped, patient on home BP meds, goal systolic range\n 160-170s\n - Monitor BPs closely, neuro checks q 4 hours\n .\n # Right leg pain: Lumbar spine MRI and R hip XR on most recent\n admission were both negative. Likely sciatica.\n - IV Morphine as needed for pain\n - Transition to po pain medications when able\n - on chronic steroids concern for potential risk of AVN of right hip,\n would consider CT of right hip on transfer out of the unit\n .\n # UTI:\n - UA grossly positive, ucx pending\n - ciprofloxacin x 3 days\n - f/u Urine culture\n - check EKGs daily while on FQ and borderline prolonged QT\n .\n # ESRD: Pt not on PD although with PD catheter. On last admission, she\n had difficulty tolerating PD secondary to pain.\n - Peritoneal dialysis as tolerated\n - Appreciate renal recommendations\n possible PD dialysis, replete\n Calcium\n .\n # Hyperkalemia: K elevated to 5.9 on admission, but moderately\n hemolyzed\n - repetat K 5.4, patient given kayexalate, checking EKGs daily now with\n borderline QT\n - cont to monitor daily electrolytes\n .\n # Anemia: Likely related to chronic disease. Baseline Hct 20, currently\n 24. Not on epo given hypertension. Past transfusion requirement.\n - Trend Hct daily, Transfer if Hct < 20\n - active T&S\n .\n # Prior SVC thrombus: Related to catheter in . INR goal 2.5 to\n 3.0. Was elevated to 3.4 on d/c on \n - this morning INR 1.7, will not bridge at this time with heparin\n - continue coumadin 5 mg PO qhs and re-check INR in AM.\n .\n # Systemic lupus erythematosus:\n - Continue prednisone daily\n .\n # HOCM: Seen on TTE in .\n - BP management as above.\n - Avoid excessive volume removal\n .\n # Thrombocytopenia: Baseline platelets approximately 100.\n - platelets are now 93, now indication for tranfusion at this time\n - consider heme/onc consult as all 3 cell lines down\n .\n # FEN: no IVFs / replete lytes prn / ADAT\n .\n # PPX: PPI / systemic anticoagulation with warfarin / bowel regimen\n .\n # ACCESS: Peripheral IV, A-line\n .\n # CONTACT: (mother) \n .\n # CODE: Full Code\n .\n # DISPO: to floor today as now off of labetalol drip\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:15 AM\n 20 Gauge - 11:25 AM\n 18 Gauge - 11:26 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": "2141-09-12 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 339289,
"text": "24 y.o. F with ESRD (not on HD or PD) and lupus, admitted for malignant\n hypertension, currently on home regimen.\n .H/O hypertension, malignant (hypertensive crisis, hypertensive\n emergency)\n Assessment:\n SBP 160-170\ns/100\ns- 110\ns with baseline SBP 130-180s, No\n symptoms/signs of hypertensive emergency as pt without seizures, no\n acute worsening of renal function (anuric at baseline) Denies HA,\n blurry vision, chest pain. Denies nausea/vomiting. No peripheral\n edema. Peripheral pulses present.\n Action:\n Re-started home regimen of nifedipine, hydralazine, clonidine patch,\n aliskiren. - Monitor BPs closely. Neuro checks q 4 hours\n Response:\n SBP at 150-160\ns/100\ns ( 2 pm hydralazine held due to SBP of 120\n Plan:\n Continue to monitor patient hemodynamic status, hypertensive meds\n ASDIR.\n Neuro: alert oriented X3, follows commands, steady gait. Incompliant\n w/some of the care. RT leg pain - Lumbar spine MRI and R hip XR on most\n recent admission were both negative. Likely sciatica\n morphine IV\n given w/some effect\n Resp: on RA sats at high 90\ns-100%. Bil LS clear, RRR, unlabored\n breathing.\n GI: abd soft non tender, non distended, positive for BS. Regular diet\n (patient been refusing renal diet). Denies N/V. PD site - c/d/i.\n dressing changed today.\n GU: HX of ESRD Pt not on PD although with PD catheter, renal consulted.\n Uses commode to void. Clean yellow urine. Dx of UTI on cipro. Urine\n cultures were sent. F/u results.\n Skin: no skin impairment\n Social: patient is a FULL CODE. Family in to visit.\n K- 5.4 kayexalate 30gr given at 11 am awaiting results. at 1500 K-5.6\n another 15gr of kayexalate given. PO4 -6.8 started on Sevelamer\n HX of SVC thrombus related to catheter in . INR goal 2.5 to 3.0.\n Patient on coumadin 5mg daily.\n SLE\n on daily prednisone.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERTENSION\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 51.6 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Precautions:\n PMH: Renal Failure\n CV-PMH: Hypertension\n Additional history: SLE diagnosed in (16yrs old) when she had\n swollen fingers, arm rash, and arthralgias. previous treatment with\n cytoxan, cellcept, currently on prednisone. complicated by uveitis\n () and ESRD ().\n CKD/ESRD, diagnosed in , initiated hemodialysis . PD catheter\n placement . pt reluctant to start PD and didn't tolerate PD flush\n well at all with severe abd pain.\n malignant hypertension, baseline sBPs 180s-120s. history of\n hypertensive crisis with seizures. history of 2 intraparenchymal\n hemorrhages that wer thought to be due to the posterior reversible\n leukoencephalopathy syndrome.\n TTP (got plasmapheresis) versus malignant HTN\n thrombotic events. SVC thrombosis () related to a catheter.\n Negative lupus anticoagulant (, , 9/).\n Negative anticardiolipin antiboties IgG and IgM x4 (-). Negtive\n Beta-2 gylcoprotein antibody (, 8/).\n -HOCM: last noted on echo .\n -anemia\n -history of left eye enucleation for fungal infection.\n -history of vaginal bleeding lasting 2 months s/p DepoProvera\n injection requiring transfusion.\n -history of coag negative Staph bacteremia and HD line infection \n and .\n past surgical histories: placement of multiple catheters including\n dialysis, tonsillectomy, left eye enucleation in , PD\n catheter placement in .\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:74\n Temperature:\n 97\n Arterial BP:\n S:157\n D:131\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,070 mL\n 24h total out:\n 450 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 02:38 PM\n Potassium:\n 5.6 mEq/L\n 02:38 PM\n Chloride:\n 110 mEq/L\n 02:38 PM\n CO2:\n 20 mEq/L\n 02:38 PM\n BUN:\n 49 mg/dL\n 02:38 PM\n Creatinine:\n 8.3 mg/dL\n 02:38 PM\n Glucose:\n 121 mg/dL\n 02:38 PM\n Hematocrit:\n 24.7 %\n 06:10 AM\n Valuables / Signature\n Patient valuables: sent w/patient\n Transferred from: MICU/\n Transferred to: 9\n Date & time of Transfer: \n"
},
{
"category": "Radiology",
"chartdate": "2141-09-11 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 1031432,
"text": " 8:54 AM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: dvt?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman with r leg pain, sob\n REASON FOR THIS EXAMINATION:\n dvt?\n ______________________________________________________________________________\n WET READ: JKPe MON 10:03 AM\n no dvt\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath and right leg pain. Evaluate for DVT.\n\n Comparison is made to exam, also noted to be negative.\n\n RIGHT LOWER EXTREMITY ULTRASOUND\n\n -scale and Doppler son of the right common femoral, superficial\n femoral, and popliteal veins demonstrate normal flow, compressibility,\n augmentation, waveforms. Appropriate color flow and compression is noted\n within the calf veins. No intraluminal thrombus is present.\n\n IMPRESSION:\n\n No evidence of right lower extremity DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031418,
"text": " 8:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman with shortness of breath\n REASON FOR THIS EXAMINATION:\n infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath.\n\n UPRIGHT PORTABLE CHEST\n\n Comparison is made to multiple chest radiographs dating back to .\n\n Exam is somewhat limited by the portable technique and patient rotation. There\n is increased vascular distention and interstitial markings extending out to\n the periphery in addition to increased patchy opacities within the lower lobes\n bilaterally. Small bilateral layering effusions are identified. Heart size\n is stably enlarged. No pneumothorax.\n\n IMPRESSION:\n\n Findings are most suggestive of moderate fluid overload in this patient with\n known end-stage renal disease/SLE. Patchy opacities at the bases may\n represent regions of alveolar edema although a superimposed pneumonia would be\n difficult to exclude. A repeat radiograph after diuresis/dialysis would be\n helpful.\n\n Small bilateral effusions.\n\n These findings were discussed with Dr. aligned shortly after exam\n acquisition.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-09-13 00:00:00.000",
"description": "Report",
"row_id": 170208,
"text": "Sinus rhythm with slowing of the rate as compared with prior tracing of .\nThe previously mentioned multiple abnormalities persist without diagnostic\ninterim change. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-09-12 00:00:00.000",
"description": "Report",
"row_id": 170209,
"text": "Sinus rhythm. There is variation in precordial lead placement as compared\nwith prior tracing of . The prominent negative terminal deflection\nof the P wave in lead V1 is no longer evident which may relate to lead\nplacement. No diagnostic interim change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2141-09-11 00:00:00.000",
"description": "Report",
"row_id": 170210,
"text": "Sinus rhythm. Left atrial enlargement. Compared to the previous tracing\nof no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2141-09-11 00:00:00.000",
"description": "Report",
"row_id": 170442,
"text": "Sinus tachycardia. The tracing is marred by baseline artifact. There is\nleft atrial enlargement. Compared to the previous tracing of \nthe rate has increased. The axis is more rightward. Otherwise, no diagnostic\ninterim change.\nTRACING #1\n\n"
}
] |
32,203 | 170,201 | 34 y/o M with AIDS, Kaposi's sarcoma, and Castleman's disease who was admitted for hypercalcemia. . # Hypercalcemia - Etiology unknown. Extensive work-up undertaken during last admission, many of the results still pending. Causes of hypercalcemia with a low PTH include malignancy, Vitamin D excess, increased bone turnover, thiazide diuretic use and Milk Alkali syndrome. Primary adrenal insufficiency can also cause a hypercalcemia decreased vascular volume and calcium clearance. Given pt's h/o malignancy, hypercalcemia of malignancy cannot be excluded. Some solid tumor malignancies can produce a PTH related peptide. Treated with IV fluids with appropriate response. PTH related peptide still pending. Vitamin D studies still pending. . # Non gap Metabolic Acidosis: Likely a renal tubular acidosis secondary to Fanconi-like syndrome due to tenofavir use. Losing glucose, phosphate, sodium, potassium in urine. FePhos 73% at last admission. D/c'd tenofavir on this admission. Given potassium and bicarb via PICC line. Discharged with potassium and sodium bicarbonate supplements and renal follow up. . # Anemia - 34.3 at time of initial admission , now 25.7. Likely this is patient's baseline as he had been hemoconcentrated in setting of nausea, vomiting and minimal PO intake. . # Hyponatremia: Recently started on steroids for adrenal insufficiency. Steroids continued in house. . # Renal failure: improved from last admission with creatinine 1.8. Still with renal failure and known proteinuria diagnosed on last admission. Unclear etiology of intrinsic renal failure. be secondary to antiretrovirals. need renal biopsy. Follow up arranged with renal as an outpatient. . # AIDS: Discontineud tenofavir and started on abacavir/lamivudine combo pill. Hope to see improvement in renal function in months. Follow up with Dr. . . # Contact - Girlfriend, . # Code Status - Full Code | Rule out pneumothorax. Brought to EW. IMPRESSION: Tip of PICC line in mid SVC. admitted to OSH with electrolyte imbalance . CHEST, PORTABLE UPRIGHT, ONE VIEW: Tip of left PICC line overlies the mid SVC. No VEA noted.BS clear. Sinus rhythm. Early R wave appearance with early repolarization variant.Possible right ventricular hypertrophy though pattern may represent a normalvariant. Found to have several electrolyes deficient with low bicarb. COMPARISON: . Given bicarb, IVF with improvement in MS. Tox screen negative. Sats 99-100 RAA/p; VSS. Follow electrolytes, temp. IV THERAPY REPLACED INFILTRATED PIV AND PT BE ASSESSED FOR MIDLINE . Hilar and mediastinal contours are normal. if he understood when asked month, yr, place.Temp 99.6PO.Voiding lge amts, lt yellow urineSBP 112, Hr 112-116. Assess line placement. ? Discharged one day PTA for anemia, weakness, FTT. Was able to tell me his name. Electrolytes repleted. CONT TO C/O THIRST.CREAT 1.8 TO START ON D5W @ 100HR WHEN K PHOS FINISHED. Trans to ICU for further managment.MS: Follows commands, MAE. Pt was noted to be driving irratically. Compared to prior tracing of no significant intervaldiagnostic change is seen. 12:16 PM CHEST PORT. ABLE TO FOLLOW SIMPLE COMMANDS AND RECOGNIZE MED NAMES.RESP: LCTA RR UNLABORED MAINT SATS 98-100%C/V: ST NO ECTOPY, BP STABLE 1TEENS-120S.F/E/N:DIFFACULTY REPLETING PHOS W/ IV K PHOS.LAST EVE K+ 3.5 PRIOR TO RECIEVING 60K PO STANDING DOSE.IONIZED CA 1.62 VOIDING 400-500CC URINE , URINE LYTES SENT. Will need French interpreter. Heart size is normal. Lungs are clear. NPN 1900 -0700NEURO: AWAKE AND ALERT, DIFFACULT TO ASSESS ORIENTATION LIMTED ENG VOCABULARY. No pleural or osseous abnormality identified. TEAM AWARE.PLAN: REPLETE PHOS, DRAW LYTES AND AM LABS AFTER REPLETION.MONITOR HEMODYNAMICS, EMOTIONAL SUPPORT FOR PT AND FAMILY 4 ICU ADMISSION/NPN 1700-190034 YO with HX HIV/visceral kaposi sarcoma, castleman's, recurrent hyponatremia, pancytopenia, FTT. No evidence of pneumothorax. No evidence of pneumothorax. Has cane but did not Primarily French speaking. Able to walk few steps from stretcher to bed. He was pulled over by police & found to be confused. | 4 | [
{
"category": "Radiology",
"chartdate": "2181-11-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 989398,
"text": " 12:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement, r/o PTX\n Admitting Diagnosis: MENTAL STATUS CHANGES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with s/p PICC placement\n REASON FOR THIS EXAMINATION:\n line placement, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 34-year-old male status post PICC placement. Assess line placement.\n Rule out pneumothorax.\n\n COMPARISON: .\n\n CHEST, PORTABLE UPRIGHT, ONE VIEW: Tip of left PICC line overlies the mid\n SVC. No evidence of pneumothorax. Heart size is normal. Hilar and\n mediastinal contours are normal. Lungs are clear. No pleural or osseous\n abnormality identified.\n\n IMPRESSION: Tip of PICC line in mid SVC. No evidence of pneumothorax.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2181-11-05 00:00:00.000",
"description": "Report",
"row_id": 1670610,
"text": " 4 ICU ADMISSION/NPN 1700-1900\n34 YO with HX HIV/visceral kaposi sarcoma, castleman's, recurrent hyponatremia, pancytopenia, FTT. admitted to OSH with electrolyte imbalance . Pt was noted to be driving irratically. He was pulled over by police & found to be confused. Brought to EW. Tox screen negative. Found to have several electrolyes deficient with low bicarb. Electrolytes repleted. Given bicarb, IVF with improvement in MS. Discharged one day PTA for anemia, weakness, FTT. Trans to ICU for further managment.\nMS: Follows commands, MAE. Able to walk few steps from stretcher to bed. Has cane but did not Primarily French speaking. Was able to tell me his name. ? if he understood when asked month, yr, place.\nTemp 99.6PO.\nVoiding lge amts, lt yellow urine\nSBP 112, Hr 112-116. No VEA noted.\nBS clear. Sats 99-100 RA\nA/p; VSS. Follow electrolytes, temp. Will need French interpreter.\n"
},
{
"category": "Nursing/other",
"chartdate": "2181-11-06 00:00:00.000",
"description": "Report",
"row_id": 1670611,
"text": "NPN 1900 -0700\n\nNEURO: AWAKE AND ALERT, DIFFACULT TO ASSESS ORIENTATION LIMTED ENG VOCABULARY. ABLE TO FOLLOW SIMPLE COMMANDS AND RECOGNIZE MED NAMES.\n\nRESP: LCTA RR UNLABORED MAINT SATS 98-100%\n\nC/V: ST NO ECTOPY, BP STABLE 1TEENS-120S.\n\nF/E/N:DIFFACULTY REPLETING PHOS W/ IV K PHOS.LAST EVE K+ 3.5 PRIOR TO RECIEVING 60K PO STANDING DOSE.IONIZED CA 1.62 VOIDING 400-500CC URINE , URINE LYTES SENT. CONT TO C/O THIRST.CREAT 1.8 TO START ON D5W @ 100HR WHEN K PHOS FINISHED. IV THERAPY REPLACED INFILTRATED PIV AND PT BE ASSESSED FOR MIDLINE . TEAM AWARE.\n\nPLAN: REPLETE PHOS, DRAW LYTES AND AM LABS AFTER REPLETION.MONITOR HEMODYNAMICS, EMOTIONAL SUPPORT FOR PT AND FAMILY\n\n\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2181-11-09 00:00:00.000",
"description": "Report",
"row_id": 219910,
"text": "Sinus rhythm. Early R wave appearance with early repolarization variant.\nPossible right ventricular hypertrophy though pattern may represent a normal\nvariant. Compared to prior tracing of no significant interval\ndiagnostic change is seen.\n\n"
}
] |
81,660 | 198,618 | 50yo woman with HIV and h/o rectal CA s/p chemoXRT currently in remission, with multiple complications including radiation fibrosis and radiation enteritis admitted for abdominal pain and ischemic bowel. Given vitamin K and FFP when she presented and admitted to the ICU. Surgery was not an option due to the radiation enteritis and fibrosis. She then developed fever and infiltrates c/w hospital-acquired pneumonia, treated with vanco/cefepime, and ARF and encephalopathy. . # Encephalopathy: Likely medication induced (pregabalin, hyoscyamine, and zolpidem stopped, methadone dose decreased, and lorazepam changed to PRN). CT and MRI head negative. Neuro consulted. EEG showed generalized encephalopathy. B12, folate, TSH normal, lactate normal, guaic negative. Encephalopathy resolved. Restarted pregabalin at lower dose . . # Ischemic/infarcted bowel/abdominal pain: Treated conservatively as no surgical options, completed 7 day course of cipro/metronidazole . Normal lactate, guaic now normal. . # Pain control: Remains stable. Due to changes in mental status, methadone decreased to 10/15/10/15 and stopped pregabalin and hyoscyamine (Levsin). Palliative Care consulted. Given her continued frequent reliance on PRN hydromorphone q2-4HR, methadone was increased from 10/15/10/15 to 15mg q6HR while the PRN hydromorphone dose was decreased (from a range 4-8 to with an aim for 3mg with each PRN dose, down from her usual 4mg). Her outpatient liquid supply of hydromorphone at 1mg/mL was not practical given her enormous usage. Concentrated hydromorphone 20mg/mL was given and then she was transitioned from IV to PO. Restarted pregabalin at lower dose 50mg TID for renal dosing and to avoid recurrent delirium. She has had good pain control with Oral Dilaudid 20 mg Q2H:PRN increasing to 30mg Q2H:prn during the night from 2200 to 0600 then back to a 20 mg Q2H:PRN at 0800. Palliative care has been involved to assist in managment. . # Hospital-acquired pneumonia: Completed 7 day course of cefepime . Vancomycin stopped . Repeat CXR showed improvement and symptoms resolved. . # Nausea and diarrhea: Chronic diarrhea due to short gut syndrome. However output increased to 5L/d last week with non-AG hyperchloremic metabolic acidosis. C diff negative and . Stool output decreasing, but still nauseous. Norovirus negative. Anti-emetics PRN. . # Thrush: Improved with nystatin. . # Sacral decubitus ulcer and coccygeal osteomyelitis: No surgical management, continued wound care, recent CT showed minimal improvement. Will continue daily dressing and packing with visiting nurses at home. . # Vaginal Bleeding: Has a history of radiation vaginitis documented on EUA on . Seen by Gyn consult without plans for intervention or further diagnostics. Will treat expectantly. Suspect this is due to radiation vaginitis and her anticoagulation with both lovenox and coumadin while bridging coumadin reinitiation. . # Nephrostomy tubes: Exchanged tubes . Then developed acute renal failure. CT showed no obstruction and urine output increased with IVFs. Serosanguinous fluid likely related to stone in setting of anticoagulation; no need for intervention. . # Acute renal failure: No obstruction on CT. Lytes consistent with prerenal cause. Muddy brown casts seen consistent with ATN from recent hypotension. Creatinine improved initially on IVFs, but now stabilizing at 1.5-1.7; IV fluids stopped. Ucx growing yeast, likely colonization. Nephrology consulted. . # Metabolic acidosis: Non-anion-gap. Repeat lactate normal. Likely due to high stool output and dilutional +/- RTA. Stool output slowing. Nephrology consulted. Acidosis improving after starting sodium bicarbonate 650mg PO BID , stopped . . # Anemia/blood loss: Normocytic, likely due to chronic disease as well as acute hematuria. Transfused 2U RBCs ( and ). No evidence of hemolysis. Continued anticoagulation. . # Leukocytosis: Due to pneumonia and ischemic colitis. Resolved. . # Rectal CA: No evidence of recurrence by CT or CEA . Palliative care and Social Work consulted. DNR/DNI, but continue maximal medical therapy. . # HIV: CD4 count 263. Continued HAART therapy. No PCP prophylaxis for now due to appropiate CD4. . # Chronic DVTs: Restarted enoxaparin and warfarin which were held due to hematuria. Increased warfarin dose from 4 to 5mg daily, but changed back to 4mg once near therapeutic at INR 1.8. The plan for patient's coumadin management was confirmed with her primary physician by phone on . . # Difficulty swallowing: Bedside swallow eval normal. . # FEN: Regular diet (per patient's wishes). Repleted hypomagnesemia and hypokalemia. . # DVT PPx: On warfarin 4mg QPM (last dose in hospital on with 5 mg). . # Precautions: Fall, contact ( in urine). . # Lines: Port. . # CODE: DNR/DNI. . Transitional Issues: 1. Coumadin titration: will have INR checked on Mon and Thurs by and results sent to Dr. . Have confirmed these plans by phone with Dr. on . 2. Sacral decubitus ulcer and coccygeal osteomyelitis: No surgical management. Will continue daily dressing and packing with visiting nurses at home. 3. Assessment of volume status and electrolyte abnormalities: has required Mg supplementation ~ twice weekly as inpatient. She will have electrolytes and CBC drawn STAT on Mon and Thurs and results sent to Dr. . She will take po Mg supplements and has IV Mg supplements available with home IV through Home therapies. If needed she can also receive IVF at home. These plans have been confirmed by phone with Dr. on . 4. Pain management: Have been using Dilaudid oral elixir 20mg/ml. of palliative care is available to Dr. to assist with pain control by email or page. | Partial obstruction of the left nephrostomy tube and patent right nephrostomy tube. Bilateral existing tube nephrostograms. The old catheter was removed. The old catheter was removed and a new 12F Nephrostomy tube was placed over the wire with the pigtail formed within the left renal pelvis, and contrast confirmed location. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. PHYSICIAN: . A 0.035 inch wire was then placed through cut catheter and coiled in the pelvis. A 0.018 inch Glidewire was placed easily through the catheter. Low precordial QRS voltage. Low precordial lead voltage. Initially, the right tube was addressed. A new 12F nephrostomy tube was placed over the wire with the pigtail formed within the left renal pelvis, and contrast confirmed location. 10:04 AM URIN CATH CHECK Clip # Reason: Assess poorly draining Left PCNT Admitting Diagnosis: ABDOMINAL PAIN Contrast: OMNIPAQUE Amt: 30 ********************************* CPT Codes ******************************** * CHG NEPHROTOMY/PYLOSTOMY TUBE -50 BILATERAL * * CHANGE PERC TUBE OR CATH W/CON CHANGE PERC TUBE OR CATH W/CON * * -59 DISTINCT PROCEDURAL SERVICE * **************************************************************************** MEDICAL CONDITION: 50 y/o woman with chronic bilateral nephrostomy tubes secondary to radiation fibrosis/ureteral obstruction. Anesthesiology service induced anesthesia, and the patient was placed prone on our angiographic table and both tubes were prepped and draped in sterile manner. Injection of small amount contrast demonstrated appropriate positioning of the pigtail in the renal pelvis and patent tube. Contrast injection showed (Over) 10:04 AM URIN CATH CHECK Clip # Reason: Assess poorly draining Left PCNT Admitting Diagnosis: ABDOMINAL PAIN Contrast: OMNIPAQUE Amt: 30 FINAL REPORT (Cont) appropriate location of the pigtail in the renal pelvis with contrast draining through sideholes. The patient was brought down to the IR suite, and a preprocedure timeout was performed. Non-specific repolarizationabnormality. PROCEDURE: 1. The catheter was secured to the skin with a silk suture and a Flexi-Trak. The catheter was secured to the skin with a silk suture and a Flexi-Trak. MEDICATIONS: The procedure was performed under general anesthesia, as the patient in the past has a low pain threshold and is unable to tolerate these procedures with moderate sedation. A 0.035 inch wire could not be advanced past last sidehole of the catheter, therefore a Glidewire was used. Had bilat PCNT last week, now with decreased drainage from left PCNT. Compared to theprevious tracing of no diagnostic change. Attention was then turned to the left tube. Patient also reports reduced output from the left kidney. IMPRESSION: 1. Wandering baseline obscures interpretation. (fellow), and Dr (attending radiologist). Additionally, the patient received IV antibiotics. Compared to the previous tracing of no majorchange. Successful exchange of both for new 12 French nephrostomy tubes. No change compared toprevious tracing. CONTRAST: 15 mL Optiray. Successful exchange of 12 French nephrostomy tubes bilaterally. PROCEDURE: Prior to initiation of the procedure, written informed consent was obtained. Please assess REASON FOR THIS EXAMINATION: Assess poorly draining Left PCNT FINAL REPORT INDICATION: 50-year-old woman with chronic bilateral nephrostomy tubes secondary to radiation fibrosis and bilateral ureteral obstruction presenting for routine exchange. 2. | 4 | [
{
"category": "ECG",
"chartdate": "2144-02-16 00:00:00.000",
"description": "Report",
"row_id": 208620,
"text": "Sinus tachycardia. Low precordial QRS voltage. No change compared to\nprevious tracing.\n\n"
},
{
"category": "ECG",
"chartdate": "2144-02-14 00:00:00.000",
"description": "Report",
"row_id": 208853,
"text": "Sinus tachycardia. Low precordial lead voltage. Non-specific repolarization\nabnormality. Wandering baseline obscures interpretation. Compared to the\nprevious tracing of no diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2144-02-03 00:00:00.000",
"description": "Report",
"row_id": 208854,
"text": "Sinus tachycardia. Compared to the previous tracing of no major\nchange.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-02-10 00:00:00.000",
"description": "BILATERAL",
"row_id": 1229746,
"text": " 10:04 AM\n URIN CATH CHECK Clip # \n Reason: Assess poorly draining Left PCNT\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OMNIPAQUE Amt: 30\n ********************************* CPT Codes ********************************\n * CHG NEPHROTOMY/PYLOSTOMY TUBE -50 BILATERAL *\n * CHANGE PERC TUBE OR CATH W/CON CHANGE PERC TUBE OR CATH W/CON *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 y/o woman with chronic bilateral nephrostomy tubes secondary to radiation\n fibrosis/ureteral obstruction. Had bilat PCNT last week, now with decreased\n drainage from left PCNT. Please assess\n REASON FOR THIS EXAMINATION:\n Assess poorly draining Left PCNT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old woman with chronic bilateral nephrostomy tubes\n secondary to radiation fibrosis and bilateral ureteral obstruction presenting\n for routine exchange. Patient also reports reduced output from the left\n kidney.\n\n PHYSICIAN: . (fellow), and Dr (attending\n radiologist).\n\n PROCEDURE:\n 1. Bilateral existing tube nephrostograms.\n 2. Successful exchange of 12 French nephrostomy tubes bilaterally.\n\n MEDICATIONS: The procedure was performed under general anesthesia, as the\n patient in the past has a low pain threshold and is unable to tolerate these\n procedures with moderate sedation. Additionally, the patient received IV\n 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 right tube was addressed. Injection of small amount contrast\n demonstrated appropriate positioning of the pigtail in the renal pelvis and\n patent tube. A 0.035 inch wire was then placed through cut catheter\n and coiled in the pelvis. The old catheter was removed. A new 12F nephrostomy\n tube was placed over the wire with the pigtail formed within the left renal\n pelvis, and contrast confirmed location. The catheter was secured to the skin\n with a silk suture and a Flexi-Trak.\n\n Attention was then turned to the left tube. Contrast injection showed\n (Over)\n\n 10:04 AM\n URIN CATH CHECK Clip # \n Reason: Assess poorly draining Left PCNT\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OMNIPAQUE Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appropriate location of the pigtail in the renal pelvis with contrast draining\n through sideholes. A 0.035 inch wire could not be advanced past last\n sidehole of the catheter, therefore a Glidewire was used. A 0.018 inch\n Glidewire was placed easily through the catheter. The old catheter was removed\n and a new 12F Nephrostomy tube was placed over the wire with the pigtail\n formed within the left renal pelvis, and contrast confirmed location. The\n catheter was secured to the skin with a silk suture and a Flexi-Trak.\n\n IMPRESSION:\n 1. Partial obstruction of the left nephrostomy tube and patent right\n nephrostomy tube.\n 2. Successful exchange of both for new 12 French nephrostomy tubes.\n\n\n"
}
] |
66,473 | 131,974 | 80 yo F with cardiac history significant for AS s/p biprosthetic AVR in 12/99, MR, Afib who initially presented for RHC +/- exercise and possible LHC to evaluate her MR in the setting of progressive SOB. During catheterization, she developed hemoptysis of 150 cc after the Swan Ganz Catheter was inflated and was subsequently found to have partially thrombosed pseudoaneurysm in RML pulmonary artery. An incidental finding of (presumed) migrated epicardial pacing wire in the main pulmonary artery was also noted. | The right internal jugular catheter ends in the mid SVC. A selective right pulmonary arteriogram was obtained. CT CHEST WITH INTRAVENOUS CONTRAST: A 1-cm round structure originating from the first branch of the right middle lobe medial segment pulmonary artery is consistent with a partially thrombosed pseudoaneurysm. PA and lateral upright chest radiographs were reviewed in comparison to , . The pulmonary artery catheter fragment is re-demonstrated in unchanged location projecting over the main pulmonary artery. Retained catheter fragment in the main pulmonary artery. The remainder of aorta is of normal caliber with atherosclerotic calcifications. 1 cm rounded density off the RML medial segment pulmonary artery c/w thrombosed aneurysm; surrounding density may represent prior hemorrhage, but currently no active extrav. LEFT HEART CATHETERIZATION Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) evidence of right heart strain. CTA of the chest obtained on showed evidence of a partially thrombosed pseudoaneurysm in a right middle lobe segmental branch of the pulmonary artery. Contrast refluxing into the IVC suggests right heart dysfunction. LEFT HEART CATHETERIZATION Contrast: OPTIRAY Amt: 276 FINAL REPORT (Cont) The sheath, catheter and wire were removed and pressure was held until hemostasis was achieved. LEFT HEART CATHETERIZATION Contrast: OPTIRAY Amt: 276 ********************************* CPT Codes ******************************** * SEL CATH PLACMT LT/RT PUL ARTE SEL CATH SEGMENTAL/SUBSEG PUL * * UNILAT PUL SEL ANGIOGRAPHY RIG EA ADD'L VESSEL AFTER BASIC A- * * MOD SEDATION, FIRST 30 MIN. Consider prior anterior wall myocardial infarction. The patient is status post AVR. FINAL REPORT INDICATION: Hemoptysis after PA perforation during right heart catheterization. 2. linear streak in main PA likely reflects motion artifact from a calcified pulmonary valve leaflet. LEFT HEART CATHETERIZATION Contrast: OPTIRAY Amt: 100 FINAL ADDENDUM ADDENDUM: Upon review of multiple prior outside studies from -, which were not available at the time of original dictation, it appears that the linear metallic density in the main pulmonary artery is a detached epicardial wire fragment, which has been in the approximately same location since . 10:58 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\RIGHT HEART CATHETERIZATION; ? Mild enlargement of the main and central pulmonary arteries suggests pulmonary hypertension. Mild enlargement of the main and central pulmonary arteries suggests pulmonary hypertension. IMPRESSION: Inability to precisely demonstrate the 1-cm pseudoaneurysm seen to arise from the right pulmonary artery within the right lung-middle lobe. Possible right neck hematoma. A linear metallic density extending from the main pulmonary outflow tract into the main pulmonary artery to the origin of the left pulmonary artery appears to be a retained catheter fragment. Patient is after median sternotomy. The aortic valve is replaced. Contrast refluxes into the IVC and hepatic veins. A hypodensity in the left kidney is noted. IV contrast refluxing into hepatic veins. Using an Omniflush catheter and a Glidewire, access was gained into the main and right pulmonary arteries. Aortic knob calcifications are noted. 11:32 AM PULMONARY Clip # Reason: catheter tip retrieval, pseudoaneurysm coiling Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\RIGHT HEART CATHETERIZATION; ? Partially thrombosed pseudoaneurysm in right middle lobe medial segment pulmonary artery with localized surrounding hemorrhage, but no active extravasation. (Over) 11:32 AM PULMONARY Clip # Reason: catheter tip retrieval, pseudoaneurysm coiling Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\RIGHT HEART CATHETERIZATION; ? A benign coarse left breast calcification is noted. Patient was referred for pulmonary arteriogram and potential embolization of the pseudoaneurysm. 5:35 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: evidence of additional bleeding from perforation of PA on 6/ Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\RIGHT HEART CATHETERIZATION; ? 5:35 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: evidence of additional bleeding from perforation of PA on 6/ Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\RIGHT HEART CATHETERIZATION; ? The heart is moderately enlarged without (Over) 5:35 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: evidence of additional bleeding from perforation of PA on 6/ Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\RIGHT HEART CATHETERIZATION; ? | 7 | [
{
"category": "Radiology",
"chartdate": "2104-06-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1195979,
"text": " 10:32 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for lung opacity\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with recent heart cath, and subsequent hemoptysis\n REASON FOR THIS EXAMINATION:\n evaluate for lung opacity\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hemoptysis after heart catheterization, evaluate for lung\n opacity.\n\n COMPARISON: , , .\n\n FINDINGS: The lungs are clear without focal consolidation. The previously\n described nodule is not visualized on the current study. The heart is\n enlarged, particularly the left atrium. Chronic widening of the mediastinum is\n unchanged since . However, the widening now extends to the right apex\n which is unchanged from , but new from . This may represent a\n possible apical lung lesion in addition to the mediastinal widening. A >3cm\n wide, rounded density at the right neck was not clearly seen yesterday and is\n definitely new from and may represent hematoma from a line placement.\n There is no pneumothorax or pleural effusion.\n\n IMPRESSION:\n 1. Nodule no longer visualized.\n 2. Chronic mediastinal widening with new right apical extension. If the\n patient has referable findings such as chest pain or Horner syndrome, CT is\n indicated to evaluate for right apical lung lesion. If CT is going to be\n performed for hemoptysis, this finding will be evaluated at that time.\n 3. Possible right neck hematoma. Correlate clinically.\n\n Findings discussed with Dr. by phone at 11:20 a.m., .\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-07-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1197245,
"text": " 7:04 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for infection\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with low grade temp and cough\n REASON FOR THIS EXAMINATION:\n evaluate for infection\n ______________________________________________________________________________\n WET READ: MLHh WED 7:41 PM\n Stable mod cardiomegaly, vasc congestion, and chronic mediastinal widening.\n No focal consolidation. R neck swelling.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Low-grade temperature and cough.\n\n PA and lateral upright chest radiographs were reviewed in comparison to , .\n\n Patient is after median sternotomy. The aortic valve is replaced.\n Cardiomegaly and mediastinal contours are unchanged. The pulmonary artery\n catheter fragment is re-demonstrated in unchanged location projecting over the\n main pulmonary artery.\n\n There is new focal opacity in the right lower lung that might reflect\n developing infectious process. No appreciable pleural effusion is noted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-07-01 00:00:00.000",
"description": "SEL CATH PLACMT LT/RT PUL ARTERY",
"row_id": 1196974,
"text": " 11:32 AM\n PULMONARY Clip # \n Reason: catheter tip retrieval, pseudoaneurysm coiling\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n Contrast: OPTIRAY Amt: 276\n ********************************* CPT Codes ********************************\n * SEL CATH PLACMT LT/RT PUL ARTE SEL CATH SEGMENTAL/SUBSEG PUL *\n * UNILAT PUL SEL ANGIOGRAPHY RIG EA ADD'L VESSEL AFTER BASIC A- *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with pulmonary artery pseudoaneurysm s/p wedging of swan ganz\n catheter, retained catheter tip in pulm outflow tract\n REASON FOR THIS EXAMINATION:\n catheter tip retrieval, pseudoaneurysm coiling\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old lady with a recent history of hemoptysis. CTA of the\n chest obtained on showed evidence of a partially thrombosed\n pseudoaneurysm in a right middle lobe segmental branch of the pulmonary\n artery. Patient was referred for pulmonary arteriogram and potential\n embolization of the pseudoaneurysm.\n\n Moderate sedation was providied by administering divided doses of Fentanyl\n and Versed throughout the total intra-service time of 3 hours and 20 minutes\n during which the patient's hemodynamic parameters were continuously monitored.\n\n TECHNIQUE: Written informed consent was obtained from the patient. The\n patient was prepped and draped in a standard sterile fashion, on the\n angiography table. A preprocedure huddle and timeout were performed per \n policy. After local anesthesia with 10 mL of lidocaine 1%, access was gained\n into the right common femoral vein using a micropuncture kit, under ultrasound\n guidance. Over wire the access was upsized to a 5 French sheath.\n Using an Omniflush catheter and a Glidewire, access was gained into the main\n and right pulmonary arteries. The catheter was then exchanged for a pigtail\n flush catheter. A selective right pulmonary arteriogram was obtained.\n\n In order to maintain stability, the pigtail catheter was removed over a super-\n stiff Glidewire and the sheath was exchanged for a 90 cm long 6 French sheath\n which was positioned in the main trunk of the right pulmonary artery. With the\n aid of a regular Glidewire and a 90-cm catheter, selective\n catheterization of different branches supplying the middle lobe of the right\n lung was performed. Selective arteriograms of each one of those branches were\n obtained. Due to our inability to precisely visualize the pseudoaneurysm, a\n three-dimensional rotation angiography scan as well as a cone beam CT scan\n were obtained while injecting contrast into the main right pulmonary artery.\n\n (Over)\n\n 11:32 AM\n PULMONARY Clip # \n Reason: catheter tip retrieval, pseudoaneurysm coiling\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n Contrast: OPTIRAY Amt: 276\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The sheath, catheter and wire were removed and pressure was held until\n hemostasis was achieved.\n\n FINDINGS: The right pulmonary arteriogram, as well as selective arteriograms\n of the segmental arteries supplying the middle lobe of the right lung did not\n show evidence of the small pseudoaneurysm seen on CT.\n\n Three-dimensional rotation angiography as well as cone beam CT reconstructions\n also failed to precisely demonstrate filling of the pseudoaneurysm.\n\n COMPLICATIONS: No immediate complications.\n\n IMPRESSION: Inability to precisely demonstrate the 1-cm pseudoaneurysm seen\n to arise from the right pulmonary artery within the right lung-middle lobe. A\n followup CT pulmonary arteriogram will be obtained to assess for persistence\n or thrombosed status of the pseudoaneurysm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-06-26 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1196423,
"text": " 5:35 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evidence of additional bleeding from perforation of PA on 6/\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Upon review of multiple prior outside studies from -, which\n were not available at the time of original dictation, it appears that the\n linear metallic density in the main pulmonary artery is a detached epicardial\n wire fragment, which has been in the approximately same location since . A\n second detached epicardial lead is identified adjacent to the left epicardium.\n\n\n Dr. notified Drs. , , and from the\n cardiology service by E-mail at 8:08pm .\n\n\n 5:35 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evidence of additional bleeding from perforation of PA on 6/\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with MR, cardiomyopathy, AF with reoccurance of hemoptysis\n after PA perforation during right heart cath\n REASON FOR THIS EXAMINATION:\n evidence of additional bleeding from perforation of PA on during right\n heart cath\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:11 PM\n 1. no PE or acute aortic syndrome.\n 2. linear streak in main PA likely reflects motion artifact from a calcified\n pulmonary valve leaflet.\n 3. 1 cm rounded density off the RML medial segment pulmonary artery c/w\n thrombosed aneurysm; surrounding density may represent prior hemorrhage, but\n currently no active extrav.\n 4. tracheobronchial tree patent.\n 5. no pleural or pericardial effusion.\n 6. no mediastinal hematoma.\n 7. IV contrast refluxing into hepatic veins.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hemoptysis after PA perforation during right heart\n catheterization.\n\n COMPARISON: No prior CTs available. CXR , , .\n\n TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed\n before and after administration of 100 mL Optiray intravenous contrast.\n Images are presented for display in the axial plane at 5-mm, 2.5-mm, and\n 0.625-mm collimation. A series of multiplanar reformation images are\n submitted for review.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: A 1-cm round structure originating from\n the first branch of the right middle lobe medial segment pulmonary artery is\n consistent with a partially thrombosed pseudoaneurysm. Surrounding\n ground-glass opacity is localized surrounding hemorrhage, but there is no\n active extravasation. A linear metallic density extending from the main\n pulmonary outflow tract into the main pulmonary artery to the origin of the\n left pulmonary artery appears to be a retained catheter fragment. The lungs\n are clear without consolidation, nodule, or mass.\n\n The ascending aorta is mildly dilated to 4.3 cm. The remainder of aorta is of\n normal caliber with atherosclerotic calcifications. There is no intramural\n hematoma or evidence of dissection. Mild enlargement of the main and central\n pulmonary arteries suggests pulmonary hypertension. Pulmonary arterial\n vasculature is well visualized to the subsegmental level without filling\n defect to suggest pulmonary embolism. The heart is moderately enlarged without\n (Over)\n\n 5:35 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evidence of additional bleeding from perforation of PA on 6/\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n evidence of right heart strain. No pathologically enlarged axillary,\n mediastinal, or hilar lymph nodes are present. There is no pleural or\n pericardial effusion. The thyroid is unremarkable without nodules. Fat\n stranding just superior to the right thoracic outlet, without discrete fluid\n collection, is seen. A benign coarse left breast calcification is noted.\n Contrast refluxes into the IVC and hepatic veins.\n\n The study is not tailored for subdiaphragmatic evaluation. A hypodensity in\n the left kidney is noted.\n\n No bone finding suspicious for malignancy or infection is seen. A sclerotic\n focus in left posterior ninth rib is a bone island. Median sternotomy wires\n are intact.\n\n IMPRESSION:\n 1. Partially thrombosed pseudoaneurysm in right middle lobe medial segment\n pulmonary artery with localized surrounding hemorrhage, but no active\n extravasation.\n 2. Retained catheter fragment in the main pulmonary artery.\n 3. Contrast refluxing into the IVC suggests right heart dysfunction.\n 4. Mild enlargement of the main and central pulmonary arteries suggests\n pulmonary hypertension.\n 5. Left renal hypodensity can be further evaluated with renal ultrasound if\n clinically indicated.\n\n Dr. discussed the findings with the pulmonary consult fellow by phone\n at 8 p.m., .\n\n Dr. discussed the finding of retained catheter fragment with Dr.\n by phone at 11 a.m., .\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-06-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1195833,
"text": " 10:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman coughing up blood sp procedure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hemoptysis after cardiac cath\n\n COMPARISON: and .\n\n FINDINGS: Low lung volumes result in bronchovascular crowding. The right\n internal jugular catheter ends in the mid SVC. No focal consolidation is\n present. A nodular density projects over the heart. The patient is status post\n AVR. Mild cardiac enlargement is stable. Hilar contours are normal. Aortic\n knob calcifications are noted. No effusion or pneumothorax.\n\n IMPRESSION:\n 1. No acute cardiopulmonary process.\n 2. Nodular density projects over the heart. Recommend PA and lateral views\n when possible.\n\n Discussed with Dr. by phone 1:44pm .\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-07-04 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1197569,
"text": " 1:14 PM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: INCREASING SHORTNESS OF BREATH\\RIGHT HEART CATHETERIZATION; ? LEFT HEART CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with fever.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old female with fever. Evaluate for interval change.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL VIEWS: Lung volumes are low. There is increased right\n infrahilar opacity and possibly new left retrocardiac opacity compatible with\n developing infection. Small bilateral pleural effusions are increased. Heart\n size is severely enlarged as before. Sternal wires are intact. Prosthetic\n aortic valve is unchanged. Atherosclerotic calcification of aortic arch is\n present and prominence of the mediastinal contour related to increased\n ascending aorta diameter is better characterized on CT.\n\n"
},
{
"category": "ECG",
"chartdate": "2104-06-23 00:00:00.000",
"description": "Report",
"row_id": 115339,
"text": "Probable sinus rhythm with atrial premature beats but low amplitude atrial wave\nforms make assessment difficult. Left bundle-branch block with left axis\ndeviation. Consider prior anterior wall myocardial infarction. Since the\nprevious tracing of the rate is faster and right precordial lead T wave\ninversion is now absent.\n\n"
}
] |